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Diagnosing Headache and Migraine – A Dog’s Breakfast.

dean — Thu, 20 Aug 2009 00:48:02 +0000

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)

What Does Blocking The Greater Occipital Nerve Do?

dean — Sun, 02 Aug 2009 23:30:25 +0000

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)

Diagnosing Headache and Migraine From Symptoms is Complex

dean — Wed, 15 Jul 2009 23:30:15 +0000

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)

Does Your Headache or Migraine Swap Sides?

dean — Wed, 17 Jun 2009 10:25:17 +0000

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

Welcome Headache and Migraine Sufferers

dean — Tue, 09 Jun 2009 11:32:08 +0000

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

Headache and Migraine Education

dean — Wed, 03 Jun 2009 10:10:30 +0000

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

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)