Headache/Migraine

Headaches affect 70% of the population and account for roughly 80 million lost work days per year. However, only 5% of those people, consult with a physician. Historically, a typical chiropractic practice sees anywhere from 20%-50% headache patients.

Recently, two dental researchers at the University of Maryland made an important discovery. They were studying the muscles of the jaw and came across a structure that had never been documented before. What they discovered was a "bridge" between the central nervous system and the muscles of the neck. This new structure is a connection between a muscle in the neck to the pain sensitive outer covering of the spinal cord, the Dura matter. The Dura is the outermost covering of the brain and spinal cord. Never before had this anatomical structure been described in modern anatomy's 500 year history. This new discovery provides an explanation as to how neck structures can affect headache pain.

Neurosurgeons have always noted that the brain is insensitive to pain but the outer coverings are extremely sensitive to tension during neuro-surgical procedures and can produce headaches. And an increasing number of researchers postulate headache pain is primarily caused by dysfunction in the neck, and we now have the anatomical basis for it.

This new way of looking at headache pain may be news to some in the healing arts, but it is not new to Chiropractors, Osteopaths and other health professionals who routinely perform spinal manipulation. A growing body of scientific literature relates headaches to injuries or pathology affecting the structures of the neck. And a growing body of clinical trials have suggested treatments such as spinal manipulation are valuable at managing headaches. Of special note, Chiropractic physicians perform over 90% of the spinal manipulation in this country.

This new discovery provides an anatomical explanation as to why Chiropractors have been successfull treating headaches. Neurosurgeons have noted a decrease in headaches when this muscle "bridge" has been surgically severed. One surgeon, in Johannesburg, South Africa, has developed a surgical procedure to cut this muscle, but I would suggest you give conservative Chiropractic care a try before trying an invasive procedure.

Medline Articles on Headache/Migraine

• The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache.
  Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. Center for Clinical Studies, Northwestern College of Chiropractic, Bloomington, MN 55431, USA. cnelson@nwchiro.edu
  J Manipulative Physiol Ther 1998 Oct;21(8):511-9
  
  BACKGROUND: Migraine headache affects approximately 11 million adults in the United States. Spinal manipulation is a common alternative therapy for headaches, but its efficacy compared with standard medical therapies is unknown. OBJECTIVE: To measure the relative efficacy of amitriptyline, spinal manipulation and the combination of both therapies for the prophylaxis of migraine headache. DESIGN: A prospective, randomized, parallel-group comparison. After a 4-wk baseline period, patients were randomly assigned to 8 wk of treatment, after which there was a 4-wk follow-up period. SETTING: Chiropractic college outpatient clinic. PARTICIPANTS: A total of 218 patients with the diagnosis of migraine headache. INTERVENTIONS: An 8-wk course of therapy with spinal manipulation, amitriptyline or a combination of the two treatments. MAIN OUTCOME MEASURES: A headache index score derived from a daily headache pain diary during the last 4 wk of treatment and during the 4-wk follow-up period. RESULTS: Clinically important improvement was observed in both primary and secondary outcomes in all three study groups over time. The reduction in headache index scores during treatment compared with baseline was 49% for amitriptyline, 40% for spinal manipulation and 41% for the combined group; p = .66. During the posttreatment follow-up period the reduction from baseline was 24% for amitriptyline, 42% for spinal manipulation and 25% for the combined group; p = .05. CONCLUSION: There was no advantage to combining amitriptyline and spinal manipulation for the treatment of migraine headache. Spinal manipulation seemed to be as effective as a well-established and efficacious treatment (amitriptyline), and on the basis of a benign side effects profile, it should be considered a treatment option for patients with frequent migraine headaches.
  
  
• Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial.
  Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Northwestern College of Chiropractic, Center for Clinical Studies, Minnesota, USA.
  J Manipulative Physiol Ther 1995 Mar-Apr;18(3):148-54
  
  OBJECTIVE: To compare the effectiveness of spinal manipulation and pharmaceutical treatment (amitriptyline) for chronic tension-type headache. DESIGN: Randomized controlled trial using two parallel groups. The study consisted of a 2-wk baseline period, a 6-wk treatment period and a 4-wk posttreatment, follow-up period. SETTING: Chiropractic college outpatient clinic. PATIENTS: One hundred and fifty patients between the ages of 18 and 70 with a diagnosis of tension-type headaches of at least 3 months' duration at a frequency of at least once per wk. INTERVENTIONS: 6 wk of spinal manipulative therapy provided by chiropractors or 6 wk of amitriptyline treatment managed by a medical physician. MAIN OUTCOME MEASURES: Change in patient-reported daily headache intensity, weekly headache frequency, over-the-counter medication usage and functional health status (SF-36). RESULTS: A total of 448 people responded to the recruitment advertisements; 298 were excluded during the screening process. Of the 150 patients who were enrolled in the study, 24 (16%) dropped out: 5 (6.6%) from the spinal manipulative therapy and 19 (27.1%) from the amitriptyline therapy group. During the treatment period, both groups improved at very similar rates in all primary outcomes. In relation to baseline values at 4 wk after cessation of treatment, the spinal manipulation group showed a reduction of 32% in headache intensity, 42% in headache frequency, 30% in over-the-counter medication usage and an improvement of 16% in functional health status. By comparison, the amitriptyline therapy group showed no improvement or a slight worsening from baseline values in the same four major outcome measures. Controlling for baseline differences, all group differences at 4 wk after cessation of therapy were considered to be clinically important and were statistically significant. Of the patients who finished the study, 46 (82.1%) in the amitriptyline therapy group reported side effects that included drowsiness, dry mouth and weight gain. Three patients (4.3%) in the spinal manipulation group reported neck soreness and stiffness. CONCLUSIONS: The results of this study show that spinal manipulative therapy is an effective treatment for tension headaches. Amitriptyline therapy was slightly more effective in reducing pain at the end of the treatment period but was associated with more side effects. Four weeks after the cessation of treatment, however, the patients who received spinal manipulative therapy experienced a sustained therapeutic benefit in all major outcomes in contrast to the patients that received amitriptyline therapy, who reverted to baseline values. The sustained therapeutic benefit associated with spinal manipulation seemed to result in a decreased need for over-the-counter medication. There is a need to assess the effectiveness of spinal manipulative therapy beyond four weeks and to compare spinal manipulative therapy to an appropriate placebo such as sham manipulation in future clinical trials.
  
  
• Cervicogenic dysfunction in muscle contraction headache and migraine: a descriptive study.
  Vernon H, Steiman I, Hagino C. Center for the Study of Spinal Health, Canadian Memorial Chiropractic College, Toronto, Ontario.
  J Manipulative Physiol Ther 1992 Sep;15(7):418-29
  
  OBJECTIVE: The prevalence and nature of findings of cervicogenic dysfunction is explored in subjects with muscle contraction/tension-type (MCH) headache and common migraine without aura (CM). DESIGN: Descriptive survey. SETTING: Chiropractic outpatient research clinic. PATIENTS: Forty-seven (47) subjects, aged 18-55 with two categories of benign headache, were studied: MCH (tension-type) n = 19 (6 males, 13 females) and CM (without aura), n = 28 (3 males, 25 females). Subjects were recruited as part of an intervention trial and, thus, form a consecutive sample of patients. The present findings were elicited as part of the initial assessment. INTERVENTION: No therapeutic intervention is reported. MAIN OUTCOME MEASURES: Standardized headache history; plain film and dynamic spinal X rays; motion palpation; and pressure algometry. RESULTS: For CM, the most prevalent headache locations were frontal (81%) and occipital (78%). Neck pain and upper back pain accompanied headache in 90% and 41% of subjects, respectively. For MCH, the most prevalent headache locations were occipital (87%) and frontal (81%). Neck and upper back pain accompanied headache in 100% and 27%, respectively, of all subjects. For the total group, 77% of all subjects and 89% of females exhibited a marked reduction, absence or reversal of the normal cervical lordosis. Ninety-seven percent of all subjects exhibited, on dynamic X-ray studies, at least one significant abnormality of segmental mobility from C1 to C7, while 43% exhibited abnormalities at four or more segments. Segmental motion at C0-C1 was reduced in 90% of subjects in flexion and 70% of subjects in extension. On motion palpation, 84% of CM and MCH subjects were found to have at least two major fixations from C0 to C2. On pressure algometry, 92% of CM and 85% of MCH had at least one verifiable tender point (TP) in the upper cervical region. The most common locations for TPs were mid-cervical (C2-C3), lateral occipital and suboccipital. CONCLUSIONS: Both MCH and CM subjects demonstrate high occurrences of: a) occipital and neck pain during headaches; b) tender points in the upper cervical region; c) greatly reduced or absent cervical curve; and d) X-ray evidence of joint dysfunction in the upper and lower cervical spine. These findings support the premise that the neck plays an important, but largely ignored role in the manifestation of adult benign headaches. A case-control study should be conducted to confirm the greater prevalence of cervicogenic dysfunction in headache as compared to nonheadache subjects.
  
  
• A randomized controlled trial of chiropractic spinal manipulative therapy for migraine.
  Tuchin PJ, Pollard H, Bonello R. Department of Chiropractic, Macquarie University, New South Wales, Australia.
  J Manipulative Physiol Ther 2000 Feb;23(2):91-5
  
  OBJECTIVE: To assess the efficacy of chiropractic spinal manipulative therapy (SMT) in the treatment of migraine. DESIGN: A randomized controlled trial of 6 months' duration. The trial consisted of 3 stages: 2 months of data collection (before treatment), 2 months of treatment, and a further 2 months of data collection (after treatment). Comparison of outcomes to the initial baseline factors was made at the end of the 6 months for both an SMT group and a control group. Setting: Chiropractic Research Center of Macquarie University. PARTICIPANTS: One hundred twenty-seven volunteers between the ages of 10 and 70 years were recruited through media advertising. The diagnosis of migraine was made on the basis of the International Headache Society standard, with a minimum of at least one migraine per month. INTERVENTIONS: Two months of chiropractic SMT (diversified technique) at vertebral fixations determined by the practitioner (maximum of 16 treatments). MAIN OUTCOME MEASURES: Participants completed standard headache diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms, and use of medication for each migraine episode. RESULTS: The average response of the treatment group (n = 83) showed statistically significant improvement in migraine frequency (P < .005), duration (P < .01), disability (P < .05), and medication use (P< .001) when compared with the control group (n = 40). Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. Expressed in other terms, 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the morbidity of each episode. CONCLUSION: The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.
  
  
• A proposed etiology of cervicogenic headache: the neurophysiologic basis and anatomic relationship between the dura mater and the rectus posterior capitis minor muscle.
  Alix ME, Bates DK. Logan College of Chiropractic, Chesterfield, Missouri, USA.
  J Manipulative Physiol Ther 1999 Oct;22(8):534-9
  
  OBJECTIVE: To examine the neurophysiologic basis and anatomic relationship between the dura mater and the rectus capitis posterior minor muscle in the etiologic proposition of cervicogenic headache. DATA SOURCES: On-line searches in MEDLINE and the Index to Chiropractic Literature, manual citation searches, and peer inquiries. RESULTS: Connective tissue bridges were noted at the atlanto-occipital junction between the rectus capitis posterior minor muscle and the dorsal spinal dura. The perpendicular arrangement of these fibers appears to restrict dural movement toward the spinal cord. The ligamentum nuchae was found to be continuous with the posterior cervical spinal dura and the lateral portion of the occipital bone. Anatomic structures innervated by cervical nerves C1-C3 have the potential to cause headache pain. Included are the joint complexes of the upper 3 cervical segments, the dura mater, and spinal cord. CONCLUSION: A sizable body of clinical studies note the effect of manipulation on headache. These results support its effectiveness. The dura-muscular, dura-ligamentous connections in the upper cervical spine and occipital areas may provide anatomic and physiologic answers to the cause of the cervicogenic headache. This proposal would further explain manipulation's efficacy in the treatment of cervicogenic headache. Further studies in this area are warranted to better define the mechanisms of this anatomic relationship.
  
  
• The effect of spinal manipulation in the treatment of cervicogenic headache.
  Nilsson N, Christensen HW, Hartvigsen J. Institute of Medical Biology (Biomechanics), Faculty of Health Science, University of Odense, Denmark.
  J Manipulative Physiol Ther 1997 Jun;20(5):326-30
  
  PURPOSE: To study whether the isolated intervention of high-speed, low-amplitude spinal manipulation in the cervical spine has any effect on cervicogenic headache. DESIGN: Prospective randomized controlled trial with a blinded observer. SETTING: Ambulatory outpatient facility in an independent research institution. PARTICIPANTS: Fifty-three subjects suffering from frequent headaches who fulfilled the International Headache Society criteria for cervicogenic headache (excluding radiological criteria). These subjects were recruited from 450 headache sufferers who responded to newspaper advertisements. INTERVENTION: After randomization, 28 of the group received high-velocity, low-amplitude cervical manipulation twice a week for 3 wk. The remaining 25 received low-level laser in the upper cervical region and deep friction massage (including trigger points) in the lower cervical/upper thoracic region, also twice a week for 3 wk. MAIN OUTCOME MEASURES: The change from week 1 to week 5 in analgesic use per day, in headache intensity per episode and in number of headache hours per day, as registered in a headache diary. RESULTS: The use of analgesics decreased by 36% in the manipulation group, but was unchanged in the soft-tissue group; this difference was statistically significant (p = .04, chi 2 for trend). The number of headache hours per day decreased by 69% in the manipulation group, compared with 37% in the soft-tissue group; this was significant at p = .03 (Mann-Whitney). Finally, headache intensity per episode decreased by 36% in the manipulation group, compared with 17% in the soft-tissue group; this was significant at p = .04 (Mann-Whitney). CONCLUSION: Spinal manipulation has a significant positive effect in cases of cervicogenic headache.