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 4, 2009 by dean · Leave a Comment 

The second ‘bill’:

“The headache sufferer has the right to be taken seriously by the healthcare providers, whose duty it is to take down a relevant history (I have no issues with these!), conduct a relevant physical examination, provide advice and reassurance and prescribe the treatment most advantageous and acceptable to the patient according to current knowledge.”

The issue I have here is with:

conduct a relevant physical examination

It is appropriate that a neurologist conduct the aspects of the physical examination which rule out serious causes of headache – however and with respect the neurologist, physician, or general practitioner are not skilled in examination of the structures of the upper neck – this is where the ‘system’ fails you, the headache or migraine sufferer …. the prognosis, treatment, advice are dependent on the examination, which at this point in time is incomplete; incomplete because your neck has not been examined comprehensively.

So let’s summarise from the first 2 of the 4 ‘bills’ of rights’:

a precise diagnosis is not possible (and besides, does it mean anything)

the nature of the disorder is a sensitised brainstem

the prognosis and best treatment options are dependent on identifying the reason for the sensitisation

the examination you will get will most likely be incomplete because your neck will not be comprehensively examined and therefore one of the most likely reasons for sensitisation (a neck disorder) will not identified ….

…. which means you are likely to be destined to a lifetime of medication which at best manages the symptoms and not the cause.

It is appropriate that as headache or migraine sufferer that you consult your medical practitioner to exclude serious causes of headache (which are extremely rare) but once the various tests have been carried out and there is nothing to find, then a skilled examination of your neck is indicated. Research has shown that information from neck disorders can sensitise the brainstem.

Cheers

Dean

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

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

The Headache and Migraine Sufferers Bill of Rights (cont)

December 3, 2009 by dean · Leave a Comment 

iStock_000007159824XSmall

The likely course or outcome of the condition is dependent on identifying the cause

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.

OK so we now need to look at:

its prognosis

The prognosis or the likely course or outcome of the condition clearly is dependent on identifying the cause of the condition, and despite the enormous amount of resources, financially and otherwise, the reason for the sensitisation of the brainstems in headache and migraine sufferers has not been identified ….. so prognosis cannot be predicted.

What next – the possible types of treatment ….. this depends on the examination and this is included in the second ‘bill’.

Until next time.

Cheers

Dean

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

© 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.

Menstrual Migraine – It’s Not Your Hormones!

November 4, 2009 by dean · Leave a Comment 

As a clinician I am often asked why I recommend the necks of menstrual migraine sufferers be examined when menstrual migraine supposedly results from hormonal imbalances or abnormal fluctuations etc.

As I have mentioned in previous posts research shows that menstrual migraine sufferers do not have irregular hormonal profiles or fluctuations and that the brainstems of menstrual migraine sufferers are sensitised just as they are in tension headache and migraine sufferers – and one source of sensitisation is abnormal information from neck disorders.

Review other posts about Menstrual Migraine by keying in Menstrual Migraine on the ‘Home Page’.

Cheers

Dean

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

Tension As A Factor In Worsening Tension Headache And Migraine

October 26, 2009 by dean · Leave a Comment 

The stress of "everyday life"

The stress and tension of "everyday life"

Research has shown that as many as 1 out of 10 migraine sufferers will develop daily migraine and whilst factors such as stressful life events, ongoing lesser every-day stressors and depression have been identified,1-6 neck disorders are not discussed.

Clearly significant life events such as divorce, death of a loved one, redundancy etc can cause significant tension for months/years and shortening of muscles in the upper neck can result. Then the stress of everyday life ‘stuff’ leads to more temporary further shortening of already shortened muscles, ligaments and capsules, exerting pressure on stiff joints leading to increased frequency of headache or migraine.

Once the daily stress lessens, headache and migraine eases, but the shortening which resulted from the stress of the major life event/s remains (this ongoing stiffness in the spinal segments is likely to result in sensitisation of the brainstem,7 which is now widely recognised as a key disorder in headache and migraine) waiting for the hassles of the next day, causing pressure on the stiff joints once again and migraine or headache results.

Headache or migraine which is increasing in frequency suggests that a neck disorder is worsening – if this is happening for you, I recommend that a skilled examination of your upper neck structures be performed as my experience suggests very strongly that your neck is the problem.

Cheers

Dean

(6. De Benedittis G, Lorenzetti A. Minor stressful life events (daily hassles) in chronic primary headache: Relationship with MMPI personality patterns. Headache. 1992;32:330-334.

1. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd edn. Cephalalgia. 2004;24(Suppl. 1):9-160.

3. Henry P, Auray JP, Gaudin AF, et al. Prevalence and clinical characteristics of migraine in France. Neurology. 2002;59:232-237.

4. Lanteri-Minet M, Auray JP, El HA, et al. Prevalence and description of chronic daily headache in the general population in France. Pain. 2003;102:143-149.

2. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache. 1998;38:497-506.

5. Scher AI, Stewart WF, Buse D, Krantz DS, Lipton RB. Major life changes before and after the onset of chronic daily headache: A population-based study. Cephalalgia. 2008;28:868-87)

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

Exercise and Migraine

October 20, 2009 by dean · Leave a Comment 

Exercise encourages serotonin production

Exercise encourages serotonin production

In a recent study 30 female migraineurs undertook an aerobic exercise program.

Measures of pain and psychological assessment (including body image, depression and quality if life) were assessed before and after completion of the 6 week exercise and exercise program.

The program led to a significant reduction migraine pain intensity. This is not surprising as exercise encourages serotonin production which desensitises the brainstem. Interestingly there was also an improvement in the depression related symptoms (I would be happier to if my migraine was less severe!), but the psychological factors were no different (good to see my experience confirmed i.e. migraine sufferers are psychologically normal!)

Sensitisation of the brainstem in my experience occurs because of a neck disorder and whilst increased serotonin is likely to improve symptoms the cause of the senstisation is still there. It is important that this (the neck) be confirmed and addressed – but start (and keep) exercising as well!

Cheers

Dean

(Dittrich SM, Guünther V, Franz G, Burtscher M, Holzner B, Kopp M. Clin J Sport Med. 2008;18:363-365 Aerobic exercise with relaxation: Influence on pain and psychological well-being in female patients. Clin J Sport Med. 2008;18:363-365)

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

Migraine Headache and Cervicogenic Headache

October 15, 2009 by dean · Leave a Comment 

The authors of this study have previously shown :

that neck pain is very common in migraine and is more often present during migraine than nausea

the presence of neck pain at the time of migraine treatment significantly decreases the chances of becoming pain-free within 2 hours

the presence of neck pain is likely to increase migraine-related disability irrespective of headache frequency and severity.

In the this study 127 migraine sufferers recorded 762 migraines and it was found that those with neck pain were less likely to achieve a pain free state and tended to have poorer outcomes than those with headache only i.e. without neck pain.

The authors considered that the presence of neck pain on the day before the migraine is associated with poorer treatment response; that neck pain before migraine is a better predictor of a poor treatment outcome than is headache only …. of course it is if the neck is not treated!

Clearly the reason for sensitisation can be abnormal information from neck disorders and if this is not addressed then treatment outcomes will be less than satisfactory.

Cheers

Dean

(Calhoun AH, Ford S. Headache or neck pain the day before: impact on migraine treatment outcome Cephalalgia 2009;29(Suppl. 1):1–166)

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

‘Tension Headache’ or ‘Migraine Without Aura’ or ‘Mixed’ Headache?

October 12, 2009 by dean · Leave a Comment 

Diagnosis cannot be done from symptoms alone

Diagnosis cannot be done from symptoms alone

This study from Spain demonstrates that diagnosing headache and migraine cannot be done from symptoms alone.

One hundred and five GPs were asked to examine and treat a patient who was considered (according to the International Headache Society’s diagnostic criteria) to be suffering migraine without aura.

Forty six diagnosed migraine correctly, 41 diagnosed the patient as tension-type headache, whilst 17 concluded ‘mixed’ headache and one GP was unable to diagnose the patient. One hundred and three recommended anti inflammatory medication as symptomatic treatment. Triptans were recommended by 67 GPs (including 15 of the 41 who had diagnosed the patient as tension-type headache). Preventive treatment was not considered by 30 GPs. A total of 66 GPs would prescribe beta-blockers (13 of the 41 who diagnosed tension-type headache), 35 amitriptyline (of whom 23 diagnosed tension-type headache) and the remaining 9, other treatments.

I have always maintained that a ‘diagnosis’ is not particularly useful – this study supports my clinical experience – what is the point of a diagnosis. The key to successful management is finding the source of the sensitisation; whilst the triptans may decrease the sensitisation they do not remove the source.

A skilled examination of the structures of the upper neck can identify relevant disorders – this involves temporary reproduction (and easing as the technique is sustained) of familiar head pain.

Cheers

Dean

(Pascual J, Sanchez A, Castillo J Dif?culties for diagnosing and treating migraine among general practitioners Cephalalgia 2009;29(Suppl. 1):1–166)

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

Are Whiplash Associated Headache, Cervicogenic Headache and Tension-Type Headache the same? Yes!

September 24, 2009 by dean · Leave a Comment 

A motor vehicle injury can result in allodynia

A motor vehicle injury can result in allodynia

Five patients who had developed headaches following a head and neck injury after a motor vehicle injury – the headaches had the same characteristics of tension-type headache.

Furthermore on examination it was found that they were all experiencing ‘allodynia’ (excessive tenderness to normal pressure). Allodynia is considered to be a sign of sensitisation of the brainstem. The area of allodynia suggested that it was as result of abnormal information from injuries sustained by structures in the neck.

This study further confirms that disorders of the neck are responsible for so-called ‘tension-type’ headache and that abnormal information from injured neck structures can sensitise the brainstem – a phenomenon which is evident not only in tension headache but also migraine, menstrual migraine and cluster headache ….. and that whiplash associated  headache exists!

Cheers

Dean

(Baruah JK and Baruah GR. Post traumatic headache and allodynia. Cephalalgia, 2009; 29(Suppl. 1):1–166

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

Varlibas A, Erdemoglu Ak. Altered trigeminal system excitability in menstrual migraine patients. The Journal of Headache and Pain 2009; 10(4):277-282)

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