Primary versus Secondary Headache and Current Guidelines for Non-Pharmacological Management

Headache is the symptom of pain anywhere in the region of the head or neck. There are a number of different classification systems for headaches. The most well-recognized is that of the International Headache Society.

There are more than 200 types of headaches and the IHS have laboriously developed a diagnostic classification, the ICHD3, in order to help healthcare practitioners in this field identify and treat the appropriate headache condition.

Headaches are broadly classified as "primary" or "secondary".

Primary Headaches

Primary headaches are benign, recurrent headaches not caused by underlying disease or structural problems.

The can be divided into:

• ●  1. Migraine

• ●  2. Tension-type headache (TTH)

• ●  3. Trigeminal autonomic cephalalgias (TACs)

• ●  4. Other primary headache disorders

  90% of all headaches are primary headaches.

  The most common primary headache types are migraine and tension-type headache (TTH), which are often referred to physiotherapy to support pharmacological treatment.

• Secondary headaches

A headache is secondary when it is caused by another condition. The most common types of secondary headache are:

• ●  1. HA attributed to trauma or injury to the head and/or neck

• ●  2. HA attributed to cranial or cervical vascular disorder

• ●  3. HA attributed to non-vascular intracranial disorder

• ●  4. HA attributed to a chemical substance or its withdrawal (e.g a hangover)

• ●  5. HA attributed to infection

• ●  6. HA attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial/cervical structures

• ●  7. HA attributed to psychiatric disorder

  A frequently reported secondary headache type seen in physiotherapy clinics is cervicogenic headache (CGH). Current evidence supports non-pharmacological approaches such as acupuncture, relaxation and physiotherapy.

  The most recent research publications have supported the use of manual therapy for primary tension-type headache. The same authors also conducted a systematic review on secondary cervicogenic headache with similar results.

  Physiotherapy in the Treatment of Primary and Secondary Headache

  Results from a 2016 systematic review further suggest that physiotherapy interventions may have a positive effect on all types of headache that they explored (migraine, tension type headache, cluster headache, cervicogenic headache). None of the meta-analyses indicated a negative effect for physiotherapy interventions on any type of headache or any outcome measure.

  Furthermore, in this 2016 review, they showed a reduction of 3.4 migraine days per month with a three-times weekly aerobic and strength training programme.

  When they included coping strategy education, they showed that aerobic exercise and a combination of physical and psychological interventions was highly effective for the reduction of migraine attack duration.

  Manual therapy showed a highly significant effect for the reduction of TTH frequency and duration.

Cervicogenic headache (CGH) had been treated only with manual therapy and trigger point therapy in the included studies. Both techniques showed highly significant results. However, no evidence for the effect of aerobic exercises, strength training and combined physical and psychological interventions was available where CGH was concerned. The choice of interventions for the treatment of headache used in included trials seemed to be based on theoretical knowledge and beliefs rather than on the patient’s individual signs and symptoms identified by the treating therapist. These standardized treatment approaches do not reflect the clinical reasoning-guided physiotherapy practice that is postulated by the World Confederation for Physical Therapy.

Interestingly, the efficacy of physiotherapy interventions in trials that defined their study sample as cervicogenic headache (CGH) was particularly high. The diagnostic title CGH implies a treatable pathology in the cervical spine. The exact source of the symptoms is unknown and could involve cervical muscles or cervical joints connected via afferents to the trigeminal nuclei.

Clinical implications of this recent Review for HA Treatment.

• ●  Physiotherapy interventions resulted in a statistically significant effect on the intensity of tension-type headache (TTH) and cervicogenic headache (CGH), the frequency of CGH, and the duration of migraine and CGH when combined in meta-analyses. Removing trials with high risk of bias domains resulted in an additional significant effect on migraine intensity and frequency. .

• ●  Statistically significant effects were identified for manual therapy for the reduction of TTH frequency and duration and for all outcomes in CGH, trigger point treatment for the reduction of the intensity of TTH and CGH, combined physical and psychological interventions as well as aerobic exercises for the reduction of the duration of migraine. .

• ●  Physiotherapy is low cost, has nearly no side effects and seems beneficial for the reduction of most headache symptoms. It should, therefore, be considered to support the medical management of headache and migraine.

• ●  The level of evidence for this effect based on methodological quality and external validity factors is low. Randomized controlled trials of high methodological rigor with adequate sample sizes are required to confirm the results of the meta-analyses.

Leudtke et al (2016) Efficacy of interventions used by physiotherapists for patients with headache and migraine—systematic review and meta-analysis. Cephalalgia 0(0) 1–19