A Case of Chronic Tension-Type Headache Treated with Multimodal Physiotherapy Based on a Biobehavioral Approach
A 34-year-old woman with a pre-diagnosed chronic tension-type headache (CTTH) presented to the clinic for moderate bilateral headaches (at least 4-5 days a week), deep burning sensation and neck pain that she was experiencing for more than a 11 months. Although the symptoms were not worsened with rigorous activity, she had experienced increased sensitivity to light. She had consumed over-the-counter pain relievers, but in vain. The patient weighed 60 kg that was appropriate for her height (BMI <23; indicating normal height-weight balance). Around three years ago, she was treated with methocarbamol plus acetylsalicylic acid and NSAIDs, had no improvement in the symptoms. Moreover, her symptoms were slightly relieved after manual therapy, but had the short term effects.
The most likely diagnosis of this presentation is
- Tension-type headache
Tension type headache (TTH) is the most common headache, affecting 0.5 to 4.8 % of the worldwide population.1 It shares quite a similar clinical features of common manifestations of muscle referred pain. The severity of TTH may vary from episodic/ moderate to chronic. Episodic TTH exhibits higher levels of peripheral excitability whereas chronic TTH clearly shows central sensitization manifestations.2 Although the corresponding mechanism remains unclear, increased peripheral levels of pro-inflammatory cytokines may act as mediators of several chronic pain disorders. Moreover, Domingues RB, et al found that interleukin-8 was increased and monocyte chemoattractant protein-1 was higher in patients with TTH, suggesting that pro-inflammatory mechanisms may participate in TTH pathophysiology. 3 Understanding the possible triggers in TTH, muscle hyperalgesia, and widespread pain sensitization, may help to develop better management regimes and possibly prevent TTH from developing into more chronic conditions. 4 Cumulative evidences suggest a combination of manual therapy (MT) and therapeutic exercise as an effective measure in reducing the medication intake and minimizing the frequency and intensity of headaches.5
A general physical examination revealed a forward head posture and pain during cervical extension and lateral bending and the ranges of cervical motion were normal. In addition, stiffness and limited cervical accessory mobility were observed and manual palpation indicated the presence of myofascial trigger points in the neck muscles. The assessment of neck flexor endurance (isometrically and against gravity) using the neck flexor muscle endurance test showed moderate reliability with a time endurance of 24.1±12.8 seconds for neck pain.
The treatment aimed to regain and maintain a mobility to the cervical vertebrae and to relax the neck muscles. To achieve the treatment goals, a multimodal physical rehabilitation approach, including manual therapy, motor control therapeutic exercise (MCTE) and therapeutic patient education was undertaken. The first two weeks of treatment involved total four sessions, two sessions a week, followed by one session of 45 minutes a week. Therapeutic patient education involved five interactive sessions lasting for 15 minutes each. These sessions included talks supported by the presentations conveying the importance of good ergonomics, self-treatment approaches (including stretching, auto-traction, diaphragmatic breathing and relaxation techniques), the neurophysiological bases of pain and the importance of the patient’s involvement in the treatment. The MCTE was taught in the clinic and advised to practice at home. The MCTE approach included, craniocervical flexors exercise, co-contraction of the flexors and extensors and a synergy exercise to retain the strength of the superficial and deep flexor. Total eleven sessions of treatment including manual therapy, motor control therapeutic exercise (MCTE) and therapeutic patient education (TPE) were applied in 72 days.
Therapeutic management of TTH should involve a multimodal approach including pharmacological and non-pharmacological interventions to reduce the symptoms. The ideal treatment approach aims to reduce the number of TTH attacks, and prevent or delay the progression.2 In recent years, non-pharmacological treatment approaches have been preferred over pharmacological treatments, as effective alternative interventions. 1
The present case was successfully evaluated and treated with multimodal therapy based on a biobehavioral approach. Pain catastrophizing refers to a cognitive factor that implies an exaggeration of the perceived threat of either a real or anticipated pain experience. This psychological construct is linked to motor disturbances, such as reduced function, impaired quality of life, impaired of exercise capacity, increased recovery time, disability and higher drug intake. Evidences have proved the importance of increased neck flexor endurance in patients with CTTH. 5
Espí-López GV and colleagues revealed that although individual manual therapy treatments impose a positive change in headache features, measures of photophobia, photophobia and pericranial tenderness can only be improved by combining the treatments suggesting that combined treatment is the most appropriate for symptomatic relief of TTH. 6
In the present case, a multimodal physical approach based on a biobehavioral approach, combining manual therapy, TPE and MCTE, resulted in a substantial reduction in pain severity, pain catastrophizing, disability and improved overall quality of life.
A multimodal physical approach based on a biobehavioral approach, combining manual therapy, TPE and MCTE, can lead to a substantial reduction in pain severity, pain catastrophizing, disability and improve overall quality of life.
- Yu S, Han X. Update of chronic tension-type headache. Curr Pain Headache Rep. 2015 Jan;19(1):469.
- de Tommaso M, Fernández-de-Las-Peñas C. Tension Type Headache. Curr Rheumatol Rev. 2015 Dec 30.
- Domingues RB, Duarte H, Rocha NP, Teixeira AL, et al. Increased serum levels of interleukin-8 in patients with tension-type headache. Cephalalgia. 2015 Aug;35(9):801-6.
- Arendt-Nielsen L, Castaldo M, Mechelli F, Fernández-de-Las-Peñas C. Muscle Triggers as a Possible Source of Pain in a Sub-group of Tension Type Headache Patients? Clin J Pain. 2015 Nov 6.
- Beltran-Alacreu h, Ibai Lopez-de-Uralde-Villanueva, and Touche RL. Multimodal Physiotherapy Based on a Biobehavioral Approach as a Treatment for Chronic Tension-Type Headache: A Case Report. Anesth Pain Med. 2015 Dec; 5(6): e32697.
- Espí-López GV, Rodríguez-Blanco C, Oliva-Pascual-Vaca A, Benítez-Martínez JC, Lluch E, Falla D. Effect of manual therapy techniques on headache disability in patients with tension-type headache. Randomized controlled trial. Eur J Phys Rehabil Med. 2014 Dec; 50(6):641-7.