Headaches/Migraines


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Headaches are among the most common of health problems. Chiropractic and other non-medical practitioners are increasingly sought out by the public. Twenty-seven percent of Americans who visit health care providers outside of the medical field do so for headache relief, according to "Unconventional Medicine in the United States" N Engl J Med. 1993 (Jan 28); 328 (4): 246-252

Intractable migraine headaches during pregnancy under chiropractic care

Abstract
Background
Lifetime prevalence of migraine headaches in women vary from 11 to 32 percent while 1-year prevalence varies from 9-22 percent. Women are three-times more likely to suffer from migraine headaches compared to men and peak during the reproductive years. Studies indicate an improvement in headaches symptoms during pregnancy due to the absence of hormone fluctuations and/or the analgesic effects of increasing β-endorphins. Some however report worsening of symptoms regardless of non-pharmacological or pharmacological approaches.  Risks of adverse events associated with medical care are of concern and are warranted. We present the successful care of a patient with intractable migraine headaches during pregnancy.

Clinical Features
A 24 yr-old gravid female with chronic migraine headaches since age 12 years presented for chiropractic care. Previous care included osteopathy, physical therapy, medications and massage with unsuccessful outcome. Medical care consisted of non-steroidal anti-inflammatory medication with codeine at the maximum amount permitted during a pregnancy (i.e., 1000mg per day) as well as caffeine intake through coffee to potentiate the medication. This resulted in only minor and temporary relief.

Intervention and Outcome
Chiropractic adjustments characterized as high-velocity, low amplitude thrusts and the Activator Instrument were applied to sites of vertebral subluxations. No reported adverse events were associated with this type of care. Massage, trigger point therapy, increase water intake and change in sleeping posture were adjunctive care.  The intensity of her migraine headaches had significantly reduced following the first three visits from pain rating of 8-9/10 to 2/10 on the verbal pain scale  and attack frequency improvement  from once daily to once every 3 days. This resulted in self-withdrawal and decrease dependence on medication.

Conclusion
This case study provides supporting evidence on the safety and effectiveness of chiropractic care during pregnancy with a chief complaint of migraine headaches.

Peer Reviewed Journals:

1)   The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for prophylaxis of migraine headache.   Nelson CF, Bronfort G, Evans R, et al.   J Manipulative Physiol Ther. 1998 (Oct); 21 (8): 511-519

  • This study compared the relative effectiveness of treating migraines by with chiropractic care alone, with the antidepressant/antianxiety drug amitriptyline (best known under the brand name Elavil); and with a combination of both the drug therapy and chiropractic care. Patients who received only chiropractic showed significant improvement, on a par with those given the powerful prescription drug (though without the side effects). The headache index, from a diary kept by each patient, showed chiropractic to have reduced the severity and frequency of headaches as well or better than the combined therapy or amitriptyline alone at each stage of the study.

2)   Spectrum of pathophysiological disorders in cervicogenic headache and its therapeutic indications.   Martelletti P, LaTour D, Giacovazzo M   Journal of the Neuromusculoskeletal System 1995; 3:182-7.

  • This describes a number of patients who were diagnosed with cervicogenic headache (headache arising from neck structures) and received chiropractic care. The patients reported improvement.

3)   Incidence of ponticulus posterior of the atlas in migraine and cervicogenic headache.   Wight S, Osborne N, Breen AC.   J Manipulative Physiol Ther. 1999 (Jan); 22 (1): 15-20

  • A common structural variation of the atlas vertebra is called ponticulus posticus (also known as foramen arcuale or "Kimmerle's anomaly"). Investigators studied the relationship between this condition and headache symptoms in 895 first-time chiropractic patients. The patients' complaints included migraine with aura (classical migraine), migraine without aura (common migraine), cervicogenic headache, neck pain only, and other problems. They were examined for the presence or absence of partial or complete ponticulus posticus. The authors found a significant correlation of ponticulus posticus with migraine without aura. They explain that because the ponticulus posticus is intimately attached to the atlanto-occipital membrane (where the spine and skull meet) and this membrane, in turn, is attached to the dura (the outermost covering of the brain and spinal cord), small tensions exerted on the dura may result in excruciating head pain of a type experienced in migraine. The beneficial results of chiropractic for migraine and cervicogenic headache are possibly related to the nature of the structures connecting the upper spine to the skull.


4)   The effect of spinal manipulation in the treatment of cervicogenic headache.   Nilsson N, Christensen HW, Hartvigsen J.   J Manipulative Physiol Ther. 1997 (Jun); 20 (5): 326-330

  • This is a randomized controlled trial performed at the University of Odense, Denmark by chiropractors and medical doctors.


    • From the abstract:   Fifty-three [patients] suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache.were recruited from 450 headache sufferers from responded to the newspaper advertisements. .28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for three wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage in the lower cervical/upper thoracic region, also twice a week for three weeks.

    Results:   The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant. The number of headache hours per day decreased by 69% in the manipulation group compared with 37% in the soft-tissue group; this was significant. Finally, the headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant. At a four-week follow-up, she remained pain free.


5)   Spinal manipulation vs. Amitriptyline for the treatment of chronic tension-type head-aches: a randomized clinical trial.   Boline PD, Kasaak K, Bronfort G, Nelson C, Anderson AV,   J Manipulative Physiol Ther. 1995 (Mar-Apr); 18 (3): 148-154

  • Six weeks of drug therapy were compared to six weeks of chiropractic adjustments. The drug therapy was considered slightly more effective than chiropractic however 82% of the patients had side effects which included drowsiness, weight gain and dry mouth. Cardiac  problems and glaucoma were also associated with amitriptyline use. Chiropractic patients had no side effects (apart from slight neck stiffness in the first two weeks of the study that 5% of the patients reported). After four weeks, chiropractic and drug   therapy was halted in both groups. The patients who used drugs began having headaches again while the chiropractic group continued to express headache relief, as well as higher levels of energy and vitality than the drug therapy group.


6)   Occipital headaches stemming from the lateral atlanto-axial (C1-2) joint.   Aprill C, Axinn MJ, Bogduk N.   Cephalalgia. 2002 (Feb); 22 (1): 15-22

  • Patients presenting with occipital pain underwent diagnostic blocks of their lateral atlanto-axial joints if they demonstrated clinical features presumptively suggestive of a C1-2 origin for their pain. Of 34 patients investigated, 21 obtained complete relief of their headache following diagnostic blocks, indicating that a C1-2 source of occipital pain is not rare. The clinical features used to select patients for blocks, however, had a positive predictive value of only 60%. Further study of headaches from C1-2 seems justified in order to establish more definitively the prevalence of this condition and how it might become better recognized in practice.


7)   A controlled trial of manipulation for migraine.   Parker GB, Tupling H, Pryor D.   Aust and New Zealand Journal of Medicine 1978 (Dec); 8 (6): 589-593

  • Spinal manipulation administered by chiropractors, spinal manipulation administered by medical practitioners and physical therapists and a mobilization procedure administered by physical therapists was studied. Eighty-five (85) patients received two manipulations per week over a 2-month period. At the end of the study, all three groups showed clinically significant improvement in the frequency, intensity, and duration of migraine headache episodes.


8)   The effect of manipulation (toggle recoil technique) for headaches with upper cervical joint dysfunction: a pilot study.   Whittingham, W, Ellis WB, and Molyneux TP,   J Manipulative Physiol Ther. 1994 (Jul-Aug); 17 (6): 369-375

  • Twenty-six patients (16 males, 10 females) all had chronic headaches with upper cervical joint dysfunction. Significant diminishing of the severity and frequency of headaches was reported in a large majority of the subjects (24 out of 26).


9)   Diagnosis and treatment of TMJ, head, neck and asthmatic symptoms in children.   Gillespie BR, Barnes JF,   Cranio. 1990 (Oct); 8 (4): 342-349

  • From the abstract:   "Pathologic strain patterns in the soft tissues can be a primary cause of headaches, neckaches, throat infections, ear infections, sinus congestion, and asthma."


10)   Manipulative therapy in the chiropractic treatment of headaches: a retrospective and prospective study.   Vernon H.   J Manipulative Physiol Ther. 1982 (Sep); 5 (3): 109-112


11)   Trauma of the cervical spine as cause of chronic headache.   Braaf M. & Rosner SJ.   J Trauma. 1975 (May); 15 (5): 441-446


12) Chiropractic Management of Migraine Without Aura: A Case Study.   Lenhart, L.J.   JNMS 1995: 3(10: 20-26.

  • A case of migraine is discussed. The author has done a number of tests to objectify his care. The patient continued his improvement two months post-spinal (cervical) adjustments.



Additional Publications:

1)   Chiropractic Treatment of Chronic Episodic Tension type Headache in Male Subjects: A Case Series Analysis.   Mootz RD, Dhami MSI, Hess JA, et al.   Journal of the Canadian Chiropractic Association, 1994; 38(3): 152-159.

  • Ten male outpatients 18-40 years old with a history of chronic headache of at least six months in duration occurring at least once a week were seen in the Palmer College of Chiropractic- West Outpatient clinic. Diversified technique was the primary care. Results showed an over 50% decrease in headache frequency and duration. Mean anchored pain scale intensity ratings changed from 5.05 to 3.37 which was "just beyond statistical significance....there was no significant changes in any McGill Pain Questionaire scores pre and post treatment. A large sampling size is suggested for a larger study.


2) Spinal curvatures-visceral disturbances in relation thereto. Ussher NT. California and Western Medical Journal, 1933, 38:423.

  • Ussher has written that spinal abnormalities could be causing visceral disorders and that X-rays could be a help in diagnosing the spine/internal organ relationship. Ussher urged "A careful neurological examination of the spine" as part of differential diagnosis.


3)   Spinal manipulation and headaches of cervical origin.   Vernon HT.   J Manipulative Physiol Ther. 1989 (Dec); 12 (6): 455-468

  • The role of the cervical spine in headache remains controversial. Often confused as tension or common migraine headache, headaches arising from the neck pose a diagnostic and therapeutic challenge. Practitioners of spinal manipulation have reported very satisfactory results, although the only published randomized controlled trial did not demonstrate that manipulation was significantly helpful. This article reviews the published clinical studies of manipulation in the treatment of tension and migraine headaches. The topic of cervical headaches in general is reviewed and the current model of cervicogenic headache is critiqued. A representative case history is used to illustrate the thesis that the current model of cervicogenic headache may be too restrictive.


4)   Occipital headaches; statistical results in the treatment of vertebragenous headache.   Droz JM, Crot F.   Swiss Annals Vlll, 1985; 127-36.

  • 332 patients received an average of 8.6 chiropractic adjustments. Results: 80% of patients had excellent (pain-free) and good (almost pain-free) outcomes with 10 reporting a 75% decrease in pain.


5)   Chiropractic adjustment in the management of visceral conditions: a critical appraisal.   Jamison JR, McEwen AP, Thomas SJ.   J Manipulative Physiol Ther. 1992 (Mar-Apr); 15 (3): 171-180

  • This was a survey of chiropractors in Australia. More than 50% of the chiropractors stated that asthma responds to chiropractic adjustments; more than 25% felt that chiropractic adjustments could benefit patients with dysmenorrhea, indigestion, constipation, migraine and sinusitis. 


6)   Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis.   Mootz, RD, Dhami MSI, Hess JA, et al.   Journal of the Canadian Chiropractic Association, September 1994; 38(3): 152-159.

  • This study was conducted at the Palmer College of Chiropractic-West Outpatient Clinic. It involved 11 men between the ages of 18 and 40 who suffer from headache. The patients reported consistent and significant reduction in the frequency and duration of headaches. However, the intensity of the headaches in this group was unchanged. The adjustments used were diversified with myofascial trigger point therapy, and moist hot packs. This study reflects a serious limitation of studies found in nearly all research on the effects of spinal care. There is no inter-technique study. Would another adjusting technique be more effective? Less effective? Unfortunately that research was not done.


7) Migraine: A statistical analysis of chiropractic treatment.   Wright JS.   J Am Chiro Assoc 1978; 12:363-67.


8) Upper cervical vertebrae and occipital headache.   Ng SY   J Manipulative Physiol Ther 1980; 3:137-41.



Case Studies:

1)   Chiropractic care of a 13-year-old with headache and neck pain: a case report.   Hewitt, EG,   Portland, Oregon.   Proceedings of the National Conference on Chiropractic and Pediatrics. Oct, 1993 Palm Springs, CA. Pub. International Chiropractors Assoc., Arlington, VA.

  • From the abstract:   Headaches are the most frequent cause of visits to primary care practitioners. Standard medical care for headaches is prescription of pain reliving medication.


2) Chiropractic care of children with headaches: five case reports.   Anderson-Peacock, ED,   Journal of Clinical Chiropractic Pediatrics, Vol.1, No.1, Jan. 1996.

  • From the abstract:   In this case series, five children presented with varying types of head-aches to a family-based chiropractic practice. In each case, spinal subluxations were present. Following reduction of those subluxations through chiropractic adjustments the child's chief complaint remised. Adjunctive therapy (education on diet, posture and exercise) was not given until the headaches remised. Thus, it was felt that the headache reduction may have been due to the restoration of nervous system function through the chiropractic adjustment. Chiropractic management of headaches should be further researched in children.


3)   Chiropractic treatment of childhood migraine headache: a case study.   Proceedings of the National Conference on Chiropractic and Pediatrics 1994, p. 85-90. As abstracted by Masarsky Cs. Headache and Torticollis (Research review) ICA International Review of Chiropractic 1995; 51(1): 45-47.

  • A case of a 10-year-old male with a three-year-history of migraine headaches. During the first month of chiropractic care, it was reported that he only had two prodromal episodes, but no full migraines.


4)   Case reports in chiropractic pediatrics.   Esch, S.   ACA J of Chiropractic December 1988.

  • A 13-day-old with a history of respiratory difficulty since birth (home birth, uncomplicated). Infant had difficulty nursing due to "stuffiness." Upon presentation patient was in considerable pain, wearing dark glasses and ear plugs to compensate for increased sensitivity to sound and light. One week beforehand he had been injured in a football game collision. Medical doctors had given the child painkillers. Patient was hospitalized in traction for two weeks with no improvement.

  • Chiropractic examination:   X-ray (Davis series) of the cervical spine showed right lateral displacement of atlas with right rotation of C-2. Following initial adjustment the patient could ride home without wearing his sunglasses and for the first time in two weeks expressed an interest in food. He returned the next day saying he felt, "The best I've felt in six weeks."


5)   A case series of migraine changes following a manipulative therapy trial.   Tuchin PJ.   Australasian Chiropractic & Osteopathy 1997 (Nov); 6 (3): 85-91

  • Four cases of migraine responded dramatically to spinal care. Many self reported symptoms were either eliminated or substantially reduced. Average frequency of episodes was reduced by 90% with the length of each headache reduced by 38%. Medication use dropped 94%. Other symptoms associated with migraine were reduced including nausea, vomiting, photophobia and phonophobia.


6)   A holistic approach to severe headache symptoms in a patient unresponsive to regional manual therapy.   Stude, DE and Sweere, JJ.   J Manipulative Physiol Ther. 1996 (Mar-Apr); 19 (3): 202-207

  • This case history deals with a woman who suffered from severe migraine headache symptoms who found no relief from medical care or cervical chiropractic adjustments. This is the case of a patient suffering from severe headache complaints who was previously unresponsive to regional cervical spine care. Chiropractic spinal adjustments were provided as the only intervention and the patient reported no visits to the emergency room, even after a 1-year follow-up, and the average visual analogue pain decreased.

  • Results:   The use of analgesics decreased by 36% in the manipulation group, but was un-changed in the soft-tissue group; this difference was statistically significant. The number of headache hours per day decreased by 69% in the manipulation group compared with 37% in the soft-tissue group; this was significant. Finally, the headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant.


7)   Chiropractic care of a 13 year-old with headache and neck pain: a case report.   Hewitt EG.   Journal of the Canadian Chiropractic Association Sept. 1994; 38(3): 160-162.

  • From the abstract:   This report describes a 13 year-old female who had suffered from unremitting headache and neck pain for five days. She described them as a throbbing and stabbing pressure that normally occurred once per week and lasted approximately one hour. She had missed one week of school. She had visited her family MD and he had recommended seeing a chiropractor. Following a series of four chiropractic treatments over a two-week period, her headache and neck pain resolved. Patient had injured her neck in gymnastics. Her neck pain and shortly after her headaches resolved. At a four-week follow-up, she remained pain free.


8)   Encephalgia / Migraine: A Case Study   Harley Bofshever DC,   ICPA Newsletter, Nov/Dec, 1999

  • HISTORY:   A 10-year-old girl was brought in to my office on 2-15-99 suffering chronic and severe migraine headaches. History reveals that this patient has been having migraine headaches 6 times a week for the past 3 years.  At the current time, the patient has not been able to go to school due to the severity of the headaches.  The patient was treated at Marino's Children's Hospital, where she recently saw a neurologist.  Her pediatrician has prescribed Periactin Syrup as a preventative, however it has not been helpful.  The patient does suffer mild allergies to mold and mildew.  She did have a double hernia at 72 ­months, which required surgery.  Past treatment for her headache, has included an illumination diet, prescribed by her pediatrician, which she has been on for the past 2 ½ years, however results have been extremely poor.  It is noted that headaches do run on the paternal side of the patient's family.

  • EXAMINATION:   Detailed examination was performed in our office revealing restricted range of motion of the cervical spine is noted.  Palpatory tenderness of Cl / C2 on the left.  There is also inflammation to the posterior cervical musculature.  At the time of examination the patient did have a headache and stated that her pain intensity of her headache was a 10.  There are also taunt and tender fibers of the posterior cervical musculature and the trapezium region bilaterally.  Cervical x-rays taken in the routine weight bearing position and analyzed revealing an atlas listing of ASLP; decreased cervical lordosis, lower cervical subluxation and rotation of the upper thoracic vertebrae.

  • CARE PLAN:   Recommendations were made for adjustments 3 times a week for 8 weeks and 2 times a week for 4 weeks due to the severity and chronicity of her headaches. At the end of that period she will be reexamined.  If patient responds well to care, the care plan may be reduced pending patient's response to treatment.

  • PROGRESS:   The patient's symptomatology improved following her third visit at which time she stopped using the Periactin Syrup.  She was advised to continue her treatment of 3 times a week.  By the end of her third week, the patient was able to begin school again.  She also started her dance classes for the first time in 2 years, and actually began to smile again.  She was leading a normal and healthy life for a child of her age by the end of the 5th visit.



Review more articles on Headache at Chiro.Org


Article on Headaches in Children:
http://www.chiroweb.com/archives/16/17/04.html

 

References from Koren Publications' brochure: Help for Headache Sufferers

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  • Bogduk, N. The anatomical basis for cervicogenic headache. JMPT Jan. 1992, pp. 67-70.

  • Kreeft, J. Headache following whiplash. In Spine: State of the art reviews: Cervical Flexion-Extension/ Whiplash Injuries, Sept. 1993, p. 395.

  • Braaf, M., & Rosner, S.J. Trauma of the cervical spine as cause of chronic headache. Trauma, 1975, 15, pp. 441-446.

  • Results of manipulative treatment on childhood migraine. Hippocrates, 1963, pp. 308-316.

  • Turk, Z. Mobilization of the cervical spine in chronic headaches. Manuel Medizin, 1987, pp. 15-17.

  • Ussher, N.T. Spinal curvatures-visceral disturbances in relation thereto. California and Western Medical Journal, 1933, 38, p. 16.

  • Vernon, H.T. Spinal manipulation and headaches of cervical origin. JMPT, 1989, 12, pp. 455-468.