We recently had National Headache and Migraine Awareness week in Australia.
Unlike other years there seemed to be more happening around it, and congratulations must go to Headache Australia for putting on a number of events, which were accessible online.
Two talks in particular gave me pause, the first from Dr David Williams of Monash Medical Centre, and the second from Dr Gerald Edmunds from Headache Australia.
The first talk from Dr David Williams I wrote about during the week, and expressed my frustration at people being labelled as ‘wired for life’ for migraines and that the best we can do is to try and increase the time between events, and try our best to minimise the severity when it does happen - primarily by using medications, botox or electrical stimulation.
All sound advice, however botox is only used once the condition has already become chronic, and medications and electrical stimulation are not preventive measures.
A broader view must be taken to recognise the extent to which we can minimise the number of events and decrease the frequency. There was certainly a sense of resignation to ‘learn to live with and minimise’ them.
At the end of the 'Awareness week' Gerald Edmunds, Secretary General for Headache Australia was interviewed on 3AW’s health show “House of Wellness”.
Gerald referred to one of the differences between a ‘headache’ and a ‘migraine’ is that migraine has a genetic basis.
"other than genes what causes migraines and whether environmental factors could be significant?
Gerald responded that that was more likely to be ‘headache’ as once you’ve got the migraine gene, you will be subject to them regardless. You just have to accept that they are going to happen and deal with them when they do.
Gerald Quigley, a pharmacist who co-hosts the show then commented that he is puzzled as to why amongst patients, particularly female, there seemed to be a ‘resignation’ that migraines are ‘just part of my lot in life’
I think it is hardly surprising that people (not only women) that they are ‘resigned to this being their lot in life’ when the key message being purveyed by ‘experts’ in awareness week is - "Learn to live with it, its genetic".
The disappointing aspect for me was not that the message of managing your triggers, relaxation and good healthy habits was being pushed. I couldn’t agree more with these sentiments.
My concern is that an opportunity has been missed to educate, and to de-mystify headache in all its forms, and that many sufferers will hear the 'its genetic so learn to live with it' line as a reason to not pursue treatments, and misrepresents what 'genetics' means and what we can do about it.
David Williams started to talk to the ‘migraine circuit’ but instead of going on to explain what this circuit is, and what types of things switch it on, he moved on to accepting that it’s a ‘bad circuit’ and lets try not to upset it.
At the end of the session Sally Obermeder suggests that maybe our modern lifestyle of looking down at our phones a lot is playing a role here. Unfortunately there was no support for the comment other than Gerald Quigley talking briefly to the effect of blue light. With the three nerves from the top of the neck feeding directly into the 'migraine circuit' in the brainstem our posture can be critical.
While I will talk quite heavily to the role of the neck in 'irritating' the migraine circuit, and the research that sows its fundamental to a well rounded approach, I will also touch on other topics over the coming weeks and months:
- such as the role of diet (not only as a trigger avoidance measure, but what foods may assist the body to minimise attacks)
- Importance of good sleep patterns
- Medication overuse headache: what is it and what drugs might pose the greatest risk
- Genetics and migraine: what does it mean?
Whilst I am not a specialist in any of these areas I think it is important to broaden the discussion across all areas, and bring you the opinions of those who are experts in the area for your own information, in the hope it may prompt you to discuss this first hand with someone who within their chosen profession (i.e. nutritionist) also has a good handle on the role their field plays in headache and migraine.
I was watching a talk by Dr David Williams from Melbourne as part of Headache and Migraine awareness week, and for the most part I was really pleased with what I heard.
He spoke about the sensitivity of the trigeminal nerves as being the underlying issue.
He spoke about not being too caught up in the classification system and that all the different types of headache are effectively slightly different variations of the same underlying process.
And that this process effectively starts in the headache centre, down in the lower part of the brain, known as the brainstem (which is where the nerves from the neck mix with the nerves from the head and face).
TICK! TICK! TICK!
At this point he went on to describe how a migraine evolves after that point and the role of medications at different stages of the migraine cycle. He is working on the assumption that you are 'wired for migraine' and that rather than change this, you need to accept it, and we need to lessen the likelihood of triggering migraines by:
a) Avoiding triggers
b) doing things both with drugs and lifestyle to 'calm down the nerve system
Whilst there is nothing wrong with this advice, I would like to discuss two assumptions that underpin some of his talk.
The first I will do in a separate blog because it is a big issue - the comments he made regarding the increased sensitivity in the face, scalp, head and neck as all being part of the migraine - which it 'can' be, without any recognition that input from these areas can in fact cause the sensitivity. More on this later.
The second one is that people are 'wired for migraine for life'.
At this comment I got frustrated. Why? Simply because this is where we blame the patient rather than the treatments.
"If I can't do more than temporarily block your migraine or decrease the frequency by 50% then its not my treatment that's at fault........you just can't be fixed and it's your 'faulty wiring' that is to blame."
I have people arrive at my clinic equally frustrated by the 'just learn to live with it' or 'you can't be fixed' comment.
Instead I would prefer this:
"The treatment I have to offer you has been effective, but only in part. We can see that there has been improvement, but to try and find the other pieces of the puzzle you really need to look beyond medications and a strictly neurological approach. You need to seek experts in other fields who focus heavily on migraine (or headaches) and see if they can help you unlock some other pieces of the puzzle.
So right now you are thinking "what's this got to do with firemen??" right?
Well, expecting a neurologist to have a deep understanding of psychology, upper cervical spine pathology and its impact on the brainstem or relaxation techniques is a lot like expecting a fireman to have an in-depth knowledge of town planning, building codes, fire retardant building materials, power pole maintenance etc. Whilst they may understand it at a basic level, our firemen are there to put out fires once they start and most of their resources are built around fire suppression. They don't have a huge role in developing and using many of the preventive measures we now take for granted.
In a similar way neurologists are about headache and migraine suppression - they try to help put the fire out - working on the assumption that 'you will always get them because of your wiring', and I don't blame them for having that as their focus.
What we need to understand is there really is a lot more we can do to 'calm down' the headache centre before episodes begin and the research is currently pointing directly at the top of the neck and particularly at the Watson Headache® Approach at being able to do this.
To his credit Dr David Williams did mention:
"It's important to consider the role of these other allied ‘specialists’ and some are going to have more important roles than others – consider the role of acupuncture and massage, the role of a psychologist, the role of a physiotherapist and even a personal trainer."
There is a lot in this one little sentence, and not enough is known and broadly understood about how impactful this aspect of the approach to treating headache and migraine can be.
Again, I don't blame the Neurologists and in fact I applaud Dr Williams for recognising, at least in some form that there is a broader aspect to management.
We focus entirely on the role of the neck in headache (all forms), but we also don't have the entire solution - we don't have an in-depth knowledge of medications, diet, or exercise physiology. It's time to work as a team and check all the boxes - prevention hand in hand with acute management or symptom suppression.
Dr Elliot Shevel, founder of the Headache Clinic in Johannesburg, South Africa has been a strong opponent to the current way we classify, and therefore diagnose and treat common headache disorders including migraines and tension-type headaches.
Interviewed in 2011, his theory (controversial at the time) was that diagnosing different headaches baswed on their presenting symptoms, rather than the source of the pain was wrong.
He argued that instead of looking a the symptoms "specialists should rather be looking at pinpointing where the pain is coming from" and treating these areas instead.
We agree whole heartedly with this point of view. When we can see s direct connection between a physical structure, such as the neck, and a patients symptoms, this should be the first line of treatment before we head down the road of medications which can, in turn start to create headaches of their own (keep an eye out for "Medication month" later this year).
Dr Shevel (a maxillo-facial surgeon) then focusses very narrowly on the arteries on the scalp and the muscles of the neck and jaw as the primary feedback mechanism. We think this is too narrow a focus, but a good start. We would prefer to broaden the scope of influence to what we can see from the science, which is that an overactive trigeminal nucleus underpins all major headache types. Any input into this area must be part of the suspect pool - not only stretch receptors in arteries, or muscle spindles in muscles, but stretch receptors in ligaments, joint capsules, mechanoreceptors, nociceptors (pain receptors) thermoreceptors........nothing can be excluded unless testes.
A good example are thermoreceptors - the nerves that tell you you feel hot or cold. In my experience it is rare that these are the primary source of 'overstimulation', however I have seen a number of patients who have described getting hot quickly (i.e. sitting in a hot car) as a trigger for a migraine, and almost instantaneously. Others will be set off with cold wind on their neck or head. To narrow the focus and rule out possible inputs is a mistake.
To focus treatment on the common area that all these inputs interact with, and indeed the area that generates the symptoms of headache and migraine is by far and away the most sensible place to start, and in many cases there is no need to look further.
The technique used at this clinic, pioneered by Australian physiotherapist Dean Watson, know as the Watson Headache® Approach, is a hands on technique that uses sustained pressures to identify 'inputs' into the trigeminal nucleus, and to desensitise, or to 'dial down' the activity that is constantly there.
As a safe, natural, drug free, non-invasive (non-surgical) approach it is the most sensible place to start the assessment and treatment process.
Roger O'Toole is the Director and Senior Clinician of the Melbourne Headache Clinic and has over 10 years experience as a physiotherapist.