Hemicrania Continua – What Is It?
August 29, 2009 by dean · Leave a Comment
I have mentioned Hemicrania Continua a few times in my blogs assuming that you are familiar with this condition.
Hemicrania Continua is a headache characterised by constant pain on one side of the head (and always on the same side), of moderate severity, with episodes of aggravation. Hemicrania responds to the medication known as Indomethacin.
Hemicrania Continua is included (along with Cluster headache, Chronic Paroxysmal Hemicrania, and SUNCT) in the third primary group of headache classified by the International headache Society.
As with all of the headache and migraine types, Hemicrania Continua is based on a set of signs and symptoms with no indication as to the cause.
Cheers
Dean
(Peres MFP, Siow HC, Rozen TD. Hemicrania continua with aura. Cephalalgia 2002;22:246-248)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Neck X-Rays, Headache and Migraine
August 28, 2009 by dean · Leave a Comment
Neck X-Ray
Generally routine neck xrays are uninformative for headache or migraine sufferers. However, this does not exclude neck disorders as the source of headache or migraine.
Therefore xrays as a form of diagnosis are not highly regarded. Nevertheless it is very important that neck xrays be undertaken in the event of any significant head or neck trauma or injury.
It is information from structures supplied by the upper three cervical nerves which have access to the brainstem and therefore the potential to sensitise the brainstem. Consequently abnormalities seen on neck xrays, involving spinal segments below C3 (third cervical vertebra) are likely to be irrelevant. This is why it is crucial that when having a CT or MRI scan of your neck for headache that the upper 3 spinal segments are included.
Degenerative changes or spondylosis of C5-6 for example is irrelevant to the sensitisation process; information from this level does not have direct access to the brainstem.
Cheers
Dean
(Goldhammer L. Second cervical root neurofibroma and ipsilateral migraine headache. Cephalalgia 1993; 13:132
Jansen J, Markakis E, Rama B, Hildebrandt J. Hemicranial attacks or permanent hemicrania – a sequel of upper cervical root compression. Cephalalgia 1989; 9:123-30
Ward TN, Levine M. Headache caused by a spinal cord stimulator in the upper cervical spine. Headache 2000; 40:689-91)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Exertional Headache, Migraine and the Neck
August 26, 2009 by dean · Leave a Comment
"Exertional Headache"
‘Benign’ (or harmless) Exertional Headache is defined as headache caused by exertion such as coughing, sneezing, bending, heavy lifting, running (how is this different to headache triggered by exercise?) or when straining at stool.
It is important that if your headache history is less than 3 months and is triggered or aggravated by these activities that you consult you doctor.
These activities create similar effects on the body as do the Valsalva manoeuvers.
Recent research1 found a wide range of symptoms in Exertional Headache, some with migrainous symptoms, and the authors suggested that the ‘triptans’ might be useful. As usual there is a lot of discussion as to the actual mechanism of Exertional Headache and indeed Exercise Induced Headache, but the causes remain unknown – why?
The Valsalva manoeuver is used (and has been for years) to identify problems or injury in the nerves of the cervical spine. Upon the exertion of pressure, pain may be felt, and may indicate increased pressure on the C2-3 intervertebral disc or other part of a cervicogenic (neck) disorder.
Clearly increased headache or headache or migraine triggered by exertion or exercise is likely to be caused by a neck disorder.
Cheers
Dean
(Chen S-P, Fuh J-L, Lu S-R, Wang S-J. Exertional headache – a survey of 1963 adolescents. Cephalalgia 2008; 29:401-407
Johnson RH, Smith AC, Spalding JM (February 1969). “Blood pressure response to standing and to Valsalva’s manoeuvre: independence of the two mechanisms in neurological diseases including cervical cord lesions”. Clin Sci 36 (1): 77–86)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Headache and Migraine Causes
August 25, 2009 by dean · Leave a Comment
The recent research has shown convincingly that migraine and headache is underpinned by sensitisation of the brainstem or central sensitisation.
One of the potential sources of senstisation of the brainstem is abnormal information from a disorders of structures within the head, structures which are supplied by the trigeminal nerve. It is then interesting to find that headache persists after blocking information carried by the trigeminal nerve. This clearly demonstrates that headache or migraine can come from other sources, for example neck disorders, and that the triptans act on structures other than in the head to ease headache or migraine … a sensitised brainstem … sensitised from another source … perhaps a neck disorder?
This can be easily confirmed by a skilled examination of the upper neck structures.
Cheers
Dean
(Matharu MS, Goadsby PJ. Persistence of attacks of cluster headache after trigeminal nerve root resection. Brain 2002;125(pt5):976-984)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
Headache, Migraine and Auras
August 23, 2009 by dean · Leave a Comment
As I have mentioned previously, recent and substantial research demonstrates that the different types of headache and migraine develop from a common, shared disorder, and that this disorder is sensitisation of the brainstem.
Auras, which initially were thought to only accompany migraine and menstrual migraine, have now been reported in Cluster Headache and Hemicrania Continua, and provides further evidence that the various forms of headache and migraine are likely to originate from common disorder.
Cheers
Dean
(Bahra A, May A, Goadsby PJ. Cluster headache: a prospective clinical study with diagnostic implications. Neurology 2002;58:354-361
Peres MFP, Siow HC, Rozen TD. Hemicrania continua with aura. Cephalalgia 2002;22:246-248
Silberstein SD, Niknam R, Rozen TD, Young WB. Cluster headache with aura. Neurology 2000;54:219-221)
© 2009 & Beyond. Watson Headache Institute, All Rights Reserved.
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.
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.