Cranial & Facial Pain

HEADACHES

Headaches are a common cause of pain and suffering that can limit completion of daily tasks. The symptoms can vary from pulsating pain to constant tension and throbbing. Visual changes and dizziness can be debilitating and prevent you from doing much of anything. Often times, the root cause is musculoskeletal in origin. Headaches can be grouped into several categories, with the ones most successfully treated through physical therapy being migraine, tension type, and cervicogenic.

TREATMENT:

Migraines are often treated with pharmacology but the addition of physical therapy can be beneficial. PT Solutions’ physical therapists perform a full assessment to determine any possible cranio-cervical impairments that may be worsening migraine symptoms and limiting the effect of medication. Spinal manipulation, upper cervical mobilization, trigger point release, and postural education can improve outcomes and reduce both frequency and intensity of migraines.

Tension type headaches (TTH) can be either episodic (<15 days a months) or chronic (>15 days a month). Chronic headaches can be present for 30 minutes to 7 days straight. They also meet at least 2 of the following criteria: bilateral location, non-pulsatile pressure, mild or moderate pain, and does not increase with physical activity. Your physical therapist will use a combination of joint and soft tissue mobilization/manipulation, trigger point release, and postural and relaxation exercises to decrease pain before utilizing a cervical and scapular strengthening program to prevent future headaches

Cervicogenic headaches can often present with a headache accompanied with dizziness. This often results from upper cervical joint impairments and trigger points in cervical and cranial muscles. Spinal manipulation, upper cervical mobilization, trigger point release, deep neck flexor endurance exercise will be used to decrease pain and dizziness. Therapeutic exercise will focus on restoring balance and proprioception as well as stabilizing upper cervical spine to minimize future impairments.

EVIDENCE:

A recent systematic review and meta-analysis demonstrated aerobic exercise can be an effective way to reduce the frequency of migraines. (Lemmens, 2019) When looking at the overall impact of exercise on migraines, a review of studies clearly highlights an inverse relationship between physical exercise and migraines. The authors stated “Overall, a general reduction of frequency, severity and duration of migraine attacks has been observed after the exercise intervention periods, and this has also been frequently associated with a considerable improvement of the quality of life of the affected subjects.” Additionally, a systematic review in Frontiers in Neurology showed manual therapy targeted towards myofascial trigger points (TrPs) can reduce the frequency, intensity, and duration of migraine and tension type headaches. (Maistrello, 2018). For cervicogenic headaches, studies show optimal outcomes occur with a combination of exercise and cervical mobilization/manipulation.

TMJ DYSFUNCTION

TMJ dysfunction affects an increasing number of patients each year. Physical therapists are in a unique position to partner with dentists and successfully manage dysfunction of the TMJ.

There is a close relationship between the cervical spine, TMJ, and masticatory (chewing) system creating the potential for pain of cervical origin to affect the facial area. Therefore, it is imperative that patients with orofacial pain receive a systematic and well-rounded approach to fully dissolve their chronic history of pain.

Poor cervical posture can result in increased tone and trigger points in both jaw and cervical musculature. The resulting hypertonicity of specific muscles, including the masseter and temporalis, leads to myofascial pain.

TREATMENTS:

At PT Solutions, we are aware that effective treatment of the TMJ and surrounding areas is achieved through joint mobilization, myofascial techniques, dry needling and exercise. We assess musculature of the cervical spine including the sternocleidomastoid, paraspinals, suboccipital musculature and upper scapular musculature for trigger points as they easily refer pain to the face and TMJ. PT Solutions can play an active role along side of dentists to effectively incorporate a multi-disciplinary approach and provide that extended manual time required to promote the long term effects sought by the chronic pain patient.

EVIDENCE:

Treatment may often include pharmacology first. However, due to the nature of most medications which are often harsh anticonvulsants and anti-depressants, reversible conservative therapies are recommended first. Though injections have been shown to help, they cannot independently change the negative effects due to chronic postural impairments in patients. There has been no long term therapeutic effects noted with use of oral splints alone. Physical therapy, which includes a combination of exercise, manual therapy, education and self-management strategies, and potentially dry needling, has shown promising short and long-term outcomes in patients suffering from TMD.

DIZZINESS & VERTIGO

Regardless of age, patients who experience dizziness report disability that reduces their quality of life. Benign paroxysmal positional vertigo (BPPV) is responsible for over 20% of all reports of dizziness. Disequilibrium and vertigo can also be caused by unilateral vestibular hypofunction (UVH), bilateral vestibular hypofunction (BVH) or a central vestibular disorder (CVD).

BPPV occurs when previously stationary otoconia become displaced into the semicircular canals. Unilateral vestibular hypofunction is most commonly caused by vestibular neuronitis and Meniere’s disease. Bilateral vestibular hypofunction is often the result of ototoxicity from certain antibodies. Other causes of vestibular dysfunction can include head trauma, migraines and cerebellar lesions. Patients with vestibular problems experience a range of symptoms including vertigo, postural instability, oscillopsia, and ataxia.

TREATMENT:

If BPPV is found to be the cause of the dizziness, patients will be treated with the appropriate repositioning maneuver, such as the Epley maneuver. Multiple randomized controlled trials have found that resolution of BPPV is 22-37 times higher in people receiving a canalith repositioning procedure than in people receiving a sham treatment.

Vestibular rehabilitation for other diagnoses includes gaze stability exercises, balance and gait exercises, and a daily walking program.

EVIDENCE:

A 2012 retrospective study of 209 patients with UVH found that 75-88% of patients showed significant improvement after performing vestibular adaptation and substitution exercises. Patients may also be instructed in habituation exercises to treat dizziness and nausea provoked by environments or positions.

A recent randomized controlled trial showed that in older adults with dizziness but no documented vestibular deficits, gaze stability exercises in addition to standard balance rehabilitation reduced fall risk.