Osteopathic Manipulative Treatment Considerations in Tension-Type Headache

Submitted June 6, 2019; accepted August 5, 2019. T ension-type headache (TTH) is estimated to affect 65.6 million people in the United States, exceeding the number of those affected by migraine. It is categorized as episodic, frequent episodic, or chronic, with significant disability and resistance to medical management associated with the latter types. The pain associated with TTH is commonly bilateral and is often described as a dull, band-like sensation around the frontal, temporal, and suboccipital regions of the head; the neck may also be affected. Tension-type headache is most commonly triggered by mental stress and muscle tension, which suggests a mind-body-spirit connection that may be optimally treated with an osteopathic approach. Superficially, the posterior neck is covered in deep cervical fascia. This fascia attaches at the midline to the external occipital protuberance, nuchal ligament, and the seventh cervical spinous process. It then spreads laterally to envelop the trapezius muscle before attaching to the scapula. The deep muscles of the posterior neck include the splenius, iliocostalis, longissimus, semispinalis, and multifidus. As a group, these muscles are extensors and rotators of the head and cervical spine, and they may become hypertonic and overactive in chronic forward-head positions. The suboccipital muscle group comprises the rectus capitis major and minor and the obliquus capitis superior and inferior, attaching to the occiput, atlas, and axis, and it may play a role in headache by exerting tension on the dura mater through myodural bridges. Innervation to the posterior head and neck is provided by the cervical spinal nerves, with a large area of the posterior head receiving its sensory innervation from the greater occipital nerve (dorsal ramus of C2), third occipital nerve (dorsal ramus of C3), and the lesser occipital and great auricular nerve (ventral ramus of C2). The trapezius and semispinalis capitis muscles are pierced by the greater occipital nerve as it courses superiorly to transmit sensory innervation from the posterior scalp. It is postulated that compression of the greater occipital nerve, facilitated by the hypertonic trapezius and semispinalis capitis, causes referred pain to the dura mater by a convergence of afferents from the trigeminal nerve and the greater occipital nerve in the dorsal horn of C2. Sensory innervation to the face occurs primarily via the 3 divisions (ophthalmic, maxillary, and mandibular) of the trigeminal nerve. Although the pathogenesis of TTH is not well understood, current theories implicate cervical myofascial trigger points, forward head posture, restrictions in cervical mobility, and referred pain. Somatic dysfunction of the muscles of the neck or suboccipital region may contribute to headache via tissue texture changes, restriction of motion, referred pain, and tenderness. A review of the literature shows improvement in pain, frequency, and headache disability index scores with manual therapy and osteopathic manipulative treatment (OMT). One randomized placebocontrolled trial showed significant improvements in the frequent episodic subtype of TTH after OMT. In another study, soft tissue and articulatory techniques were shown to reduce depression and anxiety and improve headache in patients with TTH, highlighting the interrelatedness of mind and body in this condition. Two OMT techniques that may be safe and effective in the prevention and management of TTH are bilateral cervical stretch and contralateral traction, as demonstrated in the video. Contraindications to these soft-tissue OMT techniques in the cervical region include open wounds, acute cervical fractures, cutaneous infections, local malignancy, and serious vascular OMT MINUTE