Migraine (with and without aura) is one of the most common disorders in the world, often familial in nature, and affects an average of 10-15% of the world's population.

It mainly affects women of childbearing age and is more common between the ages of 25 and 55, although it can also occur in childhood.

This is a common and debilitating form of headache. characterized by recurrent episodes of pain described as very intense and throbbing, often concentrated on just one side of the head, although it can sometimes involve both sides of the head.

Migraines tend to come on gradually, often involving only one side of the head, with pain concentrated in the forehead above the eye and temple. However, the headache may spread to both sides and worsen with movement, limiting the patient's daily activities.

Migraine can have a significant impact on the quality of life of those who suffer from it, often causing the inability to carry out normal daily activities during attacks due to the intense pain and discomfort associated with the symptom.

The exact causes of migraines are not fully understood, but it is believed that a combination of genetic, neurological, and environmental factors may contribute to the development of the condition. Changes in brain neurotransmitters, such as serotonin, may play a role in migraines, as may sensitivity to certain environmental stimuli and stress. Other factors that may trigger migraine attacks include hormonal changes, diet, sleep, and emotional stress.

The pain associated with migraine is often throbbing, intense, and localized to one side of the head.

Many migraine sufferers often find it difficult to tolerate bright lights and loud sounds during an attack, and many also experience nausea or vomiting during an episode.

It is also common for physical sensations such as tingling, numbness, or weakness to occur during a migraine attack.

Migraine may be accompanied by an aura , which consists of transient neurological symptoms such as visual, sensory, or speech changes that precede or accompany the headache attack, but we will go into this in more detail below.

Migraine management may require a multifactorial approach that includes symptomatic treatment during attacks, preventive therapies to reduce the frequency and intensity of episodes, and lifestyle modifications to manage triggers and improve overall well-being.

In summary, migraine is a complex and disabling condition that requires in-depth understanding and targeted treatment to improve patients' quality of life and reduce their daily impact.

Migraine is a common form of headache which can occur with or without aura. The main difference between migraine with aura and migraine without aura is the presence or absence of specific neurological symptoms called aura, which appear shortly before or at the beginning of the migraine itself.

Let's take a closer look at what this is all about.

As we mentioned earlier, migraine aura consists of a set of transient neurological symptoms that can precede or accompany a migraine attack. These symptoms are variable in nature and can involve vision, sensory sensitivity, language and other brain processes.

The aura can manifest itself in different ways and can be different from person to person.

The direct correlation between migraine and aura is demonstrated by the so-called “ Cortical Spreading Depression Theory (CSD) ” which represents an explanation for the episodes of “depression” (intended in a physiological and not emotional sense) of the electrical activity in the brain, which spreads through the cerebral cortex.

In simple words, this phenomenon consists of an initial phase of neuronal excitation followed by neuronal depression.

It is assumed that it all depends on an increase in cerebral blood circulation, followed by a decrease in certain areas. This increase and decrease in blood flow establishes a localized inflammatory process that reaches the fibers of the dura mater and causes the release of substances that activate the pain centers, establishing the headache .

Tension-type headache is the most common of the various forms of primary headache. It is more common in women than in men (90% of women reported at least one episode, compared to 70% of men), especially between the ages of 40 and 50. An estimate indicates that most people will have at least one episode of tension-type headache. during their lifetime.

It is usually characterized by a dull or pressing pain around the head and neck.

Although it is not usually as disabling as migraine, it can still have a significant impact on the quality of life of those affected.

Tension-type headaches often present as a feeling of pressure around the head on either side of the head, which can range from mild to moderate. The pain can be constant and persistent, with episodes lasting from a few hours to several days. Other common symptoms include muscle tension in the neck and shoulders, sensitivity to noise and light, and fatigue.

It is believed that a combination of physical, psychological and environmental factors can contribute to the development of tension headache but certainly, the main cause appears to be muscle contractures and joint stiffness in the cervical region or jaw.

Potential triggers include stress, muscle tension, poor posture, anxiety, depression, and lack of sleep.

Some individuals may be more susceptible to tension-type headache due to genetic factors or environmental factors.

• Pain: The main symptom of tension-type headache is pain around the head and neck. This pain is often described as a feeling of pressure, heaviness, or tightness, rather than a throbbing pain like in migraines. The pain may be bilateral and is usually mild to moderate in intensity.
• Duration: Episodes can last for several hours to several days. However, they rarely persist for more than one consecutive day.
• Consistency: Unlike migraine, tension-type headache tends to be constant and persistent over time, rather than having distinct, separate episodes.
• Muscle Tension: Many people may experience muscle tension in the neck, shoulders, and upper back.
• Sensory sensitivity: Although less common than migraine , some people with tension-type headaches may be sensitive to light (photophobia) or noise (phonophobia).
• Tension-type headaches may be accompanied by a general feeling of fatigue or tiredness, which can affect daily activities.
• Sleep disturbances: Some people may experience sleep disturbances, such as difficulty falling asleep or frequent nighttime awakenings.
• Stress and Anxiety: Emotional stress and anxiety can be triggers or contributors to tension-type headaches , and some people may experience increased pain during particularly stressful times.

Treatment of tension-type headache may include the use of pain medications for symptomatic relief during acute attacks, as well as preventative therapies and nonpharmacological interventions such as physical therapy (e.g., osteopathic manual treatments to relax neck and shoulder muscles), biofeedback, stress management, and cognitive behavioral therapy to reduce the frequency and intensity of episodes.

Proper management and manual treatment can help improve the quality of life and reduce the discomfort associated with this condition.

Among the causes of onset mentioned above, the most common and frequent usually lies in an incorrect postural pattern of the patient with alteration of the cervical biomechanics and consequent development of joint and muscular compensations affecting the cervical and surrounding region, often resulting from repeated cervical traumas over time (physical activity) or single ones (whiplash).

Simply put, the symptoms may be the direct consequence of a contracture of the suboccipital muscles which, as the word itself suggests, are in close contact with the base of the skull, influencing its movement, and of the posterior cervical muscles (splenius capitis and neck).

You understand well that a greater tension on this musculature can be directly reflected at the cranial level, causing symptoms that the patient feels mostly at the occipital, posterior level.

In the most severe cases, the same symptoms tend to also affect the parietal, lateral and superior regions, causing a helmet headache.

Other times, however, the headache may derive from a contracture of the muscles involved in chewing (temporal muscle, SCOM, pterygoids, suprahyoid and subhyoid), directly correlated to the functionality of the hyoid bone, involved in swallowing, which is directly related to the deep cervical fascia.

The latter, in turn, is inserted at the sternal and upper costal level and therefore an evaluation of all upper thoracic and costal biomechanics is essential, including all the muscles involved in breathing (pectoralis minor and major and scalene muscles, which are inserted directly at the cervical level).

The osteopath's goal in tension headache is to identify and reduce muscle contractures and any musculoskeletal dysfunctions that may contribute to the onset of symptoms.

In practical terms, therefore, osteopathic treatment can include various techniques, including:

• · Soft-tissue techniques, used to relax the muscles and prepare the cervical region for targeted treatment.
• · Joint mobilization techniques, aimed at improving cervical stiffness and increasing joint range of motion.
• · Traction and stretching techniques, useful for increasing flexibility and recovering the correct physiology of movement of the cervical spine.
• · HVLA techniques, which involve rapid, high-velocity, low-amplitude movement with the aim of improving joint mobility and reducing joint dysfunction in a specific body segment.

Osteopathic manipulative treatment, also known by the English acronym OMT “Osteopathic Manipulative Treatment” , is one of the non-invasive treatment strategies most sought after by patients thanks to the few possible side effects , which are much more widespread in the use and especially in the abuse of drugs.

In addition to the feeling of general well-being , osteopathy can act directly on the physiopathology of headaches thanks to the biomechanical, respiratory/circulatory, neurological and biopsychosocial models; thus contributing to reducing the use of drugs.

In the review published by Jara et al. (2022), 15 scientific articles published before 2022 were analyzed, including 13 RCTs “Randomised Controlled Trial”, which analyzed the efficacy of OMT in patients with headache ; in particular tension-type headache and migraine .

All studies showed statistically significant improvements in the various selected parameters post-treatment. Therefore, a general decrease in intensity, frequency and localized painful points was noted in patients suffering from headaches.

These results confirm that osteopathy can be a valid therapy for patients suffering from headaches, in terms of reducing frequency and intensity through myofascial release techniques, suboccipital muscle inhibition and techniques on the cranial sphere in particular.

Another important factor analyzed by some studies is how OMT is able to guarantee an improvement in the general quality of life by helping to limit the use of drugs used to reduce painful symptoms.

Cluster headache is a particularly debilitating form of headache. characterized by episodes of extremely severe pain, known as " clusters ," which occur in a cyclical and repetitive fashion.

This condition appears to be uncommon, with an estimated incidence of less than 0.5% in the male population and 0.1% in the female population.

It does not show any particular hereditary characteristic (in fact, cases of familiarity are between 2% and 7%).

It appears most commonly in adulthood (between the ages of 20 and 50) and represents a disabling pathological condition, with serious consequences on the patient's quality of life.

The pain often begins suddenly and without warning, quickly reaching extreme intensity. This pain is often described as stabbing, stinging, or piercing, and may be localized to one side of the head, behind the eye, or in the temporal region. Some people may also experience precursor symptoms, such as a feeling of discomfort or irritation in the affected area.

It is important to note that cluster headaches are characterized by episodes of extremely severe pain, known as " clusters ," that can occur regularly, even multiple times a day, during periods of active headache. During periods of remission, the pain may decrease or disappear completely, providing a moment of relief for patients suffering from this debilitating condition.

The exact causes of cluster headache are not fully understood, but it is believed that a combination of genetic, neurological, and environmental factors may contribute to the development of the condition.

It is important to note that this is a complex, multifactorial condition, and its exact cause can vary from person to person.

Cluster headaches are characterized by extremely severe, stabbing pain, often localized on one side of the head, behind the eye, or in the temporal region. The pain may be so severe that it is described as "the worst possible." Cluster headache attacks can last from 15 minutes to several hours and may occur several times a day, for weeks or months, followed by periods of remission.

During “ cluster ” periods, cluster headache attacks may occur regularly, even several times a day, making it extremely difficult for the patient to carry out normal daily activities.

Periods of remission can range from weeks to months, but the condition tends to be cyclical, with attacks recurring during “ cluster ” periods.

Other Associated Symptoms: In addition to severe pain, individuals with cluster headaches may experience additional symptoms such as red or watery eyes, nasal congestion or runny nose, ptosis (drooping of the eyelid), and facial sweating. These symptoms may be present during or before the headache attack.

The management and treatment of cluster headache requires a multidisciplinary and personalized approach to relieve pain and improve the quality of life of patients.

Treatment can be complex and may include the use of medications for symptomatic relief during acute attacks, as well as preventative manual therapies to reduce the frequency and intensity of episodes. Some patients may also require surgery or invasive procedures to effectively manage the condition.

Secondary headaches are those forms in which the headache it is a “ symptom ” of another pathology.

Therefore, they do not represent an autonomous disorder, but rather a sign of something more serious that is happening in the body and this clearly differentiates them from primary headaches .

They are generally secondary to:

• · Medical condition
• · Existing pathology
• · Trauma suffered

In some cases secondary headaches They can also depend on very serious pathologies that put the patient's life at risk and for this reason they must not be neglected, especially if they are associated with other symptoms.

Consequently, managing a patient with a suspected secondary headache may require immediate attention and sometimes even emergency intervention. The diagnostic phase must therefore be performed with great care to correctly identify the underlying cause of the headache.

Fortunately, secondary "dangerous" headaches represent only a small percentage of cases.

Some common causes of secondary headaches include:

• · Head trauma
• · Infections
• · Vascular anomalies
• · Brain tumors
• · Cerebral hemorrhages
• · Inflammatory diseases
• · Neck and temporomandibular joint (TMJ) disorders
• · Excessive intake of drugs
• · Other neurological and/or systemic pathologies

The incidence of secondary headaches varies depending on the underlying cause and the population being considered. Since these are caused by a wide range of different pathologies, traumas or medical conditions, the incidence can vary greatly.

The incidence of secondary headaches It can also vary based on age group and gender.

Symptoms of secondary headache may vary depending on the underlying cause.

The same is true for the severity and intensity of the headache perceived. Some patients may therefore experience mild or moderate headaches , while others may experience extremely severe symptoms that require immediate medical attention.

Similarly, depending on the underlying cause, secondary headaches may be associated with a number of additional neurological symptoms. These may include dizziness, visual disturbances, difficulty speaking, muscle weakness, numbness or tingling in one part of the body, and other symptoms related to nervous system involvement.

In some cases, however, they are accompanied by systemic symptoms such as fever, chills, nausea, vomiting, loss of appetite, fatigue and other signs of systemic disease.

It is also important to underline that the symptoms of secondary headache may persist or worsen over time if the underlying cause is not properly treated.

Accurate diagnosis of the underlying cause of secondary headache is essential for effective treatment. This may require a detailed medical evaluation, including the patient's medical history, physical examination, and, in some cases, specific diagnostic tests such as computed tomography (CT), magnetic resonance imaging (MRI), blood tests, or other laboratory tests.

Once the underlying cause of secondary headache is identified, treatment is aimed at managing or resolving the underlying medical condition. For example, treating infections, managing vascular or neurological conditions, removing brain tumors, or correcting structural abnormalities of the skull or neck may be part of the treatment plan.

Let's look at some of the most common cases of secondary headache together:

Headache is one of the most common symptoms following head trauma.

Acute posttraumatic headache it is a secondary headache which develops in the days following the trauma.

Interestingly, headache symptoms can appear up to a week after the trauma, as occurs in 86% of cases.

Pain associated with head trauma headache It can present itself in different forms, including headaches pressing, throbbing, or stabbing. This pain can affect different parts of the head and may be accompanied by other symptoms such as sensitivity to light or sound, nausea, and dizziness.

This particular condition may prove to be a temporary disturbance, resolving within a few days or weeks of the trauma, or in some cases, the pain may persist for a longer period and become chronic.

Headache from head trauma It can be aggravated by physical exertion or strong emotions, but tends to improve with rest and the use of analgesic drugs. In this regard, it is important to be careful not to abuse these drugs to avoid incurring a " medication overuse headache ".

Once serious anatomical damage to the skull and other pathological problems have been ruled out, osteopathic therapy can be effective in resolving chronic headaches present after head trauma. Through gentle manipulation and pressure on specific “trigger” points, this form of therapy aims to restore the balance of the skull and spine, thus contributing to the relief of symptoms associated with headaches from head trauma .

Cervical trauma headache It is a condition characterized by headache which develops following trauma or injury to the neck and cervical spine region.

This type of headache It can be caused by events such as "whiplash," in which the neck experiences sudden, violent acceleration and deceleration, as often occurs in a car accident.

Symptoms of Headache from Neck Trauma They may appear immediately after the traumatic event or may develop gradually over time. This condition may persist for weeks, months, or even years after the trauma.

The pain may resolve within three months of the traumatic event and may occur alone or accompanied by other symptoms such as dizziness, pain and stiffness in the neck and surrounding muscles, lightheadedness, fatigue, mood changes, and insomnia.

The headache in this case it can be described as a constant or throbbing pain localized mainly in the neck and skull base region.

Treatment of Headache from Cervical Trauma may include the use of pain medications and/or anti-inflammatory medications to relieve pain and reduce inflammation. Non-drug therapies such as physical therapy and osteopathic manual therapy may be helpful in restoring function and mobility to the cervical spine.

The headache caused by a temporomandibular joint disorder (TMJ) is a form of secondary headache which occurs due to problems or disorders in the TMJ, the joint that connects the jaw to the skull.

Typically, pain associated with a TMJ disorder is often localized to the area of ​​the joint itself and surrounding areas such as the temples, ears, jaw, cheeks, and neck.

Symptoms may be described as throbbing, stabbing, or dull, and may range in severity from mild to severe. They may be constant or intermittent and may be accompanied by other symptoms such as jaw stiffness, cracking, or clicking during jaw movement (chewing, speaking, yawning).

Treatment of TMJ Disorder Headache may include several therapeutic modalities, including conservative therapies such as hot/cold therapy, osteopathic manual therapy, or drug therapy to relieve pain and reduce inflammation.

In this case, collaboration between different healthcare professionals (osteopath and dentist) is essential for the treatment of disorders caused by dental malocclusion and the restoration of a correct balance through osteopathic techniques.

Sinusitis Headache It is a condition in which the headache It is caused by inflammation or infection of the sinuses, the bony cavities located around the nose and eyes.

This type of headache It usually occurs following inflammation of the sinuses due to a bacterial, viral or fungal infection, or due to allergies, irritation or obstruction of the upper airway.

Symptoms that may suggest the presence of sinusitis headaches include nasal congestion and discharge, decreased sense of smell, pain or pressure in the face or ear area. In some cases, headache It can be triggered by pressure on specific points of the face that correspond to the infected paranasal sinuses.

Sinusitis Headache Treatment depends on the underlying cause and severity of symptoms. This may include the use of nasal decongestants, antihistamines, nasal corticosteroids, antibiotics (if the infection is bacterial), saline nasal irrigation, analgesics or antipyretics to relieve pain and fever, and, in some cases, surgery to remove blockages or correct anatomical abnormalities of the sinuses.

In this case, osteopathic treatment can be useful to promote decongestion of the affected paranasal sinuses, ensuring physiological functionality of the cranial bones.

Medication Overuse Headache It is a form of secondary headache that develops due to the excessive use of painkillers, especially those used to treat headaches . This particular condition can arise when medications are taken too frequently, in excess of the recommended doses, or without following the doctor's instructions.

This occurs when pain medications are taken for more than 10-15 days a month. Chronic and frequent use of these medications can cause physical dependence and create a vicious cycle, increasing sensitivity to pain and thus contributing to the cycle of abuse.

This can lead to a full-blown dependence on the drugs and make it difficult to stop the cycle of taking them.

Symptoms of Medication Overuse Headache may be similar to those of other forms of headache , but tend to be more severe and persistent. They may include headaches daily or near-daily pain, pain that worsens with drug use, and withdrawal symptoms when drugs are stopped.

Treatment of Medication Overuse Headache is complex and may require a multidisciplinary approach. This may include monitoring and tapering of medication use, behavioral and cognitive therapies to manage pain and prevent drug use.

Psychological support and pain therapy can also be helpful in managing this condition.

Headache treatments and remedies depend on the underlying cause and the type of headache you are dealing with. However, there are some general strategies that can help you manage your headache effectively. Here are some tips:

Over the counter medicines : For headaches occasional mild or moderate, you can use over-the-counter medications. Better if prescribed by your family doctor, who will be able to identify the most appropriate therapy based on the type, frequency, triggers and symptoms of the headache .

Specific medications : If you suffer from headaches chronic or more severe, it is advisable to consult a doctor to evaluate the opportunity to use specific drugs for headache .

Rest and relaxation : Rest and relaxation can be very helpful in alleviating symptoms. Resting in a quiet, dark environment, practicing relaxation techniques such as deep breathing, stretching or massage can help relieve headaches .

Hydration : Dehydration can be a trigger for some types of headaches . It is important to make sure you drink enough water throughout the day.

Avoid triggers : Avoid triggers as much as possible, such as specific foods or drinks, stress, lack of sleep, or exposure to certain sensory stimuli such as bright light or loud sounds.

Manual therapies : Several subjects find relief from headaches through alternative manual therapies such as acupuncture, osteopathy , chiropractic or physical therapy. However, it is important to consult a healthcare professional before undertaking any therapy in order to structure a program that is appropriate for your needs.

Stress Management : Stress can be a trigger for headaches in many individuals. It is important to find alternative ways to manage stress, such as practicing relaxing activities, yoga, meditation, or cognitive behavioral therapy.

Healthy Lifestyle : Maintaining a healthy lifestyle, including a balanced diet, regular physical activity and getting enough sleep, can help reduce the frequency and intensity of headaches .

If the headache becomes frequent, severe, or significantly interferes with daily life, it is important to consult a doctor for appropriate evaluation and treatment.

So-called "red flags" are warning signs that indicate the presence of symptoms or conditions that require immediate medical attention or further in-depth evaluation.

These warning signs are used in clinical practice to identify situations where timely intervention may be necessary to diagnose and treat serious or potentially life-threatening medical conditions.

In the context of headaches , red flags are symptoms or characteristics that may indicate the presence of serious neurological conditions, head trauma, infections, brain hemorrhages, or other conditions that require immediate medical evaluation.

Among these we recognize:

• first episode of headache
• persistent headache (constant, unchanging pain)
• Worsening pain
• throbbing pain
• First episode of headache in a specific clinical context (cancer, HIV infection)
• Cervical trauma or mild head trauma in the elderly
• Age greater than 50 years with no history of headache
• Associated symptoms (visual disturbances, nausea, vomiting, dizziness)

Recognizing and identifying these red flags is essential for accurate headache assessment and to ensure that any serious conditions are treated promptly.

If you suspect you have a red flag, it is important to contact your doctor right away .