“Migraine” is a complex, chronic neurologic disorder characterized by recurrent moderate to severe headaches. Migraines can be either with or without an aura (1). “Aura” is the collection of autonomic nervous system symptoms that occur immediately prior to the headache including visual disturbances, extremity paresthesias, nausea, vomiting, and hypersensitivity to light or sound.
Worldwide, the lifetime occurrence 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). Over 80% of those with 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).
What causes migraines?
Early explanations for the genesis of migraine focused on blood vessels in the brain (3). Migraines are now recognized as a more complex series of neurologic and vascular events and vasodilation of blood vessels may or may not be present (4-8). Evidence suggests that a person with migraine’s brain is hyper-excitable and uniquely predisposed migraine headaches in much the same way that an epileptic is susceptible to seizures (8,9).
What are the risk factors for migraines?
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). Vascular risk factors include hypertension, hypercholesteralemia, impaired insulin sensitivity, coronary artery disease, and a history of stroke (18).
Overuse of medication is a risk factor:
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).
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, 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). 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 between those with migraines, 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).
Approximately 60% of sufferers report 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) Forty-one percent of migraine patients report bilateral pain and 50% report “non-pulsating” pain. (30-32)
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. (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. Motor and sensory complaints, including paresthesia and numbness rarely occur in isolation (28). The slow development of auras (5-20 minutes) is a helpful characteristic in distinguishing migraine from other cerebrovascular pathology (28).
When the migraine “hits”
Patients will typically complain of a one sided, moderate to severe, throbbing or pulsating headache. The pain may be felt anywhere in the head and neck but is most common in the front, side, and behind the eyes. 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. Eighty percent of migraine sufferers experience nausea. (30-32) Vomiting occurs in 33-50 percent of patients. (30-32) Seventy-five percent of migraine sufferers report some type of associated neck discomfort. (32).
The after affects:
Postdromal symptoms occur in the hours following a migraine and generally include fatigue, irritability, euphoria, myalgia, food insensitivity, or cravings. (22).
Do I need imaging?
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).
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)
Spinal Manipulation (adjustment) as a preventative treatment:
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)
One study demonstrated that 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)
Soft tissue manipulation and massage therapy have demonstrated success in the treatment of migraine headache. (66,67,90) 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 capitus 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.
Acupuncture may be useful in the treatment of migraine. (51,68,69,79,83)
A patient’s self-management should focus on trigger avoidance and stress management. (72)
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)
Exercising for 40 minutes, three times per week has shown similar benefit to a proven prophylactic medication. (84)
Magnesium supplementation (400-600mg/ day) has strong support for preventing and relieving migraines. (92)
Limited data supports the use of Feverfew (125mg/ day) and riboflavin (400mg/ day) for the prevention of migraine in non-pregnant patients. (50,75-78,85) Medications used for the prophylaxis of migraine include: ß-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)
At Creekside Performance Center, we are highly trained to treat each of these conditions. We are the only inter-disciplinary clinic in Sheboygan county that provides chiropractic, myofascial release, ART (Active Release Technique), massage therapy, acupuncture, physiotherapy, rehabilitative exercise, nutritional counseling, personal training, and golf performance training under one roof. Utilizing these different services, we can help patients and clients reach the best outcomes and the best versions of themselves.
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