The Uncertainty of Treating Migraine
August 21, 2009 by dean · Leave a Comment
“ … little does it concern the patient that there is an underlying cause … if the practitioner is unable to relieve his pain.” (Persian Avicienna – Critchley 1967)
This statement was made 2000 years ago and remains true today – patients are seeking treatment, but since the cause of migraine remains unclear, treatment is provided on a less than solid scientific foundation, on a ‘we’ll try this and see what affect it has’ basis.
However what is becoming increasingly clear (except to those who continue to support the notion that headache and migraine are separate entities) is that headache and migraine arise from the same (sensitised brainstem) disorder – the evidence is there – this is the underlying cause. Not only can we confirm relevant neck disorders as the source but we can offer a way of addressing it, based not on guesswork but on sound scientific evidence.
Cheers
Dean
(Anderson CD, Franks RA. Migraine and tension headache: is there a physiological difference? Headache 1981; 21:63-71
Critchley M. Migraine from cappadocia to queens square. In: Smith R, ed. Background to Migraine. London: Heinemann;1967:28
Cady RK, Gutterman D, Saires JA, Beach ME. Responsiveness of non-IHS migraine and tesnion-type headache to sumatrptan. Cephalalgia 1997;17:588-90
Cady R, Schreiber C, Farmer K, Sheftell F. Primary headaches: a convergence hypothesis. Headache 2002; 42:204-16
Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-198
Marcus D, Scharff L, Mercer S, Turk D. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache 1999; 39:21-27
Mercer S, Marcus DA, Nash J. Cervical musculoskeletal disorders in migraine and tension-type headache. Paper presented at the 68th Annual Meeting of the American Physical Therapy Association; 1993; Cincinatti, Ohio
Marcus DA. Migraine and tension-type headaches: the questionable validity of current classification systems. Clin J Pain 1992; 8:28-36
Nelson CF. The tension headache, migraine headache continuum: A hypothesis J Manipulative Physiol Ther 1994; 17:156-167
Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
Takmaz, S. et al Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri 2008 Jan;20(1):47-50)
Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. J Manipulative Physiol Ther 1992; 15:418-429
Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
Young et al Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125
Young et al. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1139)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Diagnosing Headache and Migraine – A Dog’s Breakfast.
August 20, 2009 by dean · Leave a Comment
Diagnosis, Like a Dog's Breakfast, Is All Over The Place
Q. What do diagnosing headache and migraine and a dog’s breakfast have in common?
A. It’s all over the place!
This is expressed in a recent article by Sun-Edelstein et al 2008. Since the diagnostic classification was published, there have been many attempts to confirm or otherwise the accuracy of the criteria. Because of the multiple revisions since, there exists a great deal of controversy and significant confusion, with headache specialists unsure as to which criteria to use.
Many patients after having received an initial diagnosis, are given a second diagnosis, with some requiring 3-4 diagnoses!
This is clearly unsatisfactory …. and is the result of trying to prove an untruth. The various types of headache and migraine are not separate entities, they are on a continuum, developing from a common disorder.
Cheers
Dean
(Anderson CD, Franks RA. Migraine and tension headache: is there a physiological difference? Headache 1981; 21:63-71)
Cady RK, Gutterman D, Saires JA, Beach ME. Responsiveness of non-IHS migraine and tesnion-type headache to sumatrptan. Cephalalgia 1997;17:588-90
Cady R, Schreiber C, Farmer K, Sheftell F. Primary headaches: a convergence hypothesis. Headache 2002; 42:204-16
Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-198
Featherstone HJ. Migraine and muscle contraction headaches: a continuum. Headache 1985; 25:194-8
Marcus D, Scharff L, Mercer S, Turk D. Musculoskeletal abnormalities in chronic headache: a controlled comparison of headache diagnostic groups. Headache 1999; 39:21-27
Marcus DA. Migraine and tension-type headaches: the questionable validity of current classification systems. Clin J Pain 1992; 8:28-36
Mercer S, Marcus DA, Nash J. Cervical musculoskeletal disorders in migraine and tension-type headache. Paper presented at the 68th Annual Meeting of the American Physical Therapy Association; 1993; Cincinatti, Ohio
Nelson CF. The tension headache, migraine headache continuum: A hypothesis J Manipulative Physiol Ther 1994; 17:156-167
Sun-Edelstein C, Bigal ME, Rapoport AM. Chronic migraine and medication overuse headache: clarifying the current International Headache Society classification criteria. Cephalalgia. 2008;29:445-452
Vernon H, Steiman I, Hagino C. Cervicogenic dysfunction in muscle contraction headache and migraine: A descriptive study. J Manipulative Physiol Ther 1992; 15:418-429)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Migraine In 1888 – The Same As In 2009!
August 19, 2009 by dean · Leave a Comment
Amazing! I have just come across a gentleman who in 1888 who described the migraine process in this way: “… we must not ascribe too much significance to throbbing of the increase in the pain by the cause of vascular distension; these may be due merely to the over sensitiveness of the central structures.” In other words expansion of the blood vessels is unlikely to be the cause of pain; it may be that expansion of blood vessels is misinterpreted by a sensitised central nervous system.
This information from the blood vessels has to pass through the BRAINSTEM on the way to the cortex … and what has been shown to be the disorder in headache and migraine? … a SENSITISED BRAINSTEM.
A man 120 years before his time – Bravo!
Cheers
Dean
(Gowers WR. Diseases of the brain and cranial nerves. General and functional diseases of the nervous system. A Manual of Diseases of the Nervous System, 1st Ed. Vol. 2 London: Churchill, 1888)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Avoiding Chocolate to Prevent Migraine is Not Necessary
August 18, 2009 by dean · Leave a Comment
Chocolate can be eaten without a migraine
Avoiding chocolate to prevent migraine is not necessary – it isn’t about the chocolate!
The thought of living without chocolate is unbearable but I know that for many of you, the experience is not worth it!
However, many of my patients are now eating chocolate, in fact this is what I ask them to do after 3-4 treatments – and you can imagine their (and mine!) delight when they do so without headache or migraine.
But why is it that I can eat chocolate without headache – I’m sure that chocolate has the same effect on me as it does on someone else who ends up with a headache. For example phenylethylamine (PEA) is a chemical in chocolate that causes blood vessels to expand and contract – this probably happens for everyone, but not everyone gets headache or migraine. Some might say that the chocolate sensitises their system, whilst some authorities suggest that their system is already sensitised before the chocolate came along.
I suspect that just as in migraine and tension headache sufferers, the brainstems of those whose headache or migraines are triggered by chocolate, are already sensitised. The normal response of the blood vessels to PEA is to expand, but the pain interpreting centres in the brain understands this (normal) increased activity to be much more than what it is and pain results.
What’s causing the sensitisation? It is easy to confirm a neck disorder because temporary reproduction and lessening of head pain occurs when examining the joints of the upper neck – it is important to confirm the source of sensitisation …
… then you can enjoy the benefits of eating (good quality and dark) chocolate:
a natural mood enhancer
a stress reliever
a memory enhancer
improves your levels of serotonin (which will desensitise your brainstem).
Cheers
Dean
(Marcus DA, Scharff L, Turk D, Gourley LM. A double-blind provocative study of chocolate as a trigger of headache. Cephalalgia;17(8):855-62
Scharff L, Turk DC, Marcus DA. Triggers of Headache Episodes and Coping Responses of Headache Diagnostic Groups. Headache 1995;35:397-403 )
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Diagnosing Cervicogenic Headache is Easy
August 17, 2009 by dean · Leave a Comment
I mentioned recently that blocking the greater occipital nerve and eliminating head pain is key sign of cervicogenic or neck headache and that this has been demonstrated repeatedly in migraine sufferers.
This procedure (injecting nerves) however is not necessary to diagnose cervicogenic headache which is just as well because after all it is invasive, not readily available and relatively expensive.
The ability to temporarily reproduce familiar head pain when examining joints of the upper neck is recognised by traditional medicine as one of the most important indicators of cervicogenic headache (actually, I have to disagree with this, reproduction alone is not enough – there needs to be lessening of the head pain as the examination technique is sustained – more of that later).
It is irresponsible to recommend treatment of the neck for headache or migraine when it is not the cause and therefore it is crucial that reproduction and lessening of head pain occurs during the examination.
The examination approach I have developed on the basis of 21000 hours experience is unparalleled – in recent research familiar head pain was reproduced in 100% of tension headache sufferers and 94% of migraineurs …. now I could be cynical and say that 100% had tension headache and cervicogenic headache and 94% migraine sufferers had cervicogenic headache as well.
Cheers
Dean
( Akin Takmaz et al. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri. 2008 Jan;20(1):47-50
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151
Rozen T. Cessation of hemiplegic migraine auras with greater occipital nerve blockade. Headache 2007;47:917-928
Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5
Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3
Young et al Greater occipital nerve and other anesthetic injections for primary headache disorders. Headache 2008;48:1122-1125
Young et al. The first 5 minutes after greater occipital nerve block. Headache 2008;48:1126-1139 )
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Headache and Migraine Diagnosis and Treatment
August 16, 2009 by dean · Leave a Comment
The neck can be the source of sensitisation
There are numerous case studies which have shown that injecting local anesthetic around the greater occipital nerve the pain of migraine is eased. This is also a key finding in cervicogenic headache and confirms the diagnosis of cervicogenic headache. So why is it that, in this situation, almost invariably the interpretation is that the sufferer has two types of headache that is:
cervicogenic headache,
and
migraine
I am always bemused by this, why can’t it be that the ‘migraine’ and cervicogenic are the same headache.
Why is it that the answer I often get is “… well we don’t know where migraine comes from but it can’t come from the neck.” Clearly this is a really unhelpful comment. Why is it that I need to demonstrate that the neck can be the source of sensitisation in migraine sufferers (my claim is based on over 21000 hours experience with headache and migraine sufferers)? Perhaps I should request from those who disagree to demonstrate that migraine cannot develop from a neck disorder ….
Cheers
Dean
(Akin Takmaz et al. Greater occipital nerve block in migraine headache: Preliminary results of 10 patients. Agri. 2008 Jan;20(1):47-50
Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151
Peres MF. et al Greater occipital nerve blockade for cluster headache. Cephalalgia 2002;22:520-522)
Rozen T. Cessation of Hemiplegic Migraine Auras With Greater Occipital Nerve Blockade. Headache 2007;47:917-919)
Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5
Yi, X. et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or mis diagnosis? J Pain 2005 Oct;6(10):700-3
Young WB et al. Greater Occipital Nerve and Other Anesthetic Injections for Primary Headache Disorders. Headache 2008;48:112-1125
Young, W. et al The first 5 minutes after greater occipital nerve block. Headache 2008 July 48(7):1126-8)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Paroxysmal Hemicrania Related to Menstruation
August 15, 2009 by dean · Leave a Comment
Here we go again – another headache type that occurs within the menstrual period! Last count it was migraine, tension-type headache, cluster headache …
This case study describes a 43 year old woman who initially had menstrual related migraine which later developed into a typical paroxysmal hemicrania (similar to cluster headache). So here we have menstrual migraine and menstrual paroxysmal hemicrania in the one person, both of which responded to the ‘triptans’.
Just further evidence supporting that headache and migraine develops from one condition – sensitisation of the brainstem (remember that the ‘triptans’ desensitise the brainstem).
Cheers
Dean
(Maggioni F. Menstrual paroxysmal hemicrania, a possible new entity? Cephalalgia 2007;27:1085-1087)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Menstrual Tension-type Headache?
August 14, 2009 by dean · Leave a Comment
Menstrual headaches can vary in severity from one cycle to the next
Now we have menstrual tension-type headache described. When will it all end – the last thing we need now is another headache type!
The authors interviewed 165 women with menstrual related headache and found that the characteristics of tension-type headache were evident in 21.
Isn’t this what some authorities are saying – that all headache and migraine arises from the same disorder?
Menstrual tension-type headache is just a less severe expression of menstrual migraine.
Don’t get me wrong, this is my clinical experience also. I see women whose menstrual headaches vary in severity from one cycle to the next, and some women whose headaches are less severe than those in other women, so Yes, it can present as what is considered a tension-type headache (but its not tension!).
What is needed is to determine the source of the sensitisation – and basic neuro anatomy and research tells us that neck disorders have the potential to sensitise the brainstem.
Cheers
Dean
(Arjona A et al. Menstrual Tension-Type headache: Evidence for Its Existence. Headache 2007;47:100-103)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
The ‘Triptans’ and Menstrual Migraine
August 13, 2009 by dean · Leave a Comment
It’s interesting to read that the ‘triptans’ are also effective in managing menstrual migraine, suggesting that the underlying cause for migraine, tension headache and menstrual migraine is similar, that is, a sensitised brainstem.
One underestimated source of sensitisation are neck disorders …. tired of playing around with your hormonal levels? Perhaps it is your neck that is sensitising your brainstem – a skilled examination will either confirm or eliminate this as a possibility.
Cheers
Dean
(Mannix LK, Files J. The use of triptans in the management of menstrual migraine. CNS drugs 2005;19(11):951-972)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Cluster Headache Following Trauma
August 12, 2009 by dean · Leave a Comment
Clinical experience suggests a skilled examination of the neck in cluster headache sufferers
My experience with cluster headache includes a patient who developed cluster headache 2-3 months after a whiplash accident – and treatment of his subsequent neck disorder has meant that he has been pain-free for 5 years.
A recent case study describes the onset of cluster headache after mild head trauma – and whilst most attention is given to the possibility of some trauma to structures inside the head, the neck has to stop either the moving head in relation to the body or the body in relation to the head and (the neck) is likely to be injured.
My clinical experience suggests that it is important for a skilled examination of the neck in cluster headache sufferers.
Cheers
Dean
(Lambru G et al. Post-Traumatic Cluster Headache: From the Periphery to the Central Nervous System? Headache 2009;(49)7:1059-1061)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.