Migraine Headaches
What is it?
A migraine is a complex, chronic neurological disorder characterized by recurrent moderate to severe headaches. A migraine is recognized as a more complex series of neurologic and vascular events where vasodilation may or may not be present. Evidence states that a patient with migraine brain is hyperexcitable and uniquely predisposed to migraine headaches. Patients also demonstrate changes in the performance of functional tasks, suggesting early motor control deterioration.
Over 30 million Americans suffer from at least one migraine each year. One in six American women suffers from migraine headaches. Migraine headaches cause more work-related disability and lost productivity than any other common headache. Over 80% of migraine patients miss work due to their headaches, with an average of 4-6 absences per year.
Migraine headaches demonstrate a strong genetic component.
Overweight patients are more susceptible to migraines. Low cardiovascular fitness increases one's risk as well. Vascular risks include hypertension, hypercholesterolemia, impaired insulin sensitivity, coronary artery disease, and history of stroke.
Medication overuse is one of the more important risk factors for migraine progression. Migraines tend to become “chronic” when following the overuse of medications such as acetaminophen, aspirin, etc.
Hypocalcemia and a vitamin D deficiency are usually associated with an increased risk of migraine headaches. Some known triggers include smoking, strong odors (perfumes), bright or flicking light, fluorescent light, excessive or insufficient sleep, head trauma, weather changes, lack of activity or exercise, dehydration, hunger, and hormonal changes. Some food triggers include alcohol, excessive caffeine, artificial sweeteners, soy sauce, watermelon, citrus foods, papayas, avocados, overripe bananas, sour cream, nuts, peanut butter, aged meats and cheese, and anything fermented.
Upper cervical tension or the presence of a cervicogenic headache may be a trigger to a migraine.
Clinical Presentation
Approximately 60% of sufferers report prior symptoms in the hours to days before a headache onset. These symptoms include lethargy, yawning, food cravings, mood changes, excessive thirst, fluid retention, constipation, diarrhea, and hypersensitivity to light, sound or odors. Patients may experience irritable bowel syndrome along with migraines.
Symptoms are most commonly visual but also include a combination of sensory and motor components. The most common visual symptom is a band of absent vision with an irregular shimmering border. Another visual effect is tunnel vision. Less than one in five patients experience motor symptoms, including a sense of heaviness in their limbs or speech and language disturbances. Motor and sensory complaints, including paresthesia and numbness rarely occur in isolation.
Eighty percent of migraine patients experience some nausea. Seventy-five percent of patients report some type of associated neck discomfort. Researchers have identified the presence of nausea, disability, and photophobia as the most significant predictor of migraines.
During the attack phase the patient will usually complain of a unilateral, moderate to severe, throbbing or pulsating headache. The pain may be felt anywhere in the head and neck but is most common in the frontal, temporal and ocular areas. Headache pain develops over a period of one or two hours and can last up to 4 and 72 hours. Patients often report a hypersensitivity to light and sound and may retreat to dark, quiet places.
Migraine patients often demonstrate limited upper cervical and global cervical range of motion. Patients can also experience issues with their jaw and may have TMD.
The end of a migraine attack symptoms occur a few hours after and usually includes fatigue, irritability, euphoria, myalgia, food insensitivity, or cravings.
The presence of a migraine can increase one’s risk of cardiovascular disease by up to 25%. Migraines can also be strongly associated with ischemic stroke. Not surprisingly, migraine patients are more likely to report cold extremities.
Diagnosis
Patients whose symptoms fit the broad definition of migraines rarely require imaging. The diagnosis of migraines is mostly based on the patient’s history. A thorough physical and neurological assessment is required to exclude more threatening conditions, however normal results are expected with those only experiencing migraines. When alternate pathology is suspected, an MRI is a preferred neuroimaging choice.
Management
Treatment to stop an attack is most effective when given within the first minutes of an attack. However, overuse of treatment to stop an early attack may generate a self-perpetuating, chronic rebound cycle of a migraine.
Several clinical trials and research has shown that spinal manipulation is an appropriate treatment for a migraine. Manipulation of the spine has also shown a significant reduction of intensity of a patient’s migraine attacks. About one fourth of patients reported greater than 90% fewer attacks. It also demonstrated a longer lasting benefit and fewer side effects than other medical treatment. Manipulation decreases pain though CNS activation, elevation of endorphin levels, and reduction of mechanical triggers.
Manual therapy including soft tissue manipulation and massage therapy has demonstrated success in the treatment of migraine headache. Migraine patients can harbor trigger points in the SCM, upper traps, and/or splenius capitis that when activated can reduce migraine headaches. Soft tissue manipulation and myofascial release techniques are appropriate for the treatment of related cervical,interscapular, and shoulder girdle musculature.
Clinicians should assess and treat for postural abnormalities, including weakness of the deep neck flexors and upper crossed syndrome.
Dry needling can be used to help manage migraine headaches.
Exercising for 40 minutes, three times a week has shown similar benefits to prophylactic medication. Staying hydrated because research has shown that inadequate water intake and migraines correlate with each other.
The patient should self-manage and focus on trigger avoidance and stress management. Acupuncture is a great tool for stress management and helping with migraines. Patients who are overweight should look for dietary advice. Magnesium supplementation has a strong support to preventing and relieving migraines. Vitamin D deficiency is associated with migraine attacks.