August article discussion

[sewhitta]

We have talked a lot about psychological factors, such as kinesiophobia, being a major influence on chronic pain. This article has introduced to me something that I have not considered in a patient with cervicogenic headaches; ‘cephalalgiaphobia’, or the fear of migraines.

This article aims to define the term ‘cephalalgiaphobia’ and develop a set of indicators to identify this condition. The research team formulated a definition and criteria for cervico-cephalalgiaphobia and a number of expert clinicians from various disciplines appraised the definition and criteria for content validity. The study also enrolled 134 manual physical therapists assigned to collect data on the characteristics of patients with headache meeting the criteria for cervicogenic headache. Patient inclusion criteria: 1) 18-50 yr old, 2) headaches longer than 6 months, 3) unilateral dominant headache, 4) headache with ipsilateral neck, shoulder, or arm pain, 5) pain beginning in the neck, 6) headache aggravated by neck movement or posture, 7) pressure pain over the upper cervical/occipital region, 8) restricted neck ROM, 9) varying duration of headache episodes, 10) previously treated with manual therapy.

Eight indicators were set to identify cervico-cephalalgiaphobia and used as subjective questioning: 1) use of meds due to fear of headache, 2) short-term positive effects of previous manual therapy treatment, 3) long-term positive effects of previous manual therapy treatment, 4) interval between treatment become shorter, 5) fear of headaches will increase, 6) fear of ‘locked facet joints’ in the neck, 7) manual therapists confirms ‘locked facet joints’ in the neck as the cause of headache, and 8) increased frequency of manipulation.

Cervicogenic headache is a fairly common condition that we may see in the clinic; however, I have not considered screening for the possibility of fear, or the overuse of medications during a pain-free period in anticipation of a headache in these individuals. Interestingly enough in this study, previous manual therapists had confirmed a ‘locked facet joint’ was the cause of headache in all of the patients, suggesting that the therapist could play a role in a poor outcome with these patients.

This article certainly helps me to frame my subjective questioning more specifically for this patient population and brings to light possible contributing factors influencing outcome that I would not have otherwise considered. Have a read and share your thoughts.

Have any of these indicators been on your radar with these patients?

Have you picked up on any fear avoidances, fear of headache, or overuse of medication in previous patients with cervicogenic headache?

I don’t know that I’ve stated a ‘locked facet joint’ was the cause of a headache.

I do believe I’ve stated ‘poor posture’, or overuse, leading to muscle and joint tightness could cause headaches. What are some explanations you have provided in the past? In your reflection, could you see your explanations having any negative impact on the patients’ recovery?

What kind of an impact could cephalalgiaphobia have on a patients’ outcome?

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[Kyle Feldman]

I had a lack of understanding of patients with cervicogenic headaches until listening to Cesar fernandez de las penas lecture 2 weeks ago.
There is so much behind a patient with headaches that you have to take a step back and subjectively understand what the patient is understanding first.

The easy way out is to assume that the patient is just afraid of headaches, but like the chronic pain patient, we need to assume that what they are saying is true and we are the only ones that believe them.

[Nick Law]

Interesting article Sean, thanks for posting.

I have very limited exposure treating patients whose primary complaint was headaches. Thus, I cannot say that I have much interaction with patients who seemed unduly fearful of the experience of a headache.

I did treat one patient over the past year who seemed to suffer from classic cervicogenic headache, though it was chronic in nature. He seemed very reasonable and his symptoms seemed so blatantly mechanical, and so I never queried further regarding his fears or anxieties regarding his headaches. I would say his outcome was modest, but think that it could have possibly been improved if I had questioned him more in this area/provided further education on nervous system sensitivity that is responsible for perpetuating his symptoms.

There is no doubt that a takehome point from the entire residency and that we have discussed several times via journal club/on this board is that vernacular is huge. “Locked facet joint” sure doesn’t sound good. Definitely signals a need for an external agent (e.g., YOU the PT), to “unlock” it. Even a simple change from “locked” to “stiff” sounds and feels very different.

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