3. Take a look around you at work, on the train or bus, at school with yourself or your children - and tell me with a straight face that we all have good posture that isn't causing stress in the top of the neck.
The fact is, since we start sitting, we sit badly. Whether its on the floor at school craning up to look at your teacher, head down looking at the desk, sitting on poorly fitted chairs/desks, sleeping on your side curled up, or on your back with a big pillow pushing your head forwards............from the earliest of ages we are spending an overwhelming majority of our waking and resting day with our head positioned forwards of the spine - either chin poked out or head pointed down.
This constant stress creates changes in the top of the neck which manifest themselves over years. Everyone is different as to how much of an issue this can become, just like not all people with fallen arches or 'flat feet' get shin, knee, hip and/or back pain from them, but others most certainly do and that needs to be addressed.
In the same way not everyone with bad posture gets headaches or migraines - otherwise we would all be suffering (actually, 97% of the population will suffer a headache at some point in time and we know that 60% of those can have their infrequent and mild headache reproduced by pushing on the neck).(3)
In those who are suffering, especially when a simple solution has not presented itself (as it rarely does) we whole heartedly echo the sentiments of a growing community of headache and migraine specialists calling for a skilful examination of the neck.
At the recent Migraine World Summit Dr Joel Saper (Neurologist - Michigan Head & Neurological Institute) called for action:
“It’s essential that we consider the neck very carefully. These (difficult) cases need to be with someone who can treat the neck and put it all together” .(4)
But what type of investigation do you do? Who should you see?
Not surprisingly many people with migraines have already tried neck treatment (due to the symptoms) and not had success. Why is this the case and why try again where so many have failed?
The problem is that traditional treatments have focussed on the neck without testing, or treating the way in which it is connected to the headaches. What results is people having an assessment, finding (not surprisingly) that they have a sore neck, and then treatment begins.........working on the assumption that if we just treat the pain in the neck or restore normal movement that this will result in the headaches or migraines improving.
Clinical trials in Physiotherapy, Chiropractic and Osteopathy have failed to show that we can have a significant impact using those methods.(6)
This along with variable results and a history in some areas of over servicing has seen a manual therapy or 'hands on' approach shunned.
This is a mistake. Throwing the baby out with the bath water.
Instead what is needed is an approach that is designed specifically to treat the relationship between the neck and your symptoms. An approach that before you commence treatment can show clearly whether there is a relationship between your neck and your symptoms. It is also an approach that sets high expectations about results. We will not be telling you "You've had this for 10 years - it will take months and months to see changes"
We know that if our treatment is going to work for you, then we will see significant changes within the first two weeks.
It's time to use the right tool for the right job, and seek a highly skilled examination of your neck using techniques designed to identify and treat the role of the neck in headache and migraine.
Call today and try the only hands on technique shown to lower brainstem sensitivity, and treat the underlying issue in primary headache.
(1) Ashina, S., Bendtsen, L., Lyngberg, A. C., Lipton, R. B., Hajiyeva, N., & Jensen, R. (2015). Prevalence of neck pain in migraine and tension-type headache: A population study. Cephalalgia. 35 (3): 211-219 https://doi.org/10.1177/0333102414535110
(2) Kerr, F. W. L. (1961). Structural relation of the trigeminal spinal tract to upper cervical roots and the solitary nucleus in the cat. Experimental Neurology. https://doi.org/10.1016/0014-4886(61)90036-X
(3) Watson, D. H., & Drummond, P. D. (2012). Head pain referral during examination of the neck in migraine and tension-type headache. Headache, 52(8), 1226–1235. https://doi.org/10.1111/j.1526-4610.2012.02169.x
(4) Saper, J (2018) Concussions, Brain Injuries, and Migraine. Migraine Word Summit Keynote Video - Day 3 - Risks.https://migraineworldsummit.com/talk/concussions-brain-injuries-and-migraine/
(5)Cerritelli, F., Ginevri, L., Messi, G., Caprari, E., Di Vincenzo, M., Renzetti, C., … Provinciali, L. (2015). Clinical effectiveness of osteopathic treatment in chronic migraine: 3-Armed randomized controlled trial. Complementary Therapies in Medicine, 23(2), 149–156. https://doi.org/10.1016/j.ctim.2015.01.011
‘The RoB-tool was also applied by Cerritelli and colleagues with all included studies showing unclear or high risk of bias. According to the authors, methodologic quality is poor due to limitations in randomization and incomplete reporting of outcome data. Additionally, the strength of the treatment effect cannot be evaluated based on the available evidence.’
(6) Chaibi, A., Benth, J., Tuchin, P. J., & Russell, M. B. (2017). Chiropractic spinal manipulative therapy for migraine: a three-armed, single-blinded, placebo, randomized controlled trial. European Journal of Neurology, 24(1). https://doi.org/10.1111/ene.13166
The effect continued in the CSMT (Chiropractic Spinal Manipulative Therapy) and placebo group at all follow-up time points, whereas the control group returned to baseline. The reduction in migraine days was not significantly different between the groups (P > 0.025 for interaction).
This is a good question and it doesn't have a simple answer. The reason is there are often multiple causes contributing the the problem.
Think of it like a bushfire - we have essential factors required to start a fire, but many different factors that will vary from fire to fire to cause it to be an 'out of control fire'.
The three essential elements to create the fire are, fuel, heat and oxygen. Most commonly the hear element also comes in the form of an ignition or 'trigger'.
But these are present every summer, and indeed fires start every year but we rarely see them grow out of control. We now add strong winds and sloping topography, then isolation from resources to put it out to spread the fire rapidly.
Indeed going deeper again we see building codes, communications systems and public infrastructure maintenance all playing a part in major fire events.
We can think of the causes of migraine in the same way. There may well be an obvious precipitating event or trigger (i.e. spark) - such as stress, ingestants, light, etc. and just like different major fires, different people will have different factors that contribute - be they genetic disorders related to gut or calcium channel activity, reactions to certain chemicals in food or drink, or indeed light or sound.
All these vastly different combinations...........they all lead to pain in the head.
Regardless of the trigger we know from a broad section of research that all headache sufferers have an increase in the resting activity levels of the trigeminal nucleus - the part of the brainstem housing all the nerves for the head and the face (trigeminal) and neck (upper cervical spine).
It makes perfect sense then that treatments targetting proteins in inflammatory substances in the blood (CGRP), or reducing stress, or reducing tension of scalp muscles (botox) will only be effective for a few (the lucky ones who have one major cause - i.e. a gas plant fire) as opposed to those with multiple causes.
You would expect the research to show modest changes with these types of treatments.
Thats exactly what we see.
Research into a drug that blocks CGRP, a protein that causes significant vasodilation, and botox show similar modest effects.
For CGRP, in a group suffering 18 migraine days per month the treatment group had an improvement of 6.6 days per month. (Hold your applause)
Placebo group improved by 4.2 days per month.
The botox studies showed in suffers with around 19 headache days per months treatment reducing headaches by 1.8 days per month more than placebo (7.6 days vs 5.8).
Interestingly, the usual bar of 50% reduction in frequency to be deemed effective was lowered to 30% for the botox trial........just snuck in........but then the placebo hits the mark too.
In both the case of botox and CGRP the treatments are not without potentially harmful side effects.
Maybe worth the risk if the results were outstanding, but I think I'd go with the placebo which also proved to be effective, less expensive and no side effects.
The reason for limited effect here is clear when you consider the multiple causes - these are only targeting a very narrow band.
The most effective drugs to date - the triptans, target the sensitivity of the trigeminal nucleus. By helping the body absorb serotonin, the activity in the brainstem reduces and can abort episodes.
The technique we use, the Watson Headache Approach, has been shown to do the same thing, without needing to take tablets.
In other words, if we minimise the fuel loads to begin with, it doesn't matter how hot it is, how dry it is, or how strong the wind is...............we can minimise the size of the fire, or indeed it just doesn't take hold in the first place.
We can safely, and naturally decrease the activity of the brainstem - regardless of triggers, and regardless of the multiple causes.
We target the structure that all these factors affect, and lead directly to migraine.
Roger O'Toole is the Director and Senior Clinician of the Melbourne Headache Clinic and has over 10 years experience as a physiotherapist.