STARES WEEK THREE: Analysis and Planning

Situation: I had been treating a 60 year old female who had been referred for headaches. On presentation the patient reported that they had suffered from "migraines" for 20 years. The headaches sometimes came in clusters having 3 or 4 in a row every 3 weeks. She described the pain as an ache that started in the neck and worked its way into the head. The pain most commonly occurred on the right but could shift to the left between episodes. She complained of no nausea or vomiting and only had described an aura on one occasion. Aggravating factors included stress and fatigue.

On objective examination I was unable to reproduce the patients neck pain with active movements, over-pressures, sustained movements or combined movements. Passive accessory examination produced no asterisk level. The patient did have a chin poked posture so I decided to assess her deep neck flexor recruitment and sternocleidomastoid seemed quite overactive. Her neck pain was then reproduced on palpation of the sternocleidomastoid origin. She also had decreased muscle length of upper trapezius which could be a result of her stress.

Although I don't think the patient suffered from true cervicogenic headache, on examination it seemed that the neck pain could possibly be a trigger for a her headaches. Treatment therefore consisted on addressing the patients postural issues with deep neck flexor recruitment exercises, stretches for upper trapezius and education on pain management such as the use of heat and relaxation techniques.

Task: The patient had been progressing well and not suffered from headache since starting treatment so the task was to start organising her discharge.

Action: For discharge the patient would need a comprehensive home exercise program and learn to manage her own neck pain. I continued with postural activities and stretches to maintain muscle length. I also addressed her ergonomics when sitting at her computer. As her aggravating factors were stress I taught her some relaxation techniques and suggested the use of heat for pain management. Part of my intervention was to educate her on the different type of headaches that she suffered from. I had to explain the headaches that we could manage biomechanically but that if she suffered from another aura that she would need to take her medication for migraines. Overall I had to make sure she no longer suffered from her symptoms and that she would be able to self manage in the future.

Result: The patient was going on holidays for 6 weeks so I had to decide whether to discharge her or transfer her to another physio upon return. Although she had been progressing well I had only been treating her over a 2 week period and since she suffered from headaches in clusters every 3 weeks, I was unable to tell if my treatment had been truly effective. Hence it was decided to write a transfer summary explaining the clusters of headaches and that should she need a follow up she would book an appointment after her holiday.

Evaluation: Overall I think I made the right decision. The aim of treatment is to make improvements in a patients symptoms. I was unable to ascertain whether my treatment was effective or whether natural history was the reason for her not having suffered from a headache during the time I had been treating her. Therefore giving her the option of another appointment if she suffered from a cluster of headaches in a week or twos time seemed appropriate.

Strategies: Always consider a patients natural history of symptoms when considering discharge.