CF 159: Set Yourself Apart In Your Chiropractic Care For Migraines Today we’re going to talk about chiropractic care for migraines. What does new research tell us. But first, here’s that sweet sweet bumper music
OK, we are back and you have found the Chiropractic Forward Podcast where we are making evidence-based chiropractic fun, profitable, and accessible while we make you and your patients better all the way around. We’re the fun kind of research. Not the stuffy, high-brow kind of research. We’re research talk over a couple of beers. I’m Dr. Jeff Williams and I’m your host for the Chiropractic Forward podcast. If you haven’t yet I have a few things you should do.
- Like our Facebook page,
- Join our private Facebook group and interact, and then
- go review our podcast on iTunes and other podcast platforms.
- We also have an evidence-based brochure and poster store at chiropracticforward.com
- While you’re there, join our weekly email newsletter.
You have found yourself smack dab in the middle of Episode #159 Now if you missed last week’s episode , we talked about chiropractors within a primary spine care model, we talked about frozen shoulder treatments, and we talked about how evidence-based care is more cost-effective. Make sure you don’t miss that info. Keep up with the class.
On the personal end of things…..
Alright alright alright. Christmas is over and as of the typing of this episode we are staring down New Year’s. No big deal for me. I’m not going anywhere so there’s nothing to get too excited or worked up about. I guess the biggest news for me is that my wife and I got vaccinated last week. We got the Moderna version of the vaccine. Didn’t hurt a bit. I was one of the fortunate ones. I had absolutely zero reaction. No sore arm, no fever, no aches…..nothing. I guess if you poked on my arm fairly hard it would have been a bit sore but really, nothing at all. If I had been in the research trial, I would think I got the placebo. That’s how uneventful it was for me.
My wife though, she felt a little crummy. No fever but maybe a little bit of overall achey-ness. Sore arm for a few days. But that’s about it. Nothing severe at all and she recovered quickly. I’ve had several ask me online how we got ours so quickly. The first thing I’d say is that I have a network of providers here locally that I refer to, they refer to me, and on some level, we are friends. They know how closely we work with our patients. They don’t want us getting it and they don’t want us giving it to others. So, when the vaccine came to town, they called and told us to come down and get ours. So we did. Here’s the cool part; they told me to reach out to fellow chiropractors and tell them to come to get vaccinated if they want one.
I thought to myself, “Can you imagine if this pandemic were just 10 years ago? Would the medical community have extended that offer to chiropractors then?” My guess is probably not. Here’s the not-so-cool part. I reached out to about 40 in the area and only ONE of them accepted the offer. So, we gots some work to do in making chiropractors more evidence-science-based. Though I do want to be fair. I don’t think it’s unreasonable at all to wait 4-6 weeks just to make sure everyone does OK with this thing. even though the proper trials were done….it’s not unreasonable. It’s just delaying the fact that people are going to do fine and everyone will end up getting it anyway but whatever.
What I do think is unreasonable is continuing to refuse it beyond the 4-6 week mark. This thing is far beyond the flu both in transmissibility and in the risks of death and or disability. Sometimes that disability is short-term and sometimes it’s long-term. Don’t think of this as a death vs. living thing. Long-haulers is a real thing. We don’t need to be out of work that long. We don’t need to have to figure out how to keep our employees paid while we are out sick for 2-4-6 weeks or however long we have to be out. We don’t need to think we just have a sniffle or allergies and then spread this to our elderly or immunocompromised patients. Being out of work for far too long or passing this onto risky patients….when all we had to do was just get the damn shot.
So….I got the damn shot and so far, so good.
In other news, I have formed a collection of all of my research blogs from 2007 onward. I’ve organized them into categories so they can be easily found so now I have a book. I’m in the process of getting the book cover made. This dude is about 220 pages or so. It could be much longer but I’m trying to make it skinnier on purpose. It is called “The Remarkable Truth About Chiropractic: A Unique Journey Into The Research”. We still have a lot of steps and hoops to jump through to get to the finished product but we are well on our way. Of course I’ll keep you updated on the progress. Happy New Year folks. Let’s get on with the research today.
This one is called “Association of drinking water and migraine headache severity” by Khorsha, et. al. (Khorsha F 2020) and was published in the Journal of Clinical Neuroscience in July of 2020 and that’s still a steaming pile of sizzle! Before we get into chiropractic care for migraines, let’s cover a little headache primer here for you. First thing, the history of the headache is key. In general, a headache is considered dangerous if there is any recent change in a headache’s character. Some have a long history with headaches but if that history changes, further exploration is needed. Recent onset of less than 6 months is more worrisome. Focal neurological signs. And lastly, cognitive changes. Changes in behavior for example.
Getting back to headache types, 38% of headaches seen in a clinical setting are tension-type headaches right off the bat. Only about 10% are actual migraines. Only 4% of headaches are actually classified as true cervicogenic headaches. Then cluster headaches, and on and on….those are very rare. Here’s the fine print though. Tension-type and migraine headaches exist on the same continuum. Meaning, they share characteristics. I suppose you could even say that tension-type is a very very mild form of migraine while migraine is a very very extreme tension-type.
That may be overstating it a bit but there is a relationship between the two and they can share characteristics with each other. According to Dr. Anthony Nicholson and Dr. Matthew Long with the CDI learning from the Diplomate in Neuromusculoskeletal Medicine, “It is a pervasive neurological condition with genetic underpinnings. Indeed, when you look more closely you will soon realize that migraineurs do not function normally in between headache episodes either (the interictal period). In other words, the headache symptoms are simply a feature of what might be described as a chronic neurological ‘disorder’ or ‘illness’. As we shall explore in this Drill, migraine is the manifestation of an abnormally excitable brain that is capable of over-activating the trigeminal system in genetically susceptible individuals.
The result is not only nasty headaches but also a host of other autonomic, cognitive, emotional and musculoskeletal disturbances. Furthermore, these can occur both during the headache or outside of the acute pain episode. It is therefore important that we immediately recognize a patient as a migraineur because it should influence the way we interpret their entire case. Not only that, but we certainly need to approach a migraine sufferer a little differently when it comes to dispensing manual treatment. “
If you think that makes a ton of sense, Dr. Anthony Nicholson just signed on to be a presenter for the Texas Chiropractic Association’s Winter Conference, which will be online for ALL OF YOU to enjoy. It’ll be march 5-6 and will also include myself, Annie O’Connor, Jay Greenstein, Brandon Steele, and Carlo Ammendolia as presenters. Don’t miss it folks! That’s huge. So, getting back to Dr. Nicholson’s description, we wouldn’t describe a tension-type headaches that way, would we? As you have probably experienced or at least guessed, migraines are much more difficult to address or treat than are the other types of headaches.
I don’t have the time or space to go into the full treatment of migraines here but I do want to highlight some studies that we might leverage to our advantage and we can go that extra mile to help our patients with the issues of headaches and migraines. Many times, they’re at the bottom of their rope when we get them. If we succeed where everyone else failed, well then, don’t we always enjoy being that practitioner? Hell yeah, we do. Just remember 3 important questions:
- Do you have recurrent headaches that interfere with work, family, or social functions?
- Do your headaches last at least 4 hours?
- Have you had a new or different headache in the last 6 months?
These should give you some guidance considering migraines typically last 4-72 hours and interfere with work, family, and social functions. Patients cannot simply muscle through migraines. It’s a nope.
Why They Did It
“Based on evidence dehydration is closely related to promoting migraine headache frequency and severity. The Water intake is the best intervention to reduce or prevent headache pain. water intake in migraine patients has rarely been studied. the present study aimed to evaluate the relation between water intake and headache properties in migraine.”
How They Did It
- It was a cross-sectional design with 256 women
- They were aged 18–45 years old
- They had all been referred to neurology clinics for the first time
- The diagnosis of migraine by a neurologist according to ICHD3 criteria
- To assess migraine severity the Migraine disability assessment questionnaire (MIDAS), visual analog scale (VAS), and a 30-day headache diary were used.
- Pearson correlation analysis was used to evaluate the relationship between the number of days and duration of headache with daily water intake.
What They Found
The results showed that the severity of migraine disability, pain severity, headaches frequency, and duration of headaches were significantly lower in those who consumed more water or total water. Wrap It Up “The present study found a significant negative correlation between daily water intake and migraine headache characteristics but further clinical trials are needed to interpret the causal relationship.”
Item #2 This second one is called “Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta‐Analysis” by Liampas L, et. al. (Liampas L 2020) and published in the Journal of Head and Face Pain on April 30 2020 schizza it’s hot. Why They Did It The aim of this study was to review the existing evidence for the deployment of melatonin in migraine prophylaxis. How They Did It
- MEDLINE EMBASE, CENTRAL, PsycINFO, trial registries, Google Scholar, and OpenGrey were comprehensively searched
- The quality of studies was assessed according to the Newcastle‐Ottawa Scale (case‐control studies) and the Risk‐of‐Bias Cochrane tool (RCTs)
- Random‐effects (RE) or fixed‐effects (FE) model was used based on heterogeneity among studies
- Publication bias was assessed by funnel plots.
- Literature search provided 11 case‐control studies
- Regarding the treatment‐prevention of migraine, 7 RCTs and 9 non‐randomized studies were retrieved
- Overall, melatonin was more efficacious and equally safe with placebo in the prevention of migraine in adults (3 of 4 RCTs provided superior efficacy results for melatonin
Wrap It Up
“Melatonin may be of potential benefit in the treatment‐prevention of migraine in adults, but complementary evidence from high‐quality RCTs is required.”
Next up is “Integrating Chiropractic Care Into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series” by Bernstein et. al. (Bernstein C 2019) and published in Global Advances in Health And Medicine” in 2019. Not hot but definitely not cold.
Why They Did It
They ran a case series to illustrate an integrated model of care for migraine that combines standard neurological care with chiropractic treatment.
How They Did It
- For each patient, we describe the rationale for referral, diagnosis by both the neurologist and chiropractor, the coordinated care plan, communication between the neurologist and chiropractor based on direct face-to-face “hallway” interaction, medical notes, team meetings, and clinical outcomes.
- Findings are evaluated within the broader context of the multicause nature of migraine and the impact of integrative chiropractic.
They highlighted 3 cases that we’ll touch on briefly. Case 1
- She was 40 when she first went to the neurologist for daily migraines.
- She started integrative care at 42 years old.
- She had had migraines since she was 29 years old.
- After seeing the neuro, the frequency went down to 3-4 times per week
- She also had some TMJ issues and neck pain and stiffness. with some radicular symptoms that were only a few months in duration
- Upon going to the chiro, they found trigger points that would stimulate the headache on compression, abnormal tracking of the TMJ, and tenderness over the right C2/3 facet joint.
- After spinal manipulative therapy, the patient experienced almost immediate reduction in headache and neck pain and a reduced headache frequency of 1 per month.
Shazam! Pop! Smack. KaPow! Case 2
- She was 31 at the start, 34 when integrating treatment.
- She had been having them since 12 years old that she managed with Excedrin for years. But they got more out of hand after her 2 pregnancies
- 2 of the headaches even sent her to the ER
- Associated symptoms included unilateral neck pain, nausea, and vomiting
- She tried multiple trials of different medications with limited relief
- Once making her way to the chiropractor, they found trigger points in the suboccipitals, temporalis, and masseters. Weakness in the deep neck flexor muscles, and substantial postural faults, forward head carriage, and rounded shoulders.
- Where her headaches had been rated from 7-8, after 9 months of treatment with admittedly poor adherence to the at-home exercises, she rated them at a 3 out of 10 and after 10 months experienced her first headache-free month.
Pow! Zap! Slap! Case 3
- 27 years old when first going to the neuro and 29 when she made it to the chiro
- Migraines started when she was 13
- Pounding and throbbing with aura. The whole nine yards.
- Migraines were nearly daily, disabling and interfering with life to the point she could only take 1-2 college classes each semester.
- Multiple medication trials
- She underwent botox treatments that helped her have as many as 8 pain free days in a month. Which means she still had about 22 days of headaches in a month. How miserable.
- Fortunately the botox helped the severity dampen by about 50% but she still complained of the disabling neck pain.
- The chiropractor found trigger points in the sub occipital area and the traps and could reproduce the pain on compression. The chiro also noted substantial segmental mobility restriction in the upper cervical spine.
- After seeing the chiropractor, there was a nearly immediate positive response to initial care in headache and neck pain intensity and frequency. with a reported 50% reduction in the intensity. The average headache dropped to 3.5 out of 10.
Zowey, Kapowey, Thunk!
Wrap It Up
“Our case series highlights the promise of and the need to further evaluate integrated models of chiropractic and neurologic care. Although we observed improvement in patient outcomes in this small case series, rigorously designed studies with adequate control groups are needed to determine the efficacy and safety of chiropractic care for migraine patients.”
Yep, it’s a longer podcast today but I can’t leave you without doing this paper real quick! It’s called “The Impact of Spinal Manipulation on Migraine Pain and Disability: A Systematic Review and Meta‐Analysis” by Rist et. al. and published in the Journal of Head and Face Pain on March 14, of 2019. Again, not hot but damn sure not cold. Why They Did It They wanted to perform a systematic review and meta‐analysis of published randomized clinical trials (RCTs) to evaluate the evidence regarding spinal manipulation as an alternative or integrative therapy in reducing migraine pain and disability.
How They Did It
- PubMed and the Cochrane Library databases were searched for clinical trials that evaluated spinal manipulation and migraine‐related outcomes through April 2017
- The methodological quality of retrieved studies was examined following the Cochrane Risk of Bias Tool.
What They Found
- The search identified 6 randomized controlled trials eligible for meta‐analysis.
- Intervention duration ranged from 2 to 6 months
- Outcomes included measures of migraine days (primary outcome), migraine pain/intensity, and migraine disability
- They observed that spinal manipulation reduced migraine days with an overall small effect size as well as migraine pain/intensity.
Wrap It Up
The authors concluded, “Spinal manipulation may be an effective therapeutic technique to reduce migraine days and pain/intensity. However, given the limitations to studies included in this meta‐analysis, we consider these results to be preliminary. Methodologically rigorous, large‐scale RCTs are warranted to better inform the evidence base for spinal manipulation as a treatment for migraine.” It’s like a computer. It only spits out information that is based on the information that was put into it. Same with a meta-analysis. If the studies going into it are few, your output won’t be too robust.
Of course, we know that the effect we have on migraines is much more than small. In the 3rd study we covered today, do you think any of those 3 case study patients thought that the relief they got from the chiropractor was small? Nope, they thought the results were worthy of superhero sound effects. At least if they had a brain like mine that’s what they’d think. So, for our research community, there are your marching orders. We have research on the low back in spades. Let’s prove neck pain and headache/migraine now please? I’ve been asking for 3 years now. Please?
Besides the claims of the vitalists in our profession, those are the things that keep us from really stepping up. Lack of proof for neck pain effectiveness, headache/migraine effectiveness, and the lack of risk for spinal manipulation in the cervical region. I feel the stroke risk has been debunked and handled. Now if we can get the other two firmly under our belts, we’ll be good to go. Alright, that’s it. Y’all be safe.
Keep changing our profession from your little corner of the world. Keep taking care of yourselves and everyone around you. Tough times are upon us but, the sun will shine again. Trust it, believe it, count on it. Let’s get to the message. Same as it is every week.
Store Remember the evidence-informed brochures and posters at chiropracticforward.com.
The Message I want you to know with absolute certainty that when Chiropractic is at its best, you can’t beat the risk vs reward ratio because spinal pain is primarily a movement-related pain and typically responds better to movement-related treatment rather than chemical treatments like pills and shots. When compared to the traditional medical model, research and clinical experience show us patients can get good to excellent results for headaches, neck pain, back pain, and joint pain to name just a few. It’s safe and cost-effective can decrease surgeries & disability and we do it through conservative, non-surgical means with minimal hassle to the patient. And, if the patient treats preventativly after initial recovery, we can usually keep it that way while raising the overall level of health!
Key Point: At the end of the day, patients should have the guarantee of having the best treatment that offers the least harm. When it comes to non-complicated musculoskeletal complaints…. That’s Chiropractic!
Contact Send us an email at dr dot williams at chiropracticforward.com and let us know what you think of our show and tell us your suggestions for future episodes. Feedback and constructive criticism is a blessing and so are subscribes and excellent reviews on podcast platforms. We know how this works by now. If you value something, you have to share it, interact with it, review it, talk about it from time to time, and actively hit a few buttons to support it here and there when asked. It really does make a big difference.
Connect We can’t wait to connect with you again next week. From the Chiropractic Forward Podcast flight deck, this is Dr. Jeff Williams saying upward, onward, and forward.
Social Media Links https://www.facebook.com/chiropracticforward/
Chiropractic Forward Podcast Facebook GROUP https://www.facebook.com/groups/1938461399501889/
Player FM Link https://player.fm/series/2291021
About the Author & Host Dr. Jeff Williams – Fellow of the International Academy of Neuromusculoskeletal Medicine – Chiropractor in Amarillo, TX, Chiropractic Advocate, Author, Entrepreneur, Educator, Businessman, Marketer, and Healthcare Blogger & Vlogger
- Bernstein C, W. P., Rist P, Osypiuk K, Hernandez A, Kowalski M, (2019). “Integrating Chiropractic Care Into the Treatment of Migraine Headaches in a Tertiary Care Hospital: A Case Series.” Glob Adv Health Med 8.
- Khorsha F, M. A., Togha M, Mirzaei K, (2020). “Association of drinking water and migraine headache severity.” J Clin Neuroscience 77: 81-84.
- Liampas L, S. V., Brotis A, Vikelis M, Dardiotis E, (2020). “Endogenous Melatonin Levels and Therapeutic Use of Exogenous Melatonin in Migraine: Systematic Review and Meta‐Analysis.” J Head Face Pain 60(7): 1273-1299.