Successful Headache and Migraine Treatment

December 10, 2009 by dean · Leave a Comment 

Several authorities recently summarised the reasons why headache and migraine treatment often fails.

Amongst other factors, they suggested that the diagnosis is incomplete or incorrect and that this could occur for various reasons.

One of the reasons is ‘misdiagnosis’. I have mentioned this research before but diagnosing headache and migraine is like ‘a dog’s breakfast’; it is all over the place with many patients receiving 2 or 3 diagnoses or patients being misdiagnosed – diagnosed as migraine when in fact it was a cervicogenic (neck-related) headache …..!

The medical profession refuses to acknowledge cervicogenic factors – why? Because relating to it does not fit the medical model and anything that does not fit into the medical model is discarded as unworthy of serious consideration.

The entire diagnostic process needs to be reviewed as well as approaches to treatment. Until cervicogenic factors are considered, headache and migraine treatment will remain unsatisfactory with the only option for you, the headache sufferer, being pharmacological management.

Cheers

Dean

(Lipton RB, Silberstein SD, Saper JR, Bigal ME, Goadsby PJ. Why headache treatment fails. Neurology 2003;60:1064-1070

Yi X et al Cervicogenic headache in patients with presumed migraine: missed diagnosis or misdiagnosis? J Pain. 2005 Oct;6(10):700-3)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Worsening Migraine Attacks

December 9, 2009 by dean · Leave a Comment 

Worsening Migraine Attacks are decreased significantly by cervicogenic (neck) treatment. Recent evidence suggests that migraine is an increasing condition in which over time, the attacks become more frequent, more severe, less responsive to medication, and perhaps lasting longer.

Research has shown that by decreasing information (surgically) from cervical (neck) nerves deceases the long term worsening of the migraine process. The natural progression of cervicogenic (neck) headache is exactly the same – if it is left untreated, cervicogenic headache becomes more frequent, more severe and eventually becomes continuous. This indicates that with the passage of time the neck disorder is gradually worsening (and it is likely to be loss of function or stiffness). This research supports the idea that cervicogenic (neck) disorders are the reason for not only worsening of the migraine process but also for the migraine process in the first place i.e. sensitisation of the brainstem.

Now I am not suggesting that migraine sufferers rush off and have the relatively minor surgery performed in this study (in fact I respectfully suggest that skilled treatment of the neck would have achieved the same result), but this research clearly demonstrates disorders of the upper neck are significantly involved in the migraine process.

Cheers

Dean

(Perry CJ, Blake P and Goadsby PJ Intervention altering the natural history of chronic migraine. Is chroni?cation of migraine headache a harbinger of peripheral afferent nerve involvement? Cephalalgia 2009; 29 (Suppl. 1):1–166)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

The Headache and Migraine Sufferers Bill of Rights (cont)

December 2, 2009 by dean · Leave a Comment 

The first ‘bill’ is that the headache sufferer has the right to know his/her headache diagnosis as precisely as possible, and to know the nature of the headache disorder, its prognosis and the possible types of treatment.

I have discussed the first point regarding diagnosis; now

to know the nature of the headache disorder

Clearly there is a substantial body of research which shows that the brainstems of Migraine, Tension Headache and Menstrual Migraine sufferers are sensitised.

We know that the ‘triptans’ desensitise the brainstem and are effective in preventing Migraine, Tension Headache, Cluster Headache, Hemicrania Continua, Menstrual Migraine, Cervicogenic (neck-related) Headache (which shows that cervicogenic disorders can sensitise the brainstem) ……

The underlying disorder is sensitisation of the brainstem; optimal management therefore is identifying the reason for the sensitisation ….

Stay tuned,

Cheers

Dean

(Members’ Handbook. International Headache Society 2000 Scandinavian University Press)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Headache and Migraine Sufferers ‘Bill of Rights’

December 1, 2009 by dean · Leave a Comment 

is likely to respond to treatment of relevant neck disorders.

Is a diagnosis important?

Some time ago (2000), the International Headache Society, published a Headache Sufferers ‘Bill of Rights’.

The first ‘bill’ is that the headache sufferer has the right to know his/her headache diagnosis as precisely as possible, and to know the nature of the headache disorder, its prognosis and the possible types of treatment.

I would like to spend the next few posts looking more closely at these points:-

“the headache sufferer has the right to know his/her headache diagnosis as precisely as possible”

diagnosis is difficult because it is based on a set of signs and symptoms, and the signs and symptoms of many different headache and migraine forms overlap – perhaps that is why many headache sufferers have been given 2, 3 or even 4 different diagnoses

not only do we have ‘Pure’ Menstrual Migraine, but now ‘MRM’ i.e. Menstrual Related Migraine, Menstrual Tension Headache, Menstrual Hemicrania Continua, Cluster Headache associated with menstruation etc and this is just headache or migraine supposedly associated with the menstrual cycle

the ‘triptans’, supposedly developed to stop the migraine process are effective in other forms of headache e.g. Menstrual Migraine, Cluster Headache, Cervicogenic Headache, and Hemicrania Continua

different headache and migraine forms responding to a range of cervicogenic (neck) treatments e.g. greater occipital nerve blocks, cervical spine stimulators

Is a diagnosis important? As far as I can see, and given the research, a diagnosis does not optimise the management of headache or migraine – it remains a ‘let’s try this and wait and see’ approach – clearly an unsatisfactory situation.

Cheers

Dean

(Members’ Handbook. International Headache Society 2000 Scandinavian University Press)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Tension Headache and Cervicogenic Headache

November 14, 2009 by dean · Leave a Comment 

I have just been asked to review a book:

“Tension-Type and Cervicogenic Headache. Pathophysiology, Diagnosis and Management.”

for the Physiotherapy Journal, published in the United Kingdom.

Whilst I am just getting started, I can’t help but be a little excited, because combining Tension Headache and Cervicogenic headache in the same title suggests that the authors may be implying that there is significant overlap between the two headache types. My clinical experience suggests that tension headache is an unrecognised cervicogenic headache.

Cheers

Dean

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

A Key Diagnostic Feature of Cervicogenic (Neck) Headache

September 25, 2009 by dean · Leave a Comment 

A key diagnostic feature of cervicogenic (neck) involvement in headache is the temporary reproduction of headache and migraine pain when examining structures of the upper neck. This diagnostic feature is recognised by The International Headache Society, The International Association for the Study of Pain and The International Cervicogenic Research Group.

However, in my experience and neuro anatomical principles indicate that, reproduction of headache alone is not enough to confirm that the disorder is the cause of headache.  There also needs to be lessening of the reproduced headache as the technique is sustained.

Cheers

Dean

(Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Hemicrania Continua – The Challenges of Diagnosis!

September 7, 2009 by dean · Leave a Comment 

One Sided Headache

A Constant One Sided Headache

Hemicrania continua is defined as a constant one sided (and always on the same side) headache of moderate intensity with exacerbations and which responds to Indomethacin. Other possible symptoms include redness of the eye, a watery or teary eye, a blocked or runny nostril and drooping of the eyelid.

But we have case reports which show that this supposedly one sided (always the same side) headache can occur on the other side and can also be on both sides at the same time.

Interestingly the traditional classification system of headache and migraine states that Cervicogenic (neck-related) Headache as a one sided headache (and always the same side) also. However my experience of over 21000 hours with headache and migraine patients is that a one sided headache that can occur on the other side is a Cervicogenic Headache. Does this mean that I am saying Hemicrania Continua is likely to be Cervicogenic Headache – Yes!

Cheers

Dean

(Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders, 2nd edn. Cephalalgia 2004; 24(suppl.1):1-151

Marano E, Giampiero V, Gennaro DR, di Stasio E, Bonusa S, Sorge F. ‘Hemicrania continua’: a possible case with alternating sides. Cephalalgia 1994; 14:307–8.

Matharu MS, Boes CJ, Goadsby PJ. Management of trigeminal autonomic cephalalgias and hemicrania continua. Drugs 2003; 63:1637–77.

Matharu MS, Bradbury P, Swash M. Hemicrania continua: side alternation and response to topiramate. Cephalalgia 2005; 26: 341-344

Newman LC, Lipton RB, Russell M, Solomon S. Hemicrania continua: attacks may alternate sides. Headache 1992; 32:237–8.

Newman LC, Spears RC, Lay CL. Hemicrania continua: a third case in which attacks alternate sides. Headache 2004; 44:821–3.

Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

‘Hair Wash Headache’!

September 5, 2009 by dean · Leave a Comment 

Weight of hair can pull the upper neck backwards

Weight of hair can pull the upper neck backwards

In recent correspondence to an acclaimed international headache journal, a doctor located in India reported on migrainous headache occurring after washing of the hair – as the author explains this has either not been noticed in other countries or it may be that similar headache presentations in other countries occur but are called something else.

As reported by this doctor, the crucial factor here is that many ladies from India have long hair that is plaited and it is time consuming to dry their hair (it is uncommon to use a hairdryer). Consequently many women do not wet their hair daily. On the days that they wash their hair however they describe throbbing headache developing within 10’-15’ ; their history of these headaches is usually quite long; this is the only headache they get; usage of perfumes or shampoos is uncommon … therefore the author (doctor) considers there are no other triggering factors …..

Are you thinking what I’m thinking? Imagine the weight on the back of the head of all the wet hair pulling the upper neck backwards – the stress on the neck structures would be significant …. could this be an unrecognised cervicogenic headache?

Cheers

Dean

(Ravishanka K. ‘Hair-wash headache’—an unusual trigger for migraine in Indian patients Cephalalgia 2005;(25)12:1184-1185

Ravishanka. Unusual Indian migraine trigger factors. Headache World 2000. Poster Presentation. Cephalalgia 2000; 20:359)

© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.

Hemicrania Continua and Cervicogenic (neck-related) Headache – Are They The Same Condition?

August 31, 2009 by dean · Leave a Comment 

Interesting to note a case study reporting that the head pain of a patient suffering hemicrania continua was temporarily reproduced and resolved by neck movements and later by blocking or injecting the greater occipital nerve. These two features are key diagnostic signs of cervicogenic or neck related headache and indeed this respected researcher concludes this.

Cheers

Dean

(Rothbart P. Unilateral Headache with Features of Hemicrania Continua and Cervicogenic Headache – A Case Report. Headache 1992;(32)9;459-60)

© 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.