Persistent symptoms’ does not reflect a single pathophysiological entity, but describes a constellation of non-specific post-traumatic symptoms that may be linked to coexisting and/or confounding factors, which do not necessarily reflect ongoing physiological injury to the brain (McCrory et al. 2017).
Persistent symptoms after concussive injuries often includes headaches and neck pain.
With the high impact nature of most concussive injuries, the assessment and rehabilitation of cervical spine may decrease the likelihood that an individual will develop persistent headaches and neck pain (Kennedy et al. 2017).
Post-Concussion Headaches are Often Classified as Migraine or Tension-Type Headaches
It is proposed that a portion of post-concussion headaches are cervicogenic in nature, due in part to the concomitant whiplash injury suffered at the same time of the concussive force. Researchers classify these post-traumatic headaches as migraine headaches or tension-type headaches.
In these demographics soft tissue irritation and subsequent nerve sensitization may be a major contributor to symptoms (Fernández-De-Las-Peñas et al. 2017, Luedtke et al. 2017). There is also evidence that for some patients temporomandibular disorder may be a contributing factor to headaches (von Piekartz & Hall 2013).
What role can massage therapists play?
In the past the primary management strategies for headaches and chronic pain was a pharmacological approach, but over time some of these treatments evolve into a health care crisis of their own. Early in 2016 The Center for Disease Control, expressed the need to move beyond a pharmacological approaches for symptom management.
Physicians, now more than ever are recommending conservative treatment including manual therapy, acupuncture, education and exercise as part of a multi-modal approach for patients suffering from headaches and neck pain.
Why Does Massage Therapy Work?
With massage therapy the goal is to decrease the individual’s headache frequency, intensity, duration and acute medication requirements.
A biopsychosocial framework helps put into context the interconnected and multidirectional interaction between: physiology, thoughts, emotions, behaviors, culture, and beliefs. In terms of clinical responses to massage therapy there are a couple of proposed mechanisms of action, including but not limited to: affective touch, contextual factors, endogenous pain modulation and mechanical factors.
Post-concussion headaches are multifactorial with evidence for the contributions of muscles and other structures surrounding the cervical spine. A massage therapy treatment plan should be implemented based on patient-specific assessment findings and patient tolerance. Structures to keep in mind while assessing and treating patients suffering from cervicogenic headaches may include neurovascular structures and investing fascia of:
More to Explore
Arendt-Nielsen et al. (2016). Muscle Triggers as a Possible Source of Pain in a Subgroup of Tension-type Headache Patients? The Clinical Journal of Pain.
Bendtsen et al. (2016). Muscles and their role in episodic tension-type headache: implications for treatment. Eur J Pain.
Blanpied et al. (2017). Neck Pain: Revision 2017. J Orthop Sports Phys Ther
Burstein et al. (2017). Extracranial origin of headache. Curr Opin Neurol.
Busse et al. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.
Bussières et al. (2016). The Treatment of Neck Pain–Associated Disorders and Whiplash-Associated Disorders: A Clinical Practice Guideline. Journal of Manipulative and Physiological Therapeutics.
Castaldo et al. (2017). Association between Clinical and Neurophysiological Outcomes in Patients with Mechanical Neck Pain and Whiplash-associated Disorders. Clin J Pain.
Cheever et al. (2016). Cervical Injury Assessments for Concussion Evaluation: A Review. J Athl Train.
Cohen, S.P., & Hooten, W.M. (2017). Advances in the diagnosis and management of neck pain. BMJ.
Coeytaux, R. R., & Befus, D. (2016). Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache.
Côté et al. (2019). Non-pharmacological Management of Persistent Headaches Associated with Neck Pain: A Clinical Practice Guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain.
Courtney et al. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.
Ellis et al. (2016). Multi-Disciplinary Management of Athletes with Post-Concussion Syndrome: An Evolving Pathophysiological Approach. Front Neurol.
Ellis et al. (2018). Cervical Spine Dysfunction Following Pediatric Sports-Related Head Trauma. J Head Trauma Rehabil.
Ellis et al. (2018). Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes. Front Neurol
Fakhran et al. (2016). Effect of the Suboccipital Musculature on Symptom Severity and Recovery after Mild Traumatic Brain Injury. American Journal of Neuroradiology.
Fernández-de-Las-Peñas, C., & Courtney, C.A. (2014). Clinical reasoning for manual therapy management of tension type and cervicogenic headache. J Man Manip Ther.
Fernández-de-Las-Peñas, C. (2015). Myofascial Head Pain. Curr Pain Headache Rep.
Fernández-De-Las-Peñas, C., & Arendt-Nielsen, L. (2017). Improving understanding of trigger points and widespread pressure pain sensitivity in tension-type headache patients: clinical implications. Expert Rev Neurother.
Ferracini et al. (2017). Musculoskeletal disorders of the upper cervical spine in women with episodic or chronic migraine. Eur J Phys Rehabil Med.
Ferragut-Garcías et al. (2017). Effectiveness of a Treatment Involving Soft Tissue Techniques and/or Neural Mobilization Techniques in the Management of Tension-Type Headache: A Randomized Controlled Trial. Arch Phys Med Rehabil.
Gandolfi et al. (2017). Does myofascial and trigger point treatment reduce pain and analgesic intake in patients undergoing OnabotulinumtoxinA injection due to chronic intractable migraine? A pilot, single-blind randomized controlled trial. Eur J Phys Rehabil Med.
Harmon et al. (2019). American Medical Society for Sports Medicine Position Statement on Concussion in Sport. Clin J Sport Med.
Iverson et al. (2017). Predictors of clinical recovery from concussion: a systematic review. Br J Sports Med.
Iyengar et al. (2017). The role of calcitonin gene-related peptide in peripheral and central pain mechanisms including migraine. Pain.
Kennedy et al. (2017). Clinical characteristics and outcomes of treatment of the cervical spine in patients with persistent post-concussion symptoms: A retrospective analysis. Musculoskelet Sci Pract.
Kwon et al. (2018) Anatomical analysis of the distribution patterns of occipital cutaneous nerves and the clinical implications for pain management. J Pain Res.
Lal et al. (2017). The Effect of Physical Exercise After a Concussion: A Systematic Review and Meta-analysis. Am J Sports Med.
Leddy et al. (2017). A Physiological Approach to Prolonged Recovery From Sport-Related Concussion. J Athl Train.
Leddy et al. (2019). Early Subthreshold Aerobic Exercise for Sport-Related Concussion: A Randomized Clinical Trial. JAMA Pediatr.
Lemeunier et al. (2017). Reliability and validity of clinical tests to assess the anatomical integrity of the cervical spine in adults with neck pain and its associated disorders: Part 1-A systematic review from the Cervical Assessment and Diagnosis Research Evaluation (CADRE) Collaboration. Eur Spine J.
Lucas, S., & Blume, H.K. (2017). Sport-Related Headache. Neurol Clin.
Luedtke et al. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual Therapy.
Luedtke et al. (2017). Musculoskeletal dysfunction in migraine patients. Cephalalgia.
Makdissi et al. (2017). Approach to investigation and treatment of persistent symptoms following sport-related concussion: a systematic review. Br J Sports Med.
Manley et al. (2017). A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med.
Marshall et al. (2015). The role of the cervical spine in post-concussion syndrome. The Physician and Sportsmedicine.
Mares et al. (2019). Narrative Review of the Pathophysiology of Headaches and Photosensitivity in Mild Traumatic Brain Injury and Concussion. Can J Neurol Sci.
Matuszak et al. (2016). A Practical Concussion Physical Examination Toolbox. Sports Health.
McCrory et al. (2017). Consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med.
Meyfroidt et al. (2017). Paroxysmal sympathetic hyperactivity: the storm after acute brain injury. Lancet Neurol.
Millstine et al. (2017). Complementary and integrative medicine in the management of headache. BMJ.
Nöbel et al. (2016). ATP-sensitive muscle afferents activate spinal trigeminal neurons with meningeal afferent input in rat – pathophysiological implications for tension-type headache. The Journal of Headache and Pain.
Pareja et al. (2017). Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients. Headache.
Perry et al. (2016). Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: Implications for extracranial origin of headache. Ann Neurol.
Quatman-Yates et al. (2016). Physical Rehabilitation Interventions for Post-mTBI Symptoms Lasting Greater Than 2 Weeks: Systematic Review. Phys Ther.
Schneider et al. (2014). Cervicovestibular rehabilitation in sport-related concussion: a randomised controlled trial. Br J Sports Med.
Schneider, K. J. (2016). Sport-Related Concussion: Optimizing Treatment Through Evidence-Informed Practice. Journal of Orthopaedic & Sports Physical Therapy.
Schneider et al. (2017). Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med.
Schneider, K.J. (2019). Concussion - Part I: The need for a multifaceted assessment. Musculoskelet Sci Pract.
Schneider, K.J. (2019). Concussion part II: Rehabilitation - The need for a multifaceted approach. Musculoskelet Sci Pract.
Shaw et al. (2018). Chronic post-traumatic headache in children and adolescents: systematic review of prevalence and headache features. Pain Manag.
Streifer et al. (2019). The Potential Role of the Cervical Spine in Sports-Related Concussion: Clinical Perspectives and Considerations for Risk Reduction. J Orthop Sports Phys Ther.
van der Meer et al. (2017) The Association Between Headaches and Temporomandibular Disorders is Confounded by Bruxism and Somatic Symptoms. Clin J Pain.
van der Naalt et al. (2017). Early predictors of outcome after mild traumatic brain injury (UPFRONT): an observational cohort study. Lancet Neurol.
Varatharajan et al. (2016). Are non-invasive interventions effective for the management of headaches associated with neck pain? An update of the Bone and Joint Decade Task Force on Neck Pain and Its Associated Disorders by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J.
von Piekartz, H. V., & Hall, T. (2013). Orofacial manual therapy improves cervical movement impairment associated with headache and features of temporomandibular dysfunction: A randomized controlled trial. Manual Therapy.
Watson, D. H., & Drummond, P. D. (2012). Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: The Journal of Head and Face Pain.