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.
What Does Blocking The Greater Occipital Nerve Do?
August 3, 2009 by dean · Leave a Comment
I have been mentioning the research which shows that by injecting and anaesthetising the greater occipital nerve the migraine process can be halted … so what does this do?
Anaesthetising the greater occipital nerve prevents information from (neck) structures supplied by the nerve from entering into the spinal cord (and the brainstem). The effect of this on migraine and headache symptoms suggests that this information being carried by the nerve was sensitising the brainstem and that by preventing it from reaching the brainstem, the brainstem is no longer sensitised.
This then is considered a diagnostic tool to confirm cervicogenic (neck) disorders in headache and migraine.
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;47:917-928
Sjaastad O, Fredricksen TA, Pfaffenrath V. Cervicogenic headache: diagnostic criteria. Headache 1998; 38:442-5
Tobin J,Stephen Flitman S. Nerve Blocks: When and What to Inject? Headache 2009
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 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.
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
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.
Headache and Migraine Course in Dursley
June 15, 2009 by dean · Leave a Comment
Whilst the group was small (it was on the Bank Holiday weekend!) on this Level I course there was considerable activity and the course delegates had plenty of time to practice and hone their skills. The Level II course provided delegates with an opportunity to develop their skills further.
Excerpts from feedback forwarded to Manipulation Association of Chartered Physiotherapists:
“ …Fantastic course – gave me a great understanding of headaches Ax (assessment) and Rx (treatment) skills, looking forward to trying on my patients; Excellent teaching, motivating and good feedback; small group, excellent opportunity to practice techniques and get good feedback from Dean; Good timing/pace, supportive tutor, encouraging …”
It is this feedback that is rewarding.
As usual I was well looked after by Wendy and Clif and a surprise was a meal by host Chris Stephenson (Principal of Courtyard Clinic) – and a legendary chef from all accounts – and I was impressed – Thanks Chris!
Dursley is a pretty village but I can’t help but look forward to teaching in sunny Spain!
Cheers
Dean
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Headache and Migraine Courses in Cambridge
June 13, 2009 by dean · Leave a Comment
Level II Headache and Migraine Course Presentation
I have just completed my teaching tour in the Northern Hemisphere – the first venue was the Cambridge Physiotherapy Clinic, and as usual I was well looked after by my hosts, Anne-Marie Melloy and Martin Callingham. Both Level I and II Courses were well attended and the feedback included …
Excerpts from feedback forwarded to the Manipulation Association of Chartered Physiotherapists (MACP):
“…Practical sessions, Dean’s explanations, excellent information and pack, real patients; very specific, learnt new assessment and Rx techniques; excellent manual handling teaching and clinical reasoning, having patients brought things together well; Dean’s person and experience, patient demos; plenty of practical and a lot of supervision during practical; Clinical reasoning and practical approach; well reasoned, clinically applicable course, good approachable teaching style; Excellent differential diagnosis, practical sessions supported with understandable teaching, patient demos helped integrate learning, easy techniques that can be used immediately …”
Emails received from course delegates:
“I’m ……, the Italian guy that attended your course in Cambridge in April. I write to you first of all to thank you for what you teach …. It is very helpfull and, the most important thing, it works!!! It is surprising how easy it is now for me to reproduce and lessen the patient’s headache…”
“I thoroughly enjoyed the advanced part of the course which I attended in Cambridge a couple of weeks ago, you have enthused me in wanting to specialise and become proficient in the treatment of headache and migraine.”
I was ably assisted by Jayne Davies (MSc., MCSP, MMACP), who has been instrumental in organising the interactive headache website on the Chartered Society of Physiotherapy’s website. This site enables physiotherapists to discuss issues surrounding headache diagnosis and management – Well done Jayne!
The weather was reasonable given that I had left an Aussie springtime!
Cheers
Dean
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Welcome Headache and Migraine Sufferers
June 9, 2009 by dean · Leave a Comment
In 1991 I embarked on a path that was to become the greatest challenge of my life, establishing The Headache Clinic, www.headacheclinic.com.au, in Adelaide, South Australia, in 1991. The fundamental purpose of The Headache Clinic was and is determining whether or not a neck (cervicogenic) disorder is the cause of or a significant contributing factor to headache or migraine.
We are the sum of our experiences — and my unparalleled clinical experience (having consulted over 7000 headache and migraine patients – in excess of 28000 treatments – with a range of diagnoses) suggests that neck (cervicogenic) dysfunction is significantly underestimated and can be the cause of various forms of headache and migraine. I believe therefore, that, in the presence of negative medical tests, the necks of all (primary) headache and migraine sufferers should be examined, irrespective of the diagnosis. Whilst this challenges traditionally held medical beliefs, it is incumbent to not only pass on this experience to my colleagues and headache and migraine sufferers, but to support this experience with rigorous scientific research (I am currently a PhD Candidate investigating the role of cervicogenic dysfunction in the mechanism of migraine at Murdoch University, Western Australia).
It is irresponsible to treat irrelevant cervicogenic (neck) dysfunction in migraine and headache conditions. However given that the causes of migraine and tension headache are not clear, the advances in our knowledge of pain mechanisms and the not insignificant body research supporting cervicogenic factors as key players in the headache and migraine processes, it is also irresponsible not to examine the necks of headache sufferers irrespective of the diagnosis. How much longer do we accept the notion that ‘whilst we do not know what causes migraine it can’t come from the neck’?
Over the past 15 years I have developed a series of techniques, which, by way of temporary reproduction of headache and easing of the headache as a technique is sustained, confirm that a neck disorder is the cause of or a significant factor in the mechanism of the headache or migraine – this a key diagnostic criterion for cervicogenic or neck involvement in headache according to the International Headache Society – importantly for the disorder to be related to the headache or migraine process the headache has to ease as the technique is maintained. If both reproduction and lessening are not possible then the neck may not be the source of the headache or migraine. Furthermore my experience has shown that if the techniques are performed in a specific manner it is possible to determine which spinal segment is the cause of or contributing significantly to headache and migraine. Having determined which spinal segment (or segments — there may be more than one) is involved then this significantly increases the chance of the treatment being successful because treatment can be directed at specific, relevant spinal segments.
The application of these techniques in Europe, United Kingdom and Australia has become known as the ‘Watson Headache Approach’ and forms the basis of courses I present for physiotherapists, chiropractors and osteopaths in Australia, New Zealand, Hong Kong, Singapore, United Kingdom, Northern Ireland, Belgium, The Netherlands, Switzerland, Germany, Norway and Spain — refer www.headacheeducation.com and www.headacheandmigraine.com for International Practioner Directory.
The Watson Headache Institute was established to increase the awareness of cervicogenic (neck) disorders in headache and migraine by:
imparting my (and that of others) clinical experience and knowledge
and,
undertaking and supporting rigorous clinical and scientific research in this specialty.
Dean Watson
Consultant Headache and Migraine Physiotherapist; Adjunct Lecturer, Masters Program, School of Physiotherapy, University of South Australia; PhD Candidate, Murdoch University, Western Australia
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Headache and Migraine Education
June 3, 2009 by dean · Leave a Comment
Appropriate up to date knowledge is self empowering
Appropriate and up-to-date knowledge is self-empowering; I believe that every headache and migraine sufferer has the right to know their headache and migraine diagnosis as precisely as possible (and what it means), to know the nature of their headache disorder, its outcome and possible types of treatment. What has yet to gain acceptance is my belief, supported by my unparalleled clinical experience and a significant body of international research, that it is incorrect to consider headache and migraine types as totally different entities. ‘Headache and Migraine Education’ is one of the aims of Watson Headache Institute – it is here that relevant, past and present research will be summarised and discussed…
Cheers Dean
(Afridi SK, Shields KG, Bhola R, Goadsby PJ. Greater occipital nerve injection in primary headache syndromes – prolonged effects from a single injection. Pain 2006; 122:126-9)
Anderson CD, Franks RA. Migraine and tension headache: is there a physiological difference? Headache 1981; 21:63-71
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
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
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.