A non-pharmaceutical approach to managing migraine and headache
Migraine and headache are common ailments of people living in the modern era. Dr Jon Marshall of The Singapore Headache and Migraine Clinic shares his insights with Pearl Toh on how to manage migraine and headache using non-pharmaceutical strategies, with a focus on the manual medicine approach.
Migraine was reported to affect over 330,000 people in Singapore in 2018 and this number continues to grow. A study on 606 adults surveyed in Singapore showed that migraine places a substantial economic burden on Singapore — at a cost as high as SGD$1.04 billion in 2018. [Cephalalgia Reports 2020;doi:10.1177/2515816320908241]
Migraine is a neurologic disorder caused by abnormalities in neurochemicals in the brain, particularly the trigeminal brainstem, which is the control centre of how these signals are transmitted.
Understanding the potential triggers of migraine can help patients recognize, manage, and avoid a full blown attack. Several risk factors and triggers that may increase a person’s susceptibility to migraine include:
· Environmental factors such as bright lights, weather, and differences in barometric pressures, high altitudes, and air travel
· Emotional stress
· Physical stress or trauma such as an acquired brain injury (eg, from motor vehicle accident or other physical traumas) or tension in the neck or shoulders
· Certain smells (eg, cigarette smoke)
· Hormonal: some women experience migraine around the time of their period
· Dietary: missing a meal, drinking alcohol or caffeinated drinks, and eating certain foods such as chocolate or cheese
· Medicines including certain sleeping tablets and combined contraceptive pill
· Genetic factors
Evidence on genetic predisposition for migraine comes from family and twin studies, which suggest that common migraine can be a heritable trait. In addition, women are threefold more likely than men to have migraine, possibly due to hormonal influence. [J Headache Pain 2019;20:72]
One important point to consider in migraine patient is their migraine threshold. Varying triggers can occur over a period of time and build up in combination, culminating in a migraine attack when the threshold is crossed.
Other than medications, it is possible to prevent migraine attacks through lifestyle modification to minimize interaction between migraine triggers. This may be achieved by:
· Adequate rest and sleep
· Maintain adequate hydration
· Avoiding potential triggers like alcohol, caffeine and other known food triggers and intolerancesDiagnosing migraine
Migraine diagnosis is based on a patient’s history. According to the diagnostic criteria by the International Headache Society (IHS), patients must have experienced at least five headache attacks that lasted 4–72 hours (either untreated or unsuccessfully treated) and the headache must meet at least two of the following characteristics:
· Unilateral location
· Moderate to severe pain intensity
· Aggravated by or cause avoidance of regular physical activity (eg, walking, climbing stairs)
In addition, during the headache attack, at least one of the following is present:
· Nausea and/or vomiting
· Photophobia and phonophobia
Can migraine be a sign indicative of another underlying disease?
It is crucial to rule out any potential red flags which may be indicative of serious spinal or cardiovascular disease. These include:
· Arterial dissection
· Subarachnoid haemorrhage
· Subdural haemorrhage
· Temporal/giant cell arteritis
· Cerebral venous thrombosis
· Cerebral infarction
· Intracranial hypertension
Another challenge in the management of migraine is to understand the importance of psychosocial issues faced by migraine patients, which may manifest as:
· Avoidance behaviour
Additionally, other co-existing conditions such as diabetes, hypertension or irritable bowel syndrome may also aggravate the migraine.
On the other hand, stroke may also present with severe headache pain and hence, it is essential to differentiate between the two. Migraine typically presents as unilateral pain (but can also be bilateral) and can be severe in its intensity. In addition, there may be vomiting and nausea, and sensitivity to light and sounds may also be present. For stroke, there will tend to be severe pain, onset tends to be sudden, with associated features such as disturbances in balance, slurred speech, and change in facial features.
Top 3 diagnostic predictors of migraine
As migraine is substantially underdiagnosed, a simple, 3-question, self-administered screening tool called ID Migraine™ was developed to help detect patients with unreported headache complaints in the primary care setting. The questionnaire was developed from a 9-item questionnaire that was in turn designed to evaluate patients based on the criteria for diagnosis of migraine established by the IHS.
Of the nine diagnostic screening questions, three items stood out as the strongest predictors of migraine diagnosis in a study by Lipton and colleagues: nausea, disability, and photophobia. The sensitivity and specificity of the questionnaire were similar regardless of sex, age, presence of comorbid headaches, or previous diagnoses. [Neurology 2003;61:375-382]
Specifically, the questions asked for the three items, respectively, were:
Are you nauseated or sick to your stomach when you have a headache?
Has a headache limited your activities for a day or more in the last 3 months?
Does light bother you when you have a headache?
Among patients complaining of headache, those who answered positively on two out of the three questions above were 93 percent likely to be diagnosed with migraine; and those who scored positive on all three questions had a 98 percent chance to be diagnosed with migraine.
Risk of analgesic overuse
Since migraine manifests as a pain condition, overuse of analgesic medication poses a risk. As pain worsens or becomes more frequent, patients tend to increase the use of analgesic medication —which may not help their condition.
One of the ways to avoid overuse of analgesic is to use migraine preventive therapies, such as beta blockers or antiepileptic drugs. Although these treatments are not completely effective in preventing migraine attacks, they may reduce the severity and frequency of attacks enough so that patients will not overuse or depend on acute medications.
Furthermore, increased use of analgesic medications may actually cause headaches, this is known as “analgesic rebound headaches” and not until patients are weaned off medications do their headaches improve.
Non-pharmaceutical treatment options
Preventive treatment is necessary when migraine has a substantial impact on patients’ lives and the attacks have not responded to acute care, or when the attack frequency is so high that acute medications would be overused.
The goals are to: (1) reduce attack frequency, severity, and duration; (2) to improve responsiveness to treatment of acute attacks; and (3) to improve function and reduce disability.
Migraine patients often try non-pharmacologic headache treatment before or concurrently with drug therapy. Relaxation training, thermal biofeedback combined with relaxation training, EMG biofeedback, and cognitive behavioural therapy may be used alone or in combination with preventive drug therapy to achieve additional clinical improvement for migraine relief.
Use of preventive therapies is recommended when patients experience any of the following:
• Migraine significantly interferes with the patients’ daily routines, despite acute treatment
• Frequent headaches (>2/week)
• Contraindication to, or failure, side effects, or overuse of acute therapies
• Patient preference
• Presence of uncommon migraine conditions, including hemiplegic migraine, basilar migraine, migraine with prolonged aura, or migrainous infarction
Recent research has indicated that the primary cause of headaches and migraine is related to the upper three cervical segments (C1-3) — resulting in a sensitized brainstem or the trigeminal cervical nucleus.
Therefore, a manual medicine approach can be beneficial for patients with headaches/migraines. The term “Manual Medicine” refers to the use of palpation and operator-directed techniques to aid in the diagnosis and treatment of musculoskeletal disorders. Manual medicine is based, in part, on the belief that man is a self-regulating being and that the body, when in normal structural relationship, is capable of self-healing and defence against disease. The goal of treatment is to restore maximal pain free movement of the musculoskeletal system in postural balance.
In particular, neck pain is often one of the main triggers that characterizes migraine. The aim of manual techniques is to desensitize the brain stem at the levels of C1-3 in particular as well as associated muscle and joints [Photos 1-3]. Occipital and neck symptoms commonly accompany primary headache, indicating that cervical afferents may be involved in central pain processing mechanisms of these disorders manifesting in headache. [Headache 2012;52:1226-1235]
Alternatively, acupuncture has been shown to be as effective as medication in the treatment of migraine. In a systematic review of 22 clinical trials involving 4,985 people, acupuncture reduced the frequency of headache in individuals with episodic migraine, and that the effectiveness might be similar to that observed with preventive medications. After 6 months, 59 percent of the patients treated with acupuncture experienced at least a 50-percent drop in headache frequency compared with 54 percent of those receiving preventive therapies. These findings suggest that acupuncture may be considered as a treatment option for migraine. [Cochrane Database Syst Rev 2016;2016:CD001218]
Migraines and Sleep
There is an unequivocal connection between sleep disorders and migraine. Patients with chronic migraine suffering from insomnia are at increased risk for mood and anxiety disorders. Sleep disturbance is a common denominator across the majority of sleep disorders and a wide range of associated sleep disorders may greatly benefit from sleep interventions. Addressing the comorbidity of insomnia has been shown to greatly improve headache and migraine.
It is important that GPs maintain a holistic approach in the treatment and management of migraine. In the absence of serious comorbidities, simple lifestyle education such as emphasizing the importance of adequate exercise and nutrition as well as ensuring management of any stress related issues are of the utmost importance.
Another important aim is to minimize the overprescription of pharmaceuticals. If GPs have limited success in alleviating a patient’s migraine and all the serious red flags and pathologies have been ruled out, it may be worthwhile to consider a referral to a manual medicine practitioner that specializes in the treatment of migraine and headaches if there is neck pain/stiffness and any other associated musculoskeletal pain/dysfunctions.