Chiropractic Management of Migraine Headache
The upcoming holiday season will bring changes in diet, sleep, weather, and stress, each of which is a potential trigger for migraine headaches. This month’s clinical review provides the current best-practice management of this common and debilitating problem that you’re sure to see.
Introduction & Etiology
“Migraine” is a complex, chronic neurologic disorder characterized by recurrent moderate to severe headaches. The diagnosis of migraine is subdivided into “migraine without aura” (formerly common migraine), and “migraine with aura” (formerly classic migraine). (1) “Aura” is the collection of autonomic nervous system symptoms that occur immediately prior to the headache. (2) Aura symptoms may include visual disturbances, extremity paresthesia, nausea, vomiting, and hypersensitivity to light or sound.
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Early explanations for the genesis of migraine focused on cerebrovascular vasoconstriction with subsequent vasodilation. (3) Migraine is now recognized as a more complex series of neurologic and vascular events wherein vasodilation may or may not be present. (4-8) Evidence suggests that a migraineur’s brain is hyper-excitable and uniquely predisposed to migraine headaches in much the same way that an epileptic is susceptible to seizures. (8,9) Migraineurs also demonstrate changes in the performance of functional tasks, suggesting early motor control deterioration. (87)
Worldwide, the lifetime prevalence of migraine is 14%. (10) The one-year prevalence of migraine is 10% and shows little variance worldwide. (11) Over 30 million Americans suffer at least one migraine headache each year. (12) The condition affects 18- 21% of females and 6-10 % of males and is the leading cause of “severe” headaches. (12,88) One in six American women suffers from migraine headaches. (13) Migraine headaches cause more work-related disability and lost productivity than any other common type of headache. (121) Over 80% of migraineurs miss work as a result of their headaches, with an average of 4-6 absences per year. (14) The economic cost of migraine due to lost workdays is estimated at over 13 billion dollars per year in the United States.
The incidence of migraine without aura peaks in boys at age 10 and in girls age 17. (13) Interestingly, the incidence of migraine with aura peaks almost 5 years earlier for both sexes. (13) Before puberty, migraine is more common in boys. (15) At puberty, this ratio flips, and adult females are three times more likely than their male counterparts to experience migraine. (15) Migraine prevalence peaks in the third decade, and attacks generally decrease in severity and frequency after age 40. (15,81) The onset of a new migraine headache after age 50 is rare. (15)
Various risk factors have been identified for the development of this disorder. Migraine headaches demonstrate a strong genetic component. Having a first-degree relative with migraine increases one’s risk fourfold. (16) If one parent has migraines, the child has a 50% risk of developing the disorder. If both parents are affected, the risk climbs to 75%. (17) Overweight patients are more susceptible to migraine. (18,119) Low cardiovascular fitness increase risk. (102) Vascular risk factors include hypertension, hypercholesterolemia, impaired insulin sensitivity, coronary artery disease, and a history of stroke. (18)
Medication overuse is one of the more important risk factors for migraine progression. (19) Migraines tend to become “chronic” following overuse of acetaminophen, naproxen, aspirin, opiates, barbiturates, and triptans. (19) One study demonstrated that NSAIDs were beneficial when used less than 10 days a month but induced migraine progression to a chronic state when used at a higher frequency. (19) Hypocalcemia and vitamin D deficiency are associated with an increased risk of migraine attack. (97)
The (hyper-excitable) migraineur brain is susceptible to various “triggers.” Migraines develop when the number of triggers exceeds a critical threshold for a given patient. Known triggers include: stress, smoking, strong odors (i.e. perfumes), bright or flickering lights, fluorescent lighting, excessive or insufficient sleep, head trauma, weather changes, high humidity, motion sickness, cold stimulus (i.e. ice cream headaches), lack of activity/exercise, dehydration, hunger or fasting, and hormonal changes, including menstruation, and ovulation. (20,99) Upper cervical tension or the presence of a cervicogenic headache may be a trigger for a migraine. (59,65)
Certain medications, including estrogen, oral contraceptives, vasodilators, nitroglycerine, histamines, reserpine, hydralazine, and ranitidine are known triggers. (21) Food triggers are inconsistent among migraineurs, but the following foods are regularly implicated: alcohol (especially beer or red wine with tannins), excessive caffeine, artificial sweeteners, MSG, soy sauce, citrus foods, papayas, avocados, red plums, overripe bananas, dried fruits with sulfites (figs, raisins, etc.), sour cream, buttermilk, nuts, peanut butter, sourdough bread, aged meats and cheeses, processed meats, and anything fermented, pickled or marinated. (22,23) It is unclear whether chocolate is a trigger to migraine, or a craving brought on at the onset of an attack. (22)
Download this list of potential migraine triggers for your patients:
https://d2tdnxb10ob8wc.cloudfront.net/clinics/0/form/files/migraine-triggers.pdf
Clinical Presentation
Migraine progresses through various symptomatic stages, including prodrome, aura, attack, and postdrome. The features of migraine headache, including prodrome, vary widely but tend to be consistent for any given individual. (8)
Approximately 60% of sufferers report prodromal symptoms in the hours to days before headache onset. (8) These symptoms include lethargy, yawning, food cravings, mood changes, excessive thirst, fluid retention, constipation, diarrhea, and hypersensitivity to light, sound, or odors. (8)
About 20-33 percent of migraine sufferers experience auras during or before the headache attack. (17,26) Aura symptoms develop slowly, over 5-20 minutes and can last up to an hour. Symptoms are most commonly visual but may 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 (scintillating scotoma). (8) Various other visual field defects, including tunnel vision, have been reported. Paresthesias are the next most common aura, occurring in 40% of cases. (28) Paresthesias may be followed by numbness that often begins in the hand and progresses up the arm, to the face, lips, and tongue. Less than one in five migraine sufferers experience motor symptoms, including a sense of heaviness in their limbs or speech and language disturbances. (28) Motor and sensory complaints, including paresthesia and numbness rarely occur in isolation. (28) Visual disturbances that occur in isolation are called “ophthalmic” migraine, aka “retinal,” or “ocular.”Ophthalmic migraines generally produce a lateral field deficit and are more common in children. (8) The slow development of auras (5-20 minutes) is a helpful characteristic in distinguishing migraine from other cerebrovascular pathology (Stroke, TIA). (28)
During the attack phase, patients will typically 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 to two hours and can last between 4 and 72 hours. Patients often report hypersensitivity to sound or light and retreat to quiet, dark places. Hypersensitivity to smell is reported in nearly half of migraine patients. (103) Eighty percent of migraine sufferers experience nausea. (30-32) Vomiting occurs in 1/3-1/2 of patients. (30-32) Seventy-five percent of migraine sufferers report some type of associated neck discomfort. (32)
Postdromal symptoms occur in the hours following a migraine and generally include fatigue, irritability, euphoria, myalgia, food insensitivity, or cravings. (22) Although not necessarily a postdromal symptom, migraine patients are two times more likely to suffer from chronic dry eye disease. (94)
According to the International Headaches Society, the diagnosis of migraine requires at least five episodic headaches, each lasting four to 72 hours associated with nausea/ vomiting or photophobia/ phonophobia and at least of two of the following characteristics: moderate to severe intensity, unilateral presence, pulsating quality, and aggravated by physical activity. (34) Although the aforementioned criteria “define” migraine, it is important to note that not all patients meet these criteria. Forty-one percent of migraine patients report bilateral pain and 50% report “non-pulsating” pain. (30-32)
Researchers have identified the presence of nausea, disability, and photophobia as the most significant predictors for migraine. (36) A self-administered screening tool called ID migraine ® poses the following questions:
1. Are you nauseated or sick to your stomach when you have a headache?
2. Has the headache limited your activities for a day or more in the last three months?
3. Does light bother you a lot more when you have a headache?
An affirmative response on 2 of 3 questions yields high sensitivity (81%) and specificity (75%). (36,96)
Clinicians should be alert to “red flags” that suggest a more threatening diagnosis, including: headaches that are becoming progressively worse over time, sudden onset, severe headaches, new or unfamiliar headache, headache following a recent head injury, unexplained weight loss, impaired consciousness, presence of fever, significant neck stiffness, rash, nuchal rigidity, vertigo, diplopia, drop attacks, difficulty speaking, difficulty swallowing, difficulty walking, and nystagmus.
The American Headache Society endorses the acronym “SNOOP” to identify worrisome headache red flags. (37-38)
- Systemic symptoms: fever, weight loss, or the presence of systemic risk factors (i.e. cancer, HIV).
- Neurologic signs: confusion, impaired alertness, or consciousness.
- Onset: sudden or abrupt headaches that develop and peak very quickly.
- Older: new headaches in patients over 50 (Giant cell arteritis, aka temporal arteritis)
- Previous headache history: any new headache that deviates significantly from a prior pattern of frequency, severity, and clinical features.
The diagnosis of migraine is based on the patient’s history. (39) A thorough physical and neurologic assessment is required to exclude a more threatening diagnosis; however, the results are normal in most migraine patients. Measurement of vital signs may demonstrate transient irregularities during a migraine attack, including tachycardia, bradycardia, hypertension, or hypotension. Physical exam may demonstrate a mild Horner’s syndrome (ptosis, miosis) on the same side as a headache. (8) The presence of papilledema warrants consultation. Clinicians should palpate the temporal artery in those over age 50 to exclude giant cell arteritis. Migraine patients often demonstrate limited upper cervical and global cervical range of motion. (93)
Clinicians should be cognizant of potential concurrent cardiovascular and cerebrovascular issues when assessing migraine patients. The presence of migraine increases one’s risk of cardiovascular disease (stroke and myocardial infarction) by approximately 25%. Those experiencing migraine with aura have an almost twofold increased risk of cardiovascular disease. (41,42) Migraine with aura is also strongly associated with ischemic stroke. (108) Not surprisingly, migraineurs are more likely to report “cold extremities.” (111)
Diagnostics & Differential
Patients whose symptoms fit the broad definition of migraine rarely require imaging. (43) Plain film radiographs have little value in the diagnosis of migraine headache. When alternate pathology is suspected, MRI is the preferred neuroimaging choice over CT. (43) Suspicion of cerebral vascular pathology (aneurysm, vasculitis, arterial dissection) is better screened through magnetic resonance angiography (MRA). (44) The use of EEG lacks sensitivity and specificity for the diagnosis of migraine. (45)
The primary conditions to consider in the differential diagnosis of migraine headache are tension-type headache, TIA and stroke. Tension-type headaches are typically bilateral, non-pulsatile, and not aggravated by physical activity. Patients report that their symptoms are less intense and are generally not associated with nausea or vomiting. The symptoms of stroke or TIA generally develop more quickly, last longer (days to indefinitely), and do not occur in isolation. Other conditions to consider in the differential diagnosis of migraine headache include giant cell arteritis, cluster headaches, acute glaucoma, meningitis, neoplasm, and cerebrovascular bleed. (46)
Management
Migraine treatment is subdivided into “abortive” therapies that seek to stop or reverse the progression of an existing headache and “prophylactic” treatments, which seek to prevent or reduce the frequency of future attacks. Abortive treatments are most effective when given within the first minutes of an attack. (47) Abortive medications include analgesics, NSAIDs, selective serotonin receptor agonists, and ergot alkaloids. (48) Narcotics are commonly used for the emergency treatment of migraine, although evidence suggests they are ineffective and may lead to prolonged hospital stays. (82) Overuse of abortive medical therapy may generate a self-perpetuating, chronic “rebound” cycle of migraine. (50,51) For recurrent headaches, the American Headache Society discourages the use of over-the-counter pain medications or the prescription of opioids or butalbital medications. (43)
Prophylactic treatment is aimed at controlling migraine triggers. Several clinical trials and research studies suggest that spinal manipulation is an appropriate treatment for migraine headaches. (49,52-62,95) A Harvard study found that SMT reduced migraine days as well as pain intensity. (95) Another paper demonstrated a “significant reduction” of migraine intensity in almost half of those patients receiving spinal manipulation. Nearly ¼ of migraine patients reported greater than 90% fewer attacks. (55) Spinal manipulation has demonstrated similar effectiveness but longer lasting benefit with fewer side effects when compared to a well-known and efficacious medical treatment (amitriptyline). (55,57,58,61) A study to define adverse events following chiropractic spinal manipulation for migraines found that “adverse events were mild and transient, and severe or serious adverse events were not observed.” (89) Spinal manipulation is thought to inhibit pain through various mechanisms, including CNS activation, elevation of endorphin levels, disruption of pain-spasm-pain cycles, and reduction of mechanical triggers. (63-65)
Manual therapy, including soft tissue manipulation and massage therapy, has demonstrated success in the treatment of migraine headache. (66,67,90,101) Upper cervical hypertonicity or joint dysfunction is thought to be a trigger for headaches, including migraine. (65) Migraine patients harbor trigger points in the SCM, upper trapezius, and/or splenius capitis that, when activated, can reproduce migraine headache. (86) Clinicians should pay particular attention to the suboccipital muscles, since the rectus capitis posterior minor shares a dense connective tissue bridge with the pain sensitive spinal dura at the level of the atlantooccipital junction. Soft tissue manipulation and myofascial release techniques are appropriate for the treatment of related cervical, interscapular, and shoulder girdle musculature. Dry needling may be helpful for managing migraine headaches. (106)
Clinicians should assess for and treat posture abnormalities, including weakness of the deep neck flexors and upper crossed syndrome. Acupuncture and biofeedback may be useful in the treatment of migraine. (51,68,69,79,83,100,107,109,119,120,122) Yoga may help migraine patients. (114) The FDA recently approved a transcranial magnetic stimulator (TMS) for the treatment of migraine headaches, and early studies have demonstrated improved outcomes from TMS over no treatment. (70,71)
The patient’s self-management should focus on trigger avoidance and stress management. (72) Mindfulness-based stress reduction is an effective treatment option for episodic migraine. (118) A headache diary is essential to help identify and eliminate triggers. (73) No specific diet has been shown to help migraine, but patients should be coached to identify and eliminate their unique food triggers. (22) Patients with medication triggers, including oral contraceptives and hormones, should consult with their medical providers about changing or discontinuing those drugs. (47) Aerobic exercise can provide a significant reduction in migraine frequency, intensity, and duration. (116) Exercising for 40 minutes, three times per week has shown similar benefit to a proven prophylactic medication. (84) Migraineurs, particularly those who are overweight, should be given dietary advice. (117) Migraineurs with aura should be counseled on the increased risk of stroke associated with smoking and oral contraceptive use. (8) Clinicians should encourage adequate hydration, as research has found a significant correlation between migraine and inadequate water intake. (115)
Magnesium supplementation (400-600mg/ day) has strong support for preventing and relieving migraines. (92) Vitamin D deficiency is associated with migraine attacks. (97,98) Vitamin D supplementation in a dose of 1000-4000 IU/d has been shown to reduce the frequency of migraine attacks. (98,104,105) Vitamin B6 supplementation (with or without concurrent B9 and B12) has demonstrated prophylactic benefit. (110) Limited data supports the use of various other supplements, including melatonin, Feverfew (125mg/ day), and riboflavin (400mg/ day) for the prevention of migraine in non-pregnant patients. (50,75-78,85,112)
Medications used for the prophylaxis of migraine include: beta-blockers, tricyclic antidepressants, and divalproex sodium or valproic acid. (50) Recently, Botox injections have been used with some success for the treatment of migraine. (91) Surgical deactivation of migraine trigger points is discouraged by the American Headache Society. (43)
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