A chiropractic approach to managing migraine

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1 A chiropractic approach to managing migraine

2 What is chiropractic? Chiropractic is a primary healthcare profession that specialises in the diagnosis, treatment and overall management of conditions that are due to problems with the joints, ligaments, tendons and nerves, especially related to the spine. Chiropractic treatment mainly involves safe, often gentle, specific spinal manipulation to free joints in the spine or other areas of the body that are not moving properly. Apart from manipulation and mobilisation, chiropractors may use a variety of soft tissue stretching and massage techniques, as well as ultrasound, exercise, acupuncture, and advice about posture and lifestyle. Although chiropractors are best known for treating back and neck pain, patients also consult chiropractors regarding a range of other related conditions, such as migraine. How can chiropractic help manage my migraine? Chiropractic care can help decrease the frequency and duration of migraine headaches, particularly in those who have a cervicogenic / mechanical component to their migraines. Often migraines are multifactorial, which means that they can be triggered by a number of different factors; therefore chiropractic care may be beneficial in the co-management of migraine. A chiropractic consultation will involve a detailed history taking and examination in an attempt to establish the main triggering factors in your migraine pattern. If there is a mechanical contribution to your migraine, the chiropractor should be able to treat this with various chiropractic techniques to suit your individual needs. A chiropractor is in a position to offer every individual an appropriate diagnosis, and give advice on lifestyle as well as provide a referral to another healthcare provider if this is apparent in the initial consultation. The role of a chiropractor is not limited to manual treatment.

3 FAQs How long does a treatment session last? The time spent with the chiropractor for an initial consultation for migraine and headache should take a minimum of 40 minutes with an hour being common. Follow up sessions can take between 15 and 30 minutes with the chiropractor. How many sessions will I need? The number of sessions required will vary from individual to individual and will also depend on several factors: age, occupation, lifestyle, previous injuries, overall general health, the severity of your condition, how long you have had the problems, how you respond to treatment and how much of your chiropractor s advice you follow. Typically, for headaches you should expect to see a positive response within 4 to 6 sessions. It may not be 100% but there should be a positive change. How much will a session cost? Treatment sessions will vary in cost from region to region. The initial consultation which includes taking a detailed history, completing appropriate neurological and orthopaedic tests and the initial treatment can cost between 45 and 70. Follow up sessions typically range between 30 and 45. You should only pay for treatment as you have it and the General Chiropractic Council advises against paying in advance for future treatments. Where can I find a chiropractor in my local area? Visit the General Chiropractic Council the statutory body for chiropractors. For chiropractors who are part of Headache Clinics UK contact Are there any side effects to the treatment? As with all medical and physical therapies there are risks involved. Following a chiropractic treatment you may experience short lived muscle soreness and exacerbation of headache as tissues involved in triggering your migraine may have been affected. There is also a very small risk of fracture, strokes and stroke like episodes, although the National Institute of Health states: there is no evidence that visiting a chiropractor puts people at greater risk than visiting a primary care physician. Do I have to have an x-ray? Your chiropractor will only recommend that an x-ray be taken if there is a valid clinical reason for doing so, which with migraine and headache is very rare. Can I get chiropractic care on the NHS? It is always worth asking your GP, your local Primary Care Trust or Health Board if NHS funding is available for chiropractic or contacting Headache Clinics UK.

4 Research Chaibi A., Tuchin P.J., Russell M.B. Manual therapies for migraine: a systematic review. Headache Pain (2011) 12: Summary Migraine is usually managed by medication, but some patients do not tolerate migraine medication due to side effects or prefer to avoid medication for other reasons. Nonpharmacological management is an alternative treatment option. This study systematically reviewed randomized clinical trials (RCTs) on manual therapies for migraine. The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. Chiropractic spinal manipulative treatment An Australian study included migraineurs with frequent attacks diagnosed by a neurologist. The participants were divided into three study groups; cervical manipulation by chiropractor, cervical manipulation by physiotherapist or physician, and cervical mobilization by physiotherapist or physician. Improvement was observed in all three groups post-treatment. The study did not include a control group although cervical mobilization is mentioned as the control group in the paper. A follow-up 20 months after the trial showed further improvement in the all three groups. An American study included 218 migraineurs diagnosed according to the criteria of the International Headache Society by chiropractors. The study had three treatment groups, but no control group. The headache intensity on days with headaches was unchanged in all three groups. The mean frequency was reduced equally in the three groups. Over the counter (OTC) medication was reduced from baseline to 4 weeks post-treatment with 55% in the cervical spinal manipulation therapy (CSMT) group, 28% in the amitriptyline group and 15% in the combined CSMT and amitriptyline group. A second Australian study was based on questionnaire diagnoses on migraine. The participants had migraine for a mean average of 18.1 years. The effect of CSMT was significant better than the control group. The mean reduction of migraine frequency, intensity and duration from baseline to follow-up were 42, 13, and 36% in CSMT group, and 17, 5, and 21% in the control group.

5 Research Vernon H., Jansz G., Goldsmith H. et al. Randomised, Placebo- Controlled Clinical Trial of Chiropractic and Medical Prophylactic Treatment Of Adults with Tension-Type Headache: Results from a Stopped Trial. Journal of Manipulative a n d Physiological Therapeutics 345 Volume 32, Number 5. (2009). Summary A randomized clinical trial was conducted with adult tension-type headache sufferers who experienced more than 10 headaches per month. Four groups were randomly created and each group was randomly allocated one of the following treatment plans: real cervical manipulation + real amitriptyline (a preventative drug used in the management of migraine), real cervical manipulation + placebo amitriptyline, sham cervical manipulation + real amitriptyline, and sham cervical manipulation + placebo amitriptyline. A baseline period of four weeks was followed by a treatment period of 14 weeks. The primary outcome was headache frequency obtained from a headache diary in the last 28 days of the treatment period. Nineteen subjects completed the trial. In the unadjusted analysis, a statistically significant main effect of chiropractic treatment was obtained which was just below the 3-day reduction set for clinical importance. As well, a clinically significant effect of the combined therapies was obtained, but this did not achieve statistical significance. In the adjusted analysis, neither the main effects of chiropractic nor amitriptyline were statistically significant or clinically important; however, the effect of the combined treatments was statistically significant and reached the trial s criterion for clinical importance.

6 Research Bronfort G., Assendelf W.J., Evans R., Haas M., Bouter L., Efficacy of Spinal Manipulation for Chronic Headache: A Systematic Review Journal of Manipulative and Physiological Therapeutics Volume 24, Number 7, September Summary Nine trials involving 683 patients with chronic headache were included. Based on predefined criteria, there was moderate evidence that spinal manipulation therapy (SMT) has shortterm efficacy similar to amitriptyline in the preventative treatment of chronic tension-type headache and migraine. SMT does not appear to improve outcomes when added to soft-tissue massage for episodic tension-type headache. There was also moderate evidence that SMT was more efficacious than massage for cervicogenic headache (headaches related to or affected by dysfunction of the neck).

7 Research Whin P.D., Pollard H., and Bonello R., A Randomized Controlled Trial of Chiropractic Spinal Manipulative Therapy for Migraine. Journal of Manipulative and Physiological Therapeutics Vol 23 Number 2. Feb Summary Participants completed headache diaries during the entire trial noting the frequency, intensity, duration, disability, associated symptoms, and use of medication for each migraine episode. The average response of the treatment group showed statistically significant improvement in migraine frequency, duration, disability, and medication use when compared with the control group. Four persons failed to complete the trial because of a variety of causes, including change in residence, a motor vehicle accident, and increased migraine frequency. 22% of participants reported more than a 90% reduction of migraines as a consequence of the 2 months of SMT. Approximately 50% more participants reported significant improvement in the severity of each episode. The results of this study support previous results showing that some people report significant improvement in migraines after chiropractic SMT. A high percentage (>80%) of participants reported stress as a major factor for their migraines. It appears probable that chiropractic care has an effect on the physical conditions related to stress and that in these people the effects of the migraine are reduced.

8 Research Alix M.E., Bates D.K., Proposed Etiology of Cervicogenic Headache: The Neurophysiologic Basis and Anatomic Relationship Between the Dura Mater and the Rectus Posterior Capitis Minor Muscle. Journal of Manipulative and Physiological Therapeutics Vol 22, Number 8, Oct Summary A sizable body of clinical studies note the effect of manipulation on headache. These results support its effectiveness. The dura-muscular, dura-ligamentous connections in the upper cervical spine (around the neck) and occipital areas (around the head and neck) may provide answers to the cause of the cervicogenic headache (headaches related to or affected by dysfunction of the neck). This proposal would further explain manipulation s efficacy in the treatment of cervicogenic headache. Further studies in this area are warranted to better define the mechanisms of this anatomic relationship.

9 Research Evidence Report: Behavioural and Physical Treatments for Tension-type and Cervicogenic Headache. Duke University (1996). Summary Cervical spinal manipulation (manipulation based around the neck) was associated with improvement in headache outcomes in two trials involving patients with neck pain and / or neck dysfunction and headache. Manipulation appeared to result in immediate improvement in headache severity when used to treat episodes of cervicogenic headache (headaches related to or affected by dysfunction of the neck) when compared with a placebo control group. When compared to soft-tissue therapies (massage), a course of manipulation treatments resulted in sustained improvement in headache frequency and severity. However, among patients without a neck pain / dysfunction component to their headache syndrome that is, patients with episodic or chronic tensiontype headache the effectiveness of cervical spinal manipulation was less clear. No placebo or notreatment control studies of manipulation have been performed with this control group. In one trial conducted among patients with episodic tension-type headache, manipulation conferred no extra benefit when added to a soft-tissue therapy (deep friction massage). In another trial conducted among patients with tension-type headache, amitriptyline was significantly better than manipulation at reducing headache severity during the 6-week treatment period; there was no significant difference between the two treatments for headache frequency during the same period. Interpretation of these results is difficult because all patients received the same relatively low dose of amitriptyline (30 mg). Despite the uniform and relatively low dose of amitriptyline, however, adverse effects were much more common with amitriptyline (82% of patients) than with manipulation (4%). During the 4-week period after both treatments ceased, patients who had received manipulation were significantly better than those who had taken amitriptyline for both headache frequency and severity.

10 Headache Clinics UK chiropractic approach to migraine and headache Even today there is still not a one treatment fits all for migraine and other headache types. Physical therapy is just one approach in the fight against migraine and headache and can sometimes offer an alternative to medication or help reduce the levels of medication required. The chiropractors at Headache Clinics UK have undertaken additional training in the diagnosis and management of headaches and work as part of a multidisciplinary approach. They use evidence based methods of physical therapy for migraine and headache treatment, and their results are measured using validated tools to ensure positive outcomes are achieved. When you visit a Headache Clinics UK chiropractor, they will: Take a full headache history. Conduct appropriate neurological and orthopaedic tests. Perform a full examination of head (including jaw), neck and if necessary back and shoulder structures. Complete a postural examination. Discuss your medication history (although they are not allowed to prescribe or give advice on changing your medication, they can help you with requesting a GP review of medication if necessary). Provide an initial diagnosis of headache type. Help refer you to another healthcare professional, including a neurologist if they feel it is in your best interest, and also for an MRI brain scan. Treatment approach can take the form of any or all of the following depending on your headache type and situation: Manipulation Soft tissue stretching Dry needling / acupuncture Advice on diet / supplementation Mobilisation Trigger point work Exercise Use of headache diaries The aim of treatment is to help reduce the frequency, duration and severity of your migraines and headaches, and to aid self-management with a reduction in medication where possible. Headache Clinics UK chiropractors expect to see a positive response, but not necessarily total resolution, in your migraines or headaches within 4 to 6 treatments. After that a plan of management is agreed with you on an individual basis and reviewed at each session. At Headache Clinics UK chiropractors are trained to treat you for only as many sessions as is required to gain improvement from your particular condition and will not ask you to return for unnecessary treatments.

11 Useful contacts General Chiropractic Council 44 Wicklow Street, London, WC1X 9HL. Phone: Web: The General Chiropractic Council is the body established by parliament to regulate and develop the chiropractic profession. They are a UK-wide statutory body established by the Chiropractors Act Headache Clinics UK Ltd Head office: 11 Station Road, Marsden, Huddersfield, HD7 6DG. Phone: Web: Clinics nationwide in the UK Headache Clinics UK was developed to help headache sufferers access suitable headache treatments quickly and on a national basis. Their approach is based on combining the current methods of diagnosis and investigation with multiple pathways to the most appropriate treatment and advice. Their concept of combining the skills of medical neurologists with the diagnostics and physical skills of chiropractors is unique, and contributes to their high level of patient satisfaction and patient improvement. It is a team approach, designed to give you what you want relief from your headaches. Chiropractic Patients Association 8 Centre One, Lysander Way, Old Sarum Park, Salisbury, Wiltshire, SP4 6BU. Tel: Website: The Chiropractic Patients Association (CPA) raises funds to support chiropractic research in order to advance knowledge, such that patients benefit both in treatment, rehabilitation and aftercare. Other Chiropractic Associations McTimoney Chiropractic Association - Scottish Chiropractic Association - British Chiropractic Association - United Chiropractic Association -

12 Web: Exclusive offer Headache Clinics UK, in association with Migraine Action, would like to offer you, your friends and family members a 10% discount off your 1 st 4 chiropractic treatment sessions. Just mention Migraine Action when you call Headache Clinics UK to book your 1 st treatment session. Tel: For further information, advice on migraine management and for updates on the latest migraine research, please contact Migraine Action by calling , ing or visiting the charity s website at All of our information resources and more are only made possible through donations and by people becoming members of Migraine Action. Visit to support one of our projects or visit to become a member. Acknowledgments Migraine Action would like to thank Jim O Dell, Chiropractor, Headache Clinics UK and our Medical Advisory Board for reviewing and providing information used in this booklet. Dr Andrew Dowson, Chairman of Migraine Action s Medical Advisory Board comments: Chiropractors are regulated primary health care professionals who are trained in spinal manipulation and other manual therapy modalities. Although there is growing evidence of the benefits of manual therapy in migraine and headaches there is still room for more studies, but currently manual therapy as practised by chiropractors is another tool in the treatment of migraine. As a rule Migraine Action and Headache Clinics UK suggest that those interested in trying chiropractic should try the approach for between 4 to 6 sessions and then reflect on the outcomes. Bibliography th Floor, 27 East Street, Leicester. LE1 6NB. Tel: Fax: Web: Registered Charity No Copyright 2011 Migraine Action Version 1 Created August 2011 Next Review Date March 2013 This publication provides information only. Migraine Action and its officers can accept no responsibility for any loss, howsoever caused, to any person acting or refraining from action as a result of any material in this publication or information given. Whilst this booklet has been reviewed for accuracy by members of Migraine Action s Medical Advisory Board and other experts, the information does not necessarily reflect the views of individuals. Medical advice should be obtained on any specific matter.

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