Osteopathic principles and practice/osteopathic

Osteopathic principles andpractice/osteopathicmanipulative treatmentconsiderations in cephalgia

MICHAEL L KUCHERA, DO

ephalgia and osteopathic manipula-k-4 tive treatment (OMT) have playedimportant roles in the history and success ofthe osteopathic medical profession. Tradi-tional history links the childhood headachessuffered by osteopathic medicine's founder,Andrew Taylor Still, MD, to his successfulsearch for a mechanical solution for cephal-gia. A.T. Still later wrote about episodicheadache "shut-off" sites in muscle andbones of the neck, upper dorsal, lumbar,sacral, and coccygeal regions.1

Today, although OMT is most com-monly used in the treatment of somaticproblems including back pain andheadache, it is also adjunctively useful inproviding homeostatic support of patientswith systemic problems. 2,3 Thus, OMTplays either a primary or adjunctive role inthe management of headache, dependingon cause.

Rational osteopathic treatment of thepatient experiencing headaches integrates

Dr Kuchera is professor and chairman, Depart-ment of Osteopathic Theory and Methods/Osteopathic Manipulative Medicine, KirksvilleCollege of Osteopathic Medicine, Kirksville, Mo.

Correspondence to Michael L. Kuchera,DO, Acting Vice President for Academic Affairsand Dean, Kirksville College of OsteopathicMedicine, 800 W Jefferson, Kirksville, Mo 63501.

osteopathic principles and practice (OPP)and OMT:q to address those psychic stressors thatinitiate or aggravate the headache;q to modify functional and biomechani-cal stresses placed on structures capableof acting as pain generators;q to seek to enhance homeostatic mech-anisms important in affecting the under-lying pathophysiology of primary orreferred cephalgia.

Patient-centered guidelinesThe osteopathic physician's evaluation ateach patient encounter determines theappropriateness of individualized OMT.Historical and physical findings lead to apresumptive diagnosis and appropriatemanagement. Subsequent evaluations arelikely to evolve and modify the patient'scare based on response to treatment andspecific somatic dysfunction. Documenta-tion of a separate and definable evalua-tion and management is expected in thefollow-up of patients with headache whenOMT is incorporated.

Osteopathic practice guidelines for themanagement of any patient problem(including headache) consider both hostand etiologic factors. Both factors shouldbe considered in resolving primary andsecondary somatic dysfunction, inappro-priate neural stimuli, and homeostatic dis-

11. Ferrari MD, Odink, J, Frolich M, et al. Methionine-enkephalin in migraine and tension type headache,Differences between classical migraine, commonmigraine and tension type headache, and changesduring attacks. Headache 1990;30:160-164.

12. Shimomura T, Takahashi K. Alteration of plateletserotonin in patients with chronic tension type headacheduring cold pressor test, and changes during test.Headache 1990;30:581-583.

13. Takeshima T, Takao Y, Urakami K, et al: Musclecontraction headache and migraine. Platelet activationand plasma norepinephrine during the cold pressortest. Cephalalgia 1989;9:7-13.

14.Peters BH, Fraim CJ, Masel BE: Comparison of 650mg aspirin and 1000 mg acetaminophen with eachother, and with placebo in moderate severe headache.Am J Med 1983;74:36-42.

15. Diamond S. Ibuprofen versus aspirin and placeboin the treatment of muscle contraction headache.Headache 1983;23:206-210.

16.Diamond S, Freitag FG, Balm 11C, Berry DA. the useof a combination agent of ibuprofen and caffeine in thetreatment of episodic tension type headache. Cepha-lalgia 1997;17:278.

17. Diamond S, Freitag FG, Vaura I. Bromfenac, Fior-inal and placebo in tension type headache. HeadacheQuarterly 1988. In press.

18. Friedman AP, DeSerio FJ. Symptomatic treatmentof chronically recurring tension type headaches: Aplacebo-controlled, multicenter investigation of Fioricetand acetaminophen with codeine. Clin Thor 1987;10:69-81.

19. Friedman AP, Boyles WF, Elkind AH, et al. Fiorinalwith codeine in the treatment of tension headache—thecontribution of the components to the combination drug.Clin Ther 1988;10:303-315.

20. Diamond S. Biofeedback and headache. Headache1979;19:180-184.

21. Diamond S, Medina J, Diamond-Falk J, DeVeno T.The value of biofeedback in the treatment of chronicheadache: A five-year retrospective study. Headache1979;19:90-96.

22. Greenman PE. Manipulation and mobilization. In:Tollison CD, Kunkel RS, editors. Headache Diagno-sis and Treatment. Baltimore, Md: Williams & Wilkins,1993; pp 347-355.

23. Freitag FG, Diamond S, Solomon GD. Antide-pressants in the treatment of mixed headache: MAOinhibitors and combined use of MAO inhibitors and tri-cydic antidepressants in the recidivist headache patientIn: Rose FC, editor. Advances in Headache Research.London, UK: John Libby & Company; 1987; pp 271-275.

Osteopathic manipulative treatment (OMT) can be incorporated as an effectivetool in addressing factors that initiate or aggravate headache. It has a role inmodifying functional biomechanical stresses placed on pain-generating struc-tures, limiting the reflex effect of psychoemotional stressors, and in enhancing home-ostatic mechanisms important in affecting the underlying pathophysiology ofprimary or referred cephalgia. In the hands of an osteopathic physician who rec-ognizes contraindications and who selects and effectively applies appropriatetechniques and follows the patient's response to treatment, OMT is safe andeffective.

(Key words: cephalgia, headache, osteopathic manipulative treatment,osteopathic principles and practice, somatic dysfunction, vascular dysfunction, vis-ceral dysfunction, segmental facilitation, pain referral)

S14 • JAOA • Vol 98 • No 4 • Supplement to April 1998 Kuchera • OPP/OMT considerations in cephalgia

turbances.4(p1021 ) This article presents pos-sible guidelines for management of differ-ent classifications of patients withheadache.

Structure-function relationshipsThe brain itself is insensitive to pain.Headache arises from stimulation ofextracranial and intracranial pain-sensi-tive structures that refer pain to variousbut fairly predictable sites. Thus, pain mustbe viewed as a symptom, not as a diag-nosis. Etiology constitutes a nearly end-less list of possible diagnoses—systemic,biomechanical, vascular, and psychoemo-tional. Recognition of the structuresinvolved, their innervation, sources of stim-ulation that create nociception, and thereflex linkages within the neuromuscu-loskeletal system provides significant insightinto diagnosis and treatment from an osteo-pathic perspective. This article deals large-ly with headaches arising from arthrodialand myofascial somatic dysfunction; how-ever, many of the vascular, visceral, andpsychoemotional causes of headache alsopresent with secondary somatic clues2 thatlend themselves to adjunctive OMT.

The Table links common somatic andvisceral structures with the type ofheadache or headache syndrome withwhich they are associated. The osteopath-ic musculoskeletal examination providesa distinctive and highly significant addi-tion to more traditional history and phys-ical diagnostic methods used in identifyingthe primary structural source of theheadache. In specifically addressing func-tion of the identified structures, OMT isdesigned to decrease nociception and sym-pathetic hyperactivity while improvinglymphaticovenous drainage. Additionally,in viscerosomatic referral conditions, OMTof somatic dysfunction found from thebase of the skull down to the second cer-vical nerve (C2) empirically decreasesreferred vagally mediated symptoms whileappropriate measures are directed towardtreatment of the primary visceral problem.

Osteopathic manipulative treatmentintegrated into regimens addressing dys-function of structures recognized to bepain generators in patients with headacheachieves one or more of three obvious ben-efits. First, OMT reduces afferent noci-ceptive stimulation arising from thosesomatic structures (Table). Second, OMTreduces segmental facilitation and associ-ated hypersympathetonia; improves lym-phaticovenous drainage; interrupts myofas-cial "trigger" reflex arcs; and enhances

appropriate homeostatic response tomechanical and physiologic stressors.Third, palpatory diagnosis and OMT havepowerful psychophysiologic effects rangingfrom muscle relaxation to reduction of cir-culating catecholamines.

OMT-integrated osteopathic treatmentregimens typically follow the general for-mat shown in the Figure.

Headaches arising fromthe somatic systemDysfunction or irritation of somatic struc-tures constitutes the majority of causes ofheadache. Somatic dysfunction is definedas "impaired or altered function of relatedcomponents of the somatic (body frame-work) system: skeletal, arthrodial andmyofascial structures, and related vascular,lymphatic and neural elements."' Thus,headaches arising from the somatic sys-tem can be further subdivided into eachof these three related components. Super-ficial extracranial structures of the headand neck are richly innervated. Frontalheadaches are referred by stimulation ofstructures sharing innervation by thetrigeminal nerve (CN V), which also inner-vates the dura lining the anterior (CN V1)and middle cranial fossae (CN V2) as wellas the falx cerebrum. The superior reflec-tion of the tentorium cerebelli, innervat-ed by cranial nerve V3, also refers painanteriorly from mutually innervated struc-tures located more posteriorly. Posteriorheadaches are most often referred fromstructures sharing C2 innervation. C2specifically innervates part of the posteriorcranial fossa and the inferior reflection ofthe tentorium cerebelli. The C2 fibersanatomically linked to the vagus nerve(CN X) and can concomitantly precipi-tate nausea and vomiting from irritatingthese structures. The reverse is also true.Irritation of many structures supplied bythe vagus nerve can be associated withposterior headaches.

Somatic dysfunction from skeletal,arthrodial, and dural structures producesheadaches that are typically nonthrobbingunless the somatic cause creates pressure onan adjacent arterial structure. Nociceptionarising from skeletal or ligamentous struc-tures creates sclerotomal pain, describedas a "deep, dull toothache-like pain."Referred sclerotomal pain from somaticdysfunction in the cervical or cranialregions may create anterior or posteriorheadache (or both), depending on thesource of the stimulation. A CN V distri-bution is possible through extensive cervi-

cal neural connections to the trigeminalnucleus extending well down into the cer-vical spine. Likewise, C2 somatic dys-function as well as dysfunction of the occip-itomastoid (OM) suture or occipitoatlantaljoints have direct anatomic neural con-nections capable of referring pain in a CNX distribution.

Myofascial headaches can be furthersubdivided into those arising from mus-cle trigger points or myofascial strain sec-ondary to posture or other overuse symp-toms. Muscles are not just benign paingenerators. Through entrapment phe-nomena, proprioceptor misinformation,and other related neural, vascular, andlymphatic mechanisms, secondary signsand symptoms of myofascial somatic dys-function often complicate the differentialdiagnosis of headache.

Precipitating or perpetuating factors forsomatic headaches include a variety ofbiomechanical stressors as well as the phe-nomenon of segmental facilitation thatlinks somatic headaches to both visceraland psychoemotional causes. Postural-gravitational strain is chief among thechronic biomechanical perpetuating fac-tors in somatic headaches.6'7 Accentuationof a postural curve in any of the three car-dinal planes creates not only increased loadon spinal facets and postural antigravitymuscles but also increased segmental noci-ceptive input associated with lower thresh-olds to other afferent stimuli (spinal seg-mental facilitation). Segmental facilitationis, in turn, responsible for focusing psy-choemotional stress and visceral afferentimpulses to somatic structures. Spinal facil-itation results in increased sensitivity ofperipheral nociceptors. It also increasesthe sensitivity of central pain pathways,thus heightening muscle contraction anddepression. There also occurs a reactivehypersympathetic response that aggravatessomatic stimuli through further vasocon-striction and peripheral biochemicalchanges.

Osteopathic manipulative treatmenthas long been recognized as having theability to relax muscle tension, eliminatemyofascial trigger points, and correct skele-tal-arthrodial somatic dysfunction. Its pri-mary or adjunctive use in modifying pos-tural-gravitational strain is also wellestablished. 8-" As these underlying com-ponents are corrected, peripheral nocicep-tion is decreased along with segmentalfacilitation. In cephalgia arising fromsomatic dysfunction, OMT effectively elim-inates the cause.

Kuchera • OPP/OMT considerations in cephalgia JAOA • Vol 98 • No 4 • Supplement to April 1998 • S15

TableStructure-and-Function Interrelationships in Cephalgia

Structure involved

L Extracranial

q Scalp and neck muscles

q Cranial bones & sutures

q Cervical vertebral units

H Mucosa of sinuses

q Eyes

q Stomach

q Lung/bronchi

q Blood vessels

q Vertebral artery and/orimmediate branches

q Occipital nerve

Stimulation2,19

Sustained muscle contraction(reflex or psychogenic); localmyofascial point (micro-trauma/macrotrauma, reflex,or overuse)

Impaired or alteredcraniosacral motion; micro-trauma/macrotrauma

Impaired or altered cervicalmotion; microtrauma/macro-trauma

Inflammation; pressurechange

Inflammation; increasedintraocular pressure

Reflex referral

Reflex referral

Inflammation; dilation

Dissection/thrombus

C1 to C2 joint pathology(cervical rheumatoid orosteoarthritis, fracture orcarcinoma)

Headache syndrome

Muscle contraction headache;tension-type headache;myofascial (Travell) triggerpoint (TP) headache7(P15)

Cranial headaches; cephalgiapost–head trauma

Cervicogenic headaches;spondylogenic headaches

Referred sinus headaches

Iritis; glaucoma

Gastric headache with or with-out nausea and vomiting

Pulmonary headache

Migraine; cluster headache(also intracranial dilation);temporal arteritis

Wallenberg syndrome; locked-in syndrome (posteriorheadache)

Occipital neuralgia

OPP/OMraPProach206,2o

Decrease stress/tension; relaxmuscle contraction; eliminatemyofascial trigger points as wellas C1, C2, C4, C5, occipito-mastoid, squamosal, infraorbital,and nasal Jones' counterstrainpoints; correct cervical andupper thoracic somatic dysfunc-tion; improve lymphaticovenousdrainage of head and neckstructures

Restore mobility betweencranial bones; remove somaticdysfunction

Restore mobility and/or stabilityof cervical vertebral units;remove somatic dysfunction

Modify CN V nociception;decrease T1 through T4 sympa-thetic activity; improve lymphaticdrainage from head and neckstructures; thin sinus secretions(CN VII)

OMT adjunctive: improve lymph-aticovenous drainage; decreaseT1 through T4 sympatheticnerves

OMT adjunctive: Calm (CN X),occipitoatlantal, atlantoaxial, C2,and occipitomastoid somaticdysfunction; OMT to T5 throughT9 and celiac ganglion

OMT adjunctive: calm (CN X),occipitoatlantal, atlantoaxial,C2, and occipitomastoidsomatic dysfunction; OMT toT2 through T6

Decrease T1 through T4 sympa-thetic nerves; improve lymphati-covenous drainage; calm CN Xto decrease vomiting/nausea

OMT contraindicated

OMT to restore motion anddecrease somatic afferent stim-uli from occipitoatlantal throughC3 (which have connections togreater and lesser occipitalnerves and CN V, CN IX, andCN X)OPP/OMT = osteopathic principles and practice/osteopathic manipulative treatment.


Table continuedStructure-and-Function Interrelationships in Cephalgia

Structure involved Stimulation2,19 Headache syndrome OPP/OMT* approach2,16,20

Intracranial

q Blood vessels (andadjacent dura)

q Blood vessels (andadjacent dura)

q Middle meningeal arteryand environs at restrictedsphenosquamous pivot

q Dura (and adjacent bloodvessels)

Impaired or alteredtemporosphenoidal motion;vascular irritation; autonomiccomponent

Cranial or spinal duralirritation; pressure on cranialdura; dural strain (traction/displacement) from craniumto sacrum

Hypoxia; hypoglycemia; hyper-thermia: hyperthyroidism;hangover; severe hyperten-sion; posttraumatic migraine

Meningitis; subarachnoidhemorrhage

Posttraumatic middlemeningeal "migraine"

Dural strain headaches; braintumor; hematoma; abscess;hydrocephalus; post–lumbarpuncture headaches—posterior cranial fossa (CNX/C2 distribution headache);middle or anterior cranialfossae (CN V distributionheadache)

OMT adjunct or primary:decrease T1 through T4sympathetic hyperactivity

Relative contraindicationto OMT

Restore motion at spheno-squamous pivot; balancemembranous/dural tension

OMT adjunctive or primary:remove cranial restrictedmotion; balancemembranous/dural tension;decrease T1 through T4sympathetic hyperactivity

Dilation

Inflammation

OPP/OMT = osteopathic principles and practice/osteopathic manipulative treatment.

Headache arising fromthe vascular systemAs previously stated, primary somatic dys-function is associated with dysfunction ofrelated neural, vascular, and lymphatic ele-ments. These aspects are, in turn, relievedwhen the primary skeletal, arthrodial, ormyofascial dysfunction is addressed withOMT or some other clinical treatment.After ruling out a vascular emergency, butbefore making the diagnosis of a primaryvascular headache, the osteopathic physi-cian should consider a palpatory muscu-loskeletal diagnosis and a trial of OMTto remove significant somatic dysfunction,which is often effective.

Vascular headaches usually aredescribed as throbbing and usually areaggravated by activity or by lowering thehead. Migraines are the most frequentlycited example of vascular headaches. Theosteopathic medical approach to these andother primary vascular headaches includesthe following considerations:■ Decrease aspects of sympathetic vaso-constriction on intracranial and extracra-nial vasculature by various means, includ-ing OMT to decrease T1 through T4segmental facilitation;

■ Reduce side effects of congestive phe-nomena by improving lymphaticovenousdrainage from head and neck structuresthrough the use of OMT to the base ofthe skull, anterior and posterior cervicalfascia, and structures making up the tho-racic inlet region;■ Involve the patient in prescription,dietary, stressor, and biomechanical self-improvement strategies to limit events thatmight incite primary vascular events. Thiscombination of strategies has often beenseen to reduce frequency, duration, andseverity of primary vascular headaches.

Posttraumatic, unilateral throbbingheadaches may be confused with migrainebut lack many of the typical precipitatingevents. When migraine is due to somaticdysfunction that directly affects the envi-rons of the middle meningeal artery, OMTcan produce dramatic results. Thesepatients typically begin to have headachesafter trauma to the head, and they experi-ence intermittent unilateral throbbingmigraine-like headaches in the distribu-tion of the middle meningeal artery.Anatomically, this artery crosses in themeninges overlying the suture between thesphenoid and temporal bones at the site of

the change in articular bevel called thesphenosquamal pivot. This bevel changeallows minor pivotal motion. It also pro-tects the patient's middle meningeal arteryfrom frontal blows to the head by mini-mizing shearing forces between these twobones. After a frontal blow to the head, thesphenosquamal pivot is often restrictedimmediately adjacent to the artery andcorrection of the somatic dysfunction atthis site as part of a total treatment proto-col may eliminate recurrence of headache.

Among those who incorporate manualmedicine techniques in the treatment ofpatients with cephalgia, the most fearedvascular headache involves the vertebralartery. Patients with vertebral artery dis-section often present with a severe posteriorheadache progressing to sequelae rangingfrom dizziness, nystagmus, and ataxia tolocked-in syndrome or death. Vertebralartery complications in a predisposed sub-population are more likely to occur spon-taneously than with cervical manipulationin which the incidence is estimated at1:400,000 to 1:1,000,000 cervical manip-ulations.4(pp1015-1023) The occurrence of thisrare but serious complication has beenreduced by increased recognition of the


problem. Further reductions have beenaccomplished by general use of manipula-tive techniques to the upper cervical seg-ments which avoid significant backwardbending with rotation or which avoid high-amplitude rotatory thrusting (or both). If apatient has a severe posterior headacheand nystagmus or ataxia (or the historyof either occurring after cervical manipu-lation of any kind), then OMT is con-traindicated until after appropriate testingof the vascular and central nervous sys-tems.

Headaches referred fromthe visceraViscerally referred headaches share manyof the same patterns arising from stimula-tion of the dura. Poor localization and adeep toothache-like quality are common indescriptions of the headaches referred fromeyes, ears, nose, and sinuses (associatedwith central perception of trigeminal affer-ent stimuli from these structures) and frompharyngeal, cardiac, pulmonary, and uppergastrointestinal stimuli traveling along vagalafferent fibers. In addition to cranial nervereferral pathways, visceral afferent stim-uli are capable of initiating or maintainingsegmental facilitation (or both) and shouldtherefore be included in the list of cephal-gia perpetuating factors.

Treatment of visceral headaches beginswith appropriate diagnosis of the under-lying disorder. Positive findings in theinventory of systems are useful. In patientswith headache from visceral referral, cor-relation of the secondary somatic dys-function and the location of the headacheprovides valuable somatic clues to thesource of the problem. 2 Treatment of thesecondary somatic dysfunction reducesassociated headaches while also reducingsegmental facilitation and enhancing otherhomeostatic healing properties to theinvolved viscus. If the underlying problemin visceral headache fails to resolve throughprimary treatment or self-healing mecha-nisms, OMT may be either ineffective orshort-lived.

Psychoemotional (tension-type)headachesTension-type (or muscle contraction)headache is widely considered to be themost common headache. Unfortunately,this diagnosis is often assigned without thebenefit of the differential diagnosis afford-ed by specific palpatory diagnosis forsomatic dysfunction. Failure to performspecific palpatory diagnosis for somatic

dysfunction sometimes results in tension-type headache becoming a "wastebasketdiagnosis" of all types of headache whenprecipitated or worsened by emotional,spiritual, or mental stress. The observa-tion of a wastebasket diagnosis is sup-ported by electrophysiologic evidence thatcervical or scalp muscles are as likely asnot to show increased activity in those inwhom headache is diagnosed as "tension-type.”12

This observation is not to imply thatpsychic tension does not play an importantrole in producing headaches. Althoughsuch stress is difficult, if not impossible,to quantify, its manifestation as somatictension and heightened pain perception isa well-established phenomenon. Korr andDenslow 13 measured the physiologicimpact of psychic stressors on somaticstructures of subjects in a series of studiesunderlying the rational basis for the useof OMT in a number of clinical condi-tions. From these and other studies, Korr14noted that facilitated segments in the spinalcord act as "neurologic lenses" capable offocusing any stressor on segmentally-relat-ed somatic and visceral structures. Travelland Simons? P15 ) also implicate psychicstressors in precipitating or perpetuatingmyofascial trigger points (a form of somat-ic dysfunction). They also recognize thecentral importance of the spine in mediat-ing this relationship and advocate a dualapproach in reducing both peripheral affer-ent stimuli and emotional stress.

Osteopathic management of patientswith headache in which tension enhance-ment is suspected is two-pronged, consist-ing of elimination of segmental facilitationand education to reduce stress. Correctionof the "neurologic lens" is achieved byelimination of nociceptive sources respon-sible for segmental facilitation and centralsensitization. For the somatic, vascular,and visceral structures of the head, perti-nent facilitated segments are found from T1through T4 and are perpetuated by anysignificant somatic dysfunction superiorto T4 as well as significant visceral inputfrom head, eyes, ears, nose, and throatstructures, the respiratory and upper gas-trointestinal systems, and the heart. Patienteducation and other techniques to reducemental, spiritual, and emotional stressorsare then introduced and gradually rein-forced over time. Osteopathic manage-ment of patients with tension-typeheadache strives to assist the patient indealing with—and reducing—these intan-gible stressors as well as the facilitated seg-

ments that focus them onto the physicalsystem.

ContraindicationsOsteopathic manipulative techniques areamong the safest medical treatment modal-ities a physician can provide,4(P1015) with avery low risk-to-benefit ratio in the treat-ment of headache. There are few absolutecontraindications to OMT in the patientwith cephalgia. Patients with suspectedacute cervical or cranial fractures or simi-lar pathologic conditions should not havecervical OMT. Also, patients with severerheumatoid arthritis are at particular riskto cervical direct-method OMT techniquesbecause the odontoid ligament is likely tobe weak and susceptible to rupture withresultant compromise of the spinal cord.Stability at this site also increases the riskin patients with Down syndrome. To reit-erate, direct-method techniques to theupper cervical segments should absolutelybe avoided in patients with preexistingcompromise of either of the vertebral arter-ies.

It is important to recognize the differ-ence between a technique that is con-traindicated because of its significant poten-tial to cause a true pathophysiologiccomplication as distinguished from a tech-nique that may exacerbate presentingsymptoms or cause production of a tem-porary symptom. In the latter instance,transient side effects from the use of OMTin a patient with headache may includeexacerbation of pain, cervical myalgia withor without spasm, dizziness or lighthead-edness, and nausea or vomiting (or both).Such symptoms may constitute relativecontraindications to a specific technique,and such contraindications may be in partdue to the skill and expertise of the physi-cian. Also, physicians should specificallyavoid those techniques that cause neuro-logic symptoms during the set-up phase orthat cause significant guarding on the partof the patient. Appropriate soft tissue man-agement, selection of the most appropri-ate method and activating force for the tis-sue characteristics of the patient, andexperience in applying OMT are key factorsin reducing side effects from OMT.

Treatment of somatic dysfunctionin the patient with headacheIt is beyond the scope of this article todetail the voluminous number of tech-niques and approaches that are available toosteopathic physicians in treating somaticdysfunction. These treatment techniques


■ Provide patient education,focusing on:

q Stress reductionq Wellness promotion

■ Provide OMT/medication to enhancehomeostasis related to anymedication or lifestyle risk factorindicated by examination

■ Take history■ Do physical,examination■ Do osteopathic structural

examination

•

Visceral referral OMT(See Table)

■ Make presumptive diagnosis

■ Repeat palpatory diagnosis■ Correct compensatory, adaptive, or

other significant somatic dysfunction

■ Diagnose and manage:q Any underlying postural, habitual,

or referral-siteq Precipitating or perpetuating factors

Follow-up

Primary somatic cephalgiaOMT (See Table)

- - - Vascular cephalgia OMT(See Table)

PATIENT PRESENTS WITH "HEADACHE SYMPTOMS" Figure. General outline of osteopathicmanagement of patients presenting withcephalgia. OMT = osteopathic manip-ulative treatment.

are readily available and can be found inTravell and Simons' Myofascial Pain andDysfunction: A Trigger Point Manual,?Jones' Strain and Counter-Strain, 15 and inthe Foundations for OsteopathicMedicine, 16 and other works. 17,18

One additional aspect of integratingOMT in the care of patients with cephal-gia is to consider the medications that thepatient is taking. They may be overusingnonsteroidal anti-inflammatory drugs andover-the-counter analgesics, and the sideeffects or toxicity of these agents may con-tribute to visceral dysfunction and somat-ic manifestations amenable to OMT orosteopathic management.

CommentOsteopathic management of patients withbenign headaches begins with a completeassessment of the patient and establish-

ment of a presumptive diagnosis. Treat-ment goals emphasize eliminating somat-ic, visceral, and psychic stimuli, as well asthe regions of segmental facilitation whichfocus these stimuli into pain patterns.Osteopathic manipulative treatment isapplied to and for the patient, not for thedisease. As a primary or adjunctive modal-ity, OMT provides a powerful and dis-tinctive tool in achieving these goals. Fur-thermore, OMT is safe and effective in thehands of an osteopathic physician capa-ble of recognizing contraindications, select-ing and effectively applying appropriatetechniques, and following the patient'sresponse to care.

References1. Still AT. Osteopathy, Research and Practice.Kirksville, Mo, Journal Printing Co, 1910, p 358.

2. Kuchera ML, Kuchera WA. Osteopathic Considera-tions in Systemic Dysfunction, 2nd edition. Columbus,Ohio: Greyden Press; 1994.

3. DiGiovanna EL, Schiowitz S, editors. An OsteopathicApproach to Diagnosis and Treatment, 2nd edition.Philadelphia, Pa: JB Lippincott Co; 1997.

4 DiGiovanna Kuchera M1_, Greenman PE. Efficacyand complications. In: Ward RC, editor. Foundations forOsteopathic Medicine. Baltimore, Md: Williams &Wilkins, 1997, pp 1015-1023.

5. Educational Council on Osteopathic Principles: Glos-sary of osteopathic terminology. In: AOA Yearbookand Directory of Osteopathic Physicians. Chicago, Ill:American Osteopathic Association, 1998.

6. Kuchera ML. Gravitational stress, musculoligamen-tous strain and postural alignment Spine State of ArtRev 1995;9(2):463-490.

7. Travel! JG, Simons DG. Myofascial Pain and Dys-function: The Trigger Point Manual Volume I. Balti-more, Md: Williams & Wilkins; 1983.

8. Peterson B, editor. Postural Balance and Imbalance.Newark, Ohio: American Academy of Osteopathy;1983.

9. Kuchera WA, Kuchera ML. Osteopathic Principles inPractice, 2nd edition. Columbus, Ohio: Greyden Press;1994.

10. DiGiovanna EL, Schiowitz S, editors. An Osteo-pathic Approach to Diagnosis and Treatment, 2nd edi-tion. Philadelphia, Pa: JB Lippincott Co; 1997.

11.Kuchera ML Treatment of gravitational strain patho-physiology. In Vleeming A, Mooney V, Snijders CJ,Dorman TA, Stoeckart R, editors. Movement, Stabilityand Low Back Pain: The Essential Role of the Pelvis.New York, NY: Churchill-Livingstone; 1997; pp 477-499.

12. Pikoff H. Is the muscular model of headache stillviable? A review of conflicting data. Headache1984;24(7)1 84-194.

13.Denslow JS, Koff IM. In: Peterson B, editor. The Col-lected Papers of Irvin M. Korr. Colorado Springs, Colo:American Academy of Osteopathy, 1979.

14. Korr IM. Somatic dysfunction, osteopathic manip-ulative treatment and the nervous system: A few facts,some theories, many questions. JAOA 1986;86(2)1 09-114.

15. Jones LH: Jones' Strain-Counterstrain. Boise, Id:Jones' Strain-Counterstrain, Inc; 1995.

16. Ward RC, editor. Foundations for OsteopathicMedicine. Baltimore, Md: Williams & Wilkins; 1997.

17. Kimberly PE. Outline of Osteopathic ManipulativeProcedure, 3rd edition. Kirksville, Mo: KCOM Press;1980.

18. Greenman P. Principles of Manual Medicine. Bal-timore, Md: Williams & Wilkins; 1989.

19. Stein JH, editor. Internal Medicine, 3rd edition.Boston, Mass: Little, Brown & Co; 1990; p 1917.

20. Magoun HI Sr. Osteopathy in the Cranial Field,2nd edition. Kirksville, Mo: Journal Printing Co; 1966.


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