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Attractive woman with a migraine touches her temples. Square shot. Isolated on white.

This is the first of a series of posts about a topic that is going to require more than a few sentences to tackle. I’ll be discussing one of the few instances in life of something that almost everyone can relate to – HEADACHES. Headaches are the most commonly reported symptom in family and internal medicine practices, with more than 50% of people reporting a headache each year and more than 90% of people reporting at least one significant headache in their lifetime (Source). But here’s the thing – not all headaches are created equally. In fact, that is why many people struggle with chronic headaches and don’t ever get any lasting relief. If different types of headaches have distinct causes and triggers, then it is reasonable to conclude they will require unique treatment approaches in order to overcome them. Sadly, many people don’t have a clear understanding of the cause of their headaches and, thus, are never matched with the correct treatment. I’m going to discuss several of the most common types of headaches and how they can be managed and alleviated without extensive imaging and testing or medications and injections that can cause profound side effects. The topic of this first post is the most sinister and misunderstood of all headache types – migraines.

Migraine headaches are one of the most challenging diagnoses to manage throughout the healthcare community for numerous reasons. First of all, the term “migraine” is very similar to the term “sciatica” in that it is often used to describe pain of a known location but an unknown cause. In other words, your symptoms match what would be expected of someone experiencing a migraine, but a thorough examination of the head and neck is never performed to correlate or verify these symptoms with true impairments. Or even more simply, “your head hurts, but we don’t know why.” Secondly, migraines have proven to be debilitating for many people. In fact, 90% of migraine sufferers report some type of “headache-related disability” and 50% report “severe disability” that requires bed rest. Multiple peer-reviewed studies have shown that migraines have a bigger impact on quality of life than osteoarthritis or diabetes (Source). Migraines are clearly a burden on many individuals and society as a whole. I know, I know – so far, there only seems to be bad news when it comes to migraines. There is good news coming soon, but we need to be clear on what actually constitutes a migraine before we can discuss treatment options.

Migraines have a highly variable presentation across the general population, so there is no exclusive and complete list of symptoms that clearly identifies a headache as a migraine. However, there are a few unique characteristics to migraines. First, migraines commonly have a trigger or some type of precipitating stimulus. Common triggers include light, noise, certain food or drinks, sleep deprivation, stress, and exercise. Migraines also usually present as a throbbing, pulsing sensation rather than feeling of pressure, aching, or tightness commonly felt with other types of headaches. Migraines are unique in that they frequently feature autonomic symptoms such as sweating, facial flushing, fullness/stuffiness of the nose and ears, drooping and swelling of the eyelids, and tear production. (Source: American Migraine Foundation) Several other characteristics of migraines are not distinct or consistent. The location of pain, intensity of pain, response to medication, and role of head/neck movement are highly variable across migraines and are not useful in diagnosing a headache as a migraine. These characteristics are often more consistent and clear in other types of headaches such as cervicogenic headaches and tension headaches, so stay tuned for more info on those types of headaches if the symptoms listed above don’t seem to match how you feel when you experience headaches.

Now that we understand the extent of the problems caused by migraines and some of the basics about identifying migraines, it is time to get down to the business of treating these headaches. The easiest method of treating migraines is identifying and avoiding triggers. If someone can easily and clearly identify the triggers of his or her migraines, then simply avoiding those triggers can minimize or eliminate the frequency and intensity of these headaches. Here’s the problem with that approach – no one wants to live in a closet with noise-cancelling headphones on all day! That’s right – light and noise are two of the most common triggers. The only way to truly avoid these is isolation, which has its own consequences and is not reasonable or practical. What else can we do? Pharmacological management is the most common and most studied approach to managing migraines, but there are a few problems with this approach. First, medication is meant for managing symptoms of migraines and not addressing the underlying cause of headaches, so although they can provide profound relief, they aren’t able to help reduce how often the headaches are occurring. They can simply decrease the intensity and duration of the headaches after they have started. In addition – this won’t come as a shock to most people – the most commonly prescribed medications for migraines (Topamax and Depacon) come with a wide variety of side effects including dizziness, weight changes, nausea, vomiting, tingling in the extremities, bleeding, abdominal pain, and weakness. Botox injections are also commonly used in the management of migraines and the published results on this treatment are mixed. However, the effects often only last 12 weeks, and side effects including neck pain and stiffness, shortness of breath, and even increased headaches have been reported. So although these strategies can be effective, avoiding triggers is not always practical or reasonable, and pharmacological management has mixed results with the possibility of significant side effects. There has to be a better treatment option.

A study published in 2018 by Maistrello et al. (Link to Original Article) verifies what I have seen in my own clinical practice – manual therapy techniques focused on myofascial trigger points such dry needling, ischemic compression, and myofascial release helped facilitate significant reductions in frequency, intensity, and duration of migraines. These techniques have extremely low risk of side effects and have proven to be effective in not only providing immediate and short-term relief, but also long-lasting reduction in frequency and intensity of migraines. I have seen numerous patients have life-changing results from just a few sessions with me focusing on conquering these pain-generating trigger points and addressing deficits in mobility, strength, and coordination of the head and neck. In fact, few things bring me more joy than to see the smile on the face on a chronic headache-sufferer who tells me how long it has been since they have experienced a headache. These results aren’t unique, and the evidence for physical therapy management of headaches is piling up. I’m so glad to be a part of the solution to an issue that continues to be such a burden in our community and I hope to be able to help some of you with your headaches as well!

I would love to hear from any of you who have questions about your headaches and your treatment options. Just do me a favor – don’t just sit there and continue to suffer! Relief is out there if you’re willing to seek it out!