Headache and Migraine Diagnosis and Treatment

August 16, 2009 by dean · Leave a Comment 

The neck can be the source of sensitisation

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.

Migraine, Sinus Headache and the ‘Triptans’ – There’s More!

August 9, 2009 by dean · Leave a Comment 

Further to my comment earlier, the ‘triptans’ have been shown to be useful in differentiating migraine from sinus headache.

As in past studies patients with a self-diagnosis or physician-diagnosis of ‘sinus’ headache were assessed. An overwhelming 82% had a significant reduction in their headache symptoms.

This extraordinary response provides further (not that any more is required!) evidence that the significant majority of ‘sinus’ headaches are migraine and that the ‘triptans’ aid diagnosis.

Don’t want to take a ‘triptan’? That’s OK because a skilled examination of your upper neck will quickly tell you that it isn’t ‘sinus’ headache, but an unrecognised cervicogenic (neck) headache.

Cheers

Dean

(Kari E, DelGaudio JM. treatment of sinus headache as migraine: the diagnostic utility of triptans. Larygoscope 2008 Dec;118(12):2235-9)

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

Identifying Headache and Migraine

July 29, 2009 by Dean Watson · Leave a Comment 

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Cervicogenic (neck) Headache and Migraine or the Same Condition?

July 24, 2009 by dean · Leave a Comment 

Why is it that if treatment of the neck provides relief that it is assumed that cervicogenic (neck) co-exists with migraine or that it is a misdiagnosed migraine? Why can’t it be that cervicogenic factors are instrumental in the migraine process?

Clearly when patients with ‘migraine’ who have not responded to recognised migraine treatments, achieve substantial pain relief to numbing of the greater occipital nerve, there can be only one conclusion …noxious (abnormal) information from the neck is responsible for the migraine process.

Cheers

Dean

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

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

Diagnosing Headache and Migraine From Symptoms is Complex

July 16, 2009 by dean · Leave a Comment 

Diagnosing headache and migraine is complex primarily because of overlapping symptoms (which once again suggests that there is a common mechanism involved in headache and migraine), leading to misdiagnosis.

In a recent trial, four females with a diagnosis of migraine, and in whom migraine therapies had not any substantial effect, were found to have significant signs of cervical (neck) involvement. After anaesthetising (numbing) the occipital nerve with a local anaesthetic, which prevents information from selected neck structures entering the brainstem, all four patients achieved either complete or substantial relief for up to 2 months.

The authors concluded that at least some migraine is misdiagnosed and is in fact a cervicogenic (neck-related) headache – this can be easily determined by a skilled examination of the upper cervical spine and temporarily reproducing familiar headache or migraine pain.

I have done this in the presence of international research organisations, respected researchers and headache and migraine authorities in Australia, Norway and the UK – this is what I teach on my courses in the UK and Europe.

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

Jull G, Bogduk N, Marsland A. The accuracy of manual diagnosis for cervical zygapophyseal joint pain syndromes. Med J Aust. 1988 Mar 7;148(5):233-6

Katsavara Z, Giffin N, Diener HC, Kaube H. Abnormal habituation of ‘nociceptive’ blink reflex in migraine – evidence for increased excitability of trigeminal nociception. Cephalalgia 2003; 23:814-819

Katsavara Z, Lehnerdt G, Duda B, Ellrich J, Diener HC, Kaube H. Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis. Neurology 2002; 59:1450-1453

Kaube H, Katasavara Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache. Possible sensitization of neurons in the spinal trigeminal nucleus? Neurology 2002; 58:1234-1238

Milanov I, Bogdanova D. Trigemino-cervical reflex in patients with headache. Cephalalgia 2003; 23:35-38

Nardone R et al Trigemino-Cervical Reflex Abnormalities in Patients with Migraine and Cluster Headache. Headache 2008; 48(4):578-585

Nardone R, Tezzon F. The trigemino-cervical reflex in tension-type headache. European Journal of Neurology 2003; 10(3):307-312

Sandrini G, Cecchini AB, Milanov I, Tassorelli C, Buzzi MG, Nappi G. Electrophysiological evidence for trigeminal neuron sensitisation in patients with migraine. Neurosci Lett 2002; 317:135-138

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)

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

Post Traumatic Headache, Cervicogenic (Neck) Headache and Migraine or Tension Headache

July 8, 2009 by dean · Leave a Comment 

Is there any difference between post traumatic headache, cervicogenic (neck) headache and migraine or tension headache?

Several studies have shown that symptoms of whiplash-induced headache are often similar to those of spontaneous, natural headaches.

In one study of 48 patients experiencing chronic post-traumatic headaches, 36 patients (75%) were diagnosed with chronic tension-type headaches, 10 (21%) were classified as migraine without aura, and 2 (4%) were undiagnosed. The symptoms of the headaches within each diagnostic group were then compared to those in a control group with naturally occurring, non traumatic headaches of the same type. No appreciable differences between the post-traumatic and control groups were found. Hence, post-traumatic headaches are symptomatically identical to either tension-type headache or migraine.

This result supports the role of cervicogenic (neck) mechanism in not only causing post-traumatic headache but also involvement in other (non traumatic) headaches – tension headache and migraine.

Cheers

Dean

(De Benedittis G, De Santis A. Chronic post-traumatic headache: clinical, psychopathological features and outcome determinants. J Neurosug Sci 1983;27(3):177-186

Haas DC. Chronic post-traumatic headaches classified and compared with natural headaches. Cephalalgia 1996;16:486-93

Weiss HD, Stern BJ, Goldberg J. Post-traumatic migraine: chronic migraine precipitated by minor head or neck trauma. Headache 1991;31(7):451-456)

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

How to Avoid Unnecessary Sinus Surgery for Your Headache or Migraine

July 6, 2009 by dean · Leave a Comment 

True sinus headache is rare.

Clinical studies have demonstrated that nearly 90 per cent of patients with a diagnosis of ‘sinus’ headache have migraine or tension headache and therefore it is not surprising that recent research has shown that the ‘triptans’, medication developed specifically for migraine and which has been shown to be effective in tension headache, also relieved ‘sinus’ headache – if this happens then clearly it is not a sinus headache!

However we also know that Cervicogenic (neck-related) headache is often misdiagnosed as migraine or tension headache and that the ‘triptans’ are effective in cervicogenic headache (that is why there is a misdiagnosis!). This suggests that the mechanisms of migraine, tension headache and neck-related headache are similar and that a neck disorder is capable of referring pain into the facial region, raising the possibility that ‘sinus’ headache may actually be referred pain from a neck disorder.

Indeed my experience is (and a significant body of research demonstrates) that facial pain and pressure is often a referred pain from a neck disorder. A very aware Ear, Nose and Throat surgeon sends me patients with ‘sinus’ headache to determine if it is referred from the neck before embarking on surgery, thus avoiding unnecessary and the not insignificant surgery!

Cheers

Dean

(Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin North Am 2004 Apr;37(2):267-88

Kari E, DelGaudio JM. treatment of sinus headache as migraine: the diagnostic utility of triptans. Larygoscope 2008 Dec;118(12) :2235-9

Pavese N, Bibbiani F, Nuti A, Bonuccelli U. Sumatriptan in cervicogenic headache. Proceedings European Headache Federation 2nd International Conference 1994; Abstract 131

Tepper SJ. New thoughts on sinus headache. Allergy Asthma Proc 2004 Mar-Apr;25(2):95-96 ;

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.

Does Your Headache or Migraine Swap Sides?

July 3, 2009 by dean · Leave a Comment 

If headache or migraine swap sides it is a cervicogenic (neck) headache

If headache or migraine swap sides it is a cervicogenic (neck) headache

The traditional medical model of headache defines cervicogenic headache as a side-locked headache i.e. it is always on the same side. However if a headache alternates or shifts from side to side, either between (attacks), or within the same attack, then it is migraine.

My experience of over 21000 hours with headache and migraine patients contradicts this view - if your headache or ‘migraine’ swaps sides, it is a cervicogenic (neck) headache – no doubt. A significant majority of migraine headaches swap sides – does this mean I am saying that a significant majority of migraine headaches are cervicogenic headaches – yes, this is my experience!

These alternating headaches are usually triggered by neck flexion (forward bending) and in those who have had a neck X-ray 75% have a decreased neck lordosis (the naturally occurring inward curve). Neck flexion decreases the lordosis even further ….

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.

Does Your Headache or Migraine Swap Sides?

June 17, 2009 by dean · Leave a Comment 

If headache/migraine swaps sides it is a neck headache

If headache/migraine swaps sides it is a neck headache

The traditional medical model of headache and migraine, describes one of the key diagnostic criteria for cervicogenic headache as being a side-locked headache – which means that it is always on the same side – never on the other.

I have news for you. Based on over 13000 hours clinical experience with headache and migraine sufferers, I can confidently say that if your headache or migraine swaps sides between attacks, or within the same attack, it is a cervicogenic headache! … and the problem lies with the C2-3 spinal segment.

Cheers  Dean

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