June is National Migraine and Headache Awareness Month. Where does Physical Therapy Fit In?

By: Cheryl “Chae” Dimapasoc Canon, PT, DPT;  OptimisPT Director of Implementation and Compliance

Migraines are the 3rd most prevalent illness in the world where every 10 seconds, someone in the U.S. goes to the emergency room complaining of head pain, and approximately 1.2 million visits are for acute migraine attacks. A migraine is more than just a bad headache. Attacks are often accompanied by one or more of the following disabling symptoms: visual disturbances, nausea, vomiting, dizziness, extreme sensitivity to sound, light, touch and smell, and tingling or numbness in the extremities or face.  Migraines often go undiagnosed in children.  About 10% of school-age children suffer from migraine, and up to 28% of adolescents between the ages of 15-19 are affected by it. Migraines are about three times more prevalent in women than men, affecting 28 million women in the U.S. More severe and more frequent attacks often result from fluctuations in estrogen levels. More than 157 million workdays are lost each year in the US due to migraine.  These numbers are staggering, and we haven’t even talked about headaches, in general, yet.

Pain of any type that occurs in any part of the head is called a headache. The American Journal of Medicine indicates that approximately 1 billion dollars each year are spent on unnecessary brain imaging of primary headache disorders.  There are 14 different classifications of headaches; four primary and ten secondary. As with most conditions, the more specifically you can identify the type of headache, the more specific and successful the intervention(s) could be.  

Physical therapy is often underutilized in the treatment of headaches and migraines.  The two most common reasons are because of the public’s perception of physical therapists’ focus on musculoskeletal systems not strongly associated with migraines and traditional reliance on pain medication as a first defense.  The most common types we see in physical therapy are primary headaches: migraine, tension headache and cluster headache, which constitute nearly 98% of all headaches; however, secondary headaches are important to recognise as they are serious and may be life threatening. 

The most common secondary headaches include:

  • space-occupying lesions, mainly intracranial tumours;
  • infections of the central nervous system, mainly meningitis or encephalitis;
  • subarachnoid haemorrhage;
  • giant-cell arteritis;
  • cerebral venous thrombosis;
  • idiopathic intracranial hypertension.

The British Journal of Pain lists two extremely important considerations in our evaluation and treatment of headaches in our patients: Questions to consider during the subjective assessment related to headaches and red flags related to secondary headaches.

Key Questions in Headache History

  • When did the headache first start?
  • How many different types of headaches do you have?
  • How often do you get a headache? (to establish chronic vs episodic)
  • How long does a headache episode last? (with or without treatment)
  • Have you recently noticed a change in the characteristics of your headache?
  • What is the intensity, location, nature and quality of pain?
  • What associated symptoms do you get? (such as nausea, vomiting)
  • Are there any aggravating or relieving factors? (early morning headaches and worse on 
  • straining suggest raised intracranial pressure)
  • Is there a presence of focal neurological symptoms? (visual, sensory, speech that may 
  • suggest aura)
  • What do you do when you have a headache? (patients with migraine typically avoid physical 
  • activity)
  • What worries you about your headache? (most patients worry about brain tumours)

The Red Flag Symptoms (adapted from BASH, 2010)

  1. Thunderclap headache (intense, exploding and hyperacute onset)
  2. New-onset headache in patients >50 or <10
  3. Persistent morning headache with nausea
  4. New onset of headache in a patient with history of cancer
  5. New onset of headache in a patient with history of HIV infection
  6. Progressive headache, worsening over weeks
  7. Headaches associated with postural changes
  8. Aura symptoms that:
    • Last longer than an hour
    • Include motor weakness
    • Are different from previous aura
    • Occur for the first time on using oral contraceptive pill

Often when patients present to physical therapy they come for neck pain, dizziness, balance disorder or something completely unrelated, where we may screen for headaches and ask deeper questions to help determine if the patient would benefit from treatment for the headaches as well. As clinicians that can develop an effective treatment plan to address headaches, we should actively promote our services to patients and referral sources with education on how physical therapy can help.  A physical therapy plan of care consisting of manual therapy, strengthening of the postural muscles, mobility activities and educational strategies have proven to:

  • Decrease or resolve the intensity, frequency, and duration of headaches.
  • Decrease medication use.
  • Improve function and mobility.
  • Improve ease of motion in the neck.
  • Improve quality of life.

A disease awareness month plays a vital role in raising public knowledge, addressing stigma and building a stronger community of patient advocates.  Join us in advocating and spreading awareness!

OptimisPT contains clinical content and pattern recognition for cervicogenic headaches based on clinical practice guidelines.   To learn more Schedule a Demo.


Resources and Further Reading

Ahmed, F. Headache disorders: differentiating and managing the common subtypes. Br J Pain. 2012 Aug; 6(3): 124–132.

Callaghan, B.C., Kerber, K.A., Pace, R.J. et al. Headaches and neuroimaging. High utilization and costs despite guidelines. JAMA Intern Med. 2014; 174: 819-821

Choosr PT. APTA. 3 Ways a Physical Therapist Can Help Manage Headaches. https://www.choosept.com/resources/detail/3-ways-physical-therapist-can-help-manage-headache

Choose PT. APTA.  Physical Therapy Guide to Headaches. https://www.choosept.com/symptomsconditionsdetail/physical-therapy-guide-to-headaches

Fontana, S. Everyday Health. Migraine and Headache Awareness Month: June 2021. https://www.everydayhealth.com/migraine/awareness-month/

Headache Classification Committee of the International Headache Society (HIS). The International Classification of Headache Disorders. 3rd edition (beta version). Cephalalgia. 2013; 33: 629-808.

Michigan Headache & Neurological Institute. Physical Therapy and Migraine Headaches. https://mhni.com/headache-pain-faq/migraine-headaches/physical-therapy-migraine-headaches

Migraine Research Foundation: https://migraineresearchfoundation.org/about-migraine/migraine-facts/

National Headache Foundation. Physical Therapy for Headaches. https://headaches.org/2016/10/11/physical-therapy-headache/

National Migraine and Headache Awareness Month. https://www.migraineheadacheawarenessmonth.org/

Stovner L.J., Hagen K., Jensen R. et al.The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia. 2007; 27: 193-210

Rizzoli, P., Mullally, W. Headache.the American Journal of Medicine. Volume 131, Issue 1, 2018: P17-24.

Victoria Espí-López G, Arnal-Gómez A, Arbós-Berenguer T, González ÁAL, Vicente-Herrero T. Effectiveness of Physical Therapy in Patients with Tension-type Headache: Literature Review. J Jpn Phys Ther Assoc. 2014;17(1):31-38. doi:10.1298/jjpta.Vol17_005