The kids are back at school (…..finally…… ) and families everywhere are getting back into their ‘routines’.
As a young child we crave routine because so much of what is happening around is new, and ‘unknown’ and we find safety and comfort in things that are familiar. As we go through life we become exposed to the same situations over and over. Our brains quickly get used to our daily habits and are constantly seeking for patterns to the extent that our brain will begin to anticipate certain events – for example, starting every morning with a coffee, or taking a pain relieving medication at the same time every day. Your brain will anticipate the arrival of the caffeine or medication and start to make changes so that the arrival of the substance (i.e. caffeine) doesn’t come as a ‘shock’ and the system is already preparing for it. Some might refer to the feeling this gernates as a craving, and indeed the response if we don’t provide the subtsance that is expected can cause some ill feeling – a withdrawal response. The result of a disordered and ‘unepxected’ day is a stress response or ‘reacting’ and using our ‘fight, flight or flop’ response.
Migraine is a routine illness, in that, there are routines we have that create or upset the status quo. The migraine brain craves routine.
Here are two key daily routines that can impact on migraines:
Driven by our circadian rhythm our brain goes through daily sleep/wakes cycles. Someone setting their alarm for the same time everyday will often find that after a while their brain starts to rouse and wake in the minutes before the alarm goes off. The internal clock is anticipating the alarm, and rather than be ’startled’ out of sleep it begins a gentler process of progressing from deep sleep to a state of wakefulness.
Right through the migraine cycle the interaction with the sleep/wake centres is obvious to see.
Not only do we see yawning, fatigue and unusual dreams/sleep behavior as a prodrome, but in the midst of an episode many sufferers will find comfort in getting to sleep, often waking improved and reporting that the reason for taking some medication is the drowsiness and sleep they induce.
We also frequently hear that changes in sleep patterns (too much or not enough) can be a trigger, with ‘brain fog’, lethargy and inability to process information being some of the most universally shared symptoms after pain, nausea/vomiting and sensitivity to light or sound.
A small investment in good sleep health may have a positive impact on the frequency, duration and/or severity of your migraines.
For the next month try going to sleep at the same time every night, waking the same time each morning (I’m sorry, yes, even on weekends) and provide your brain with some predictability. It’s just one piece of the puzzle, but in some it may be an essential piece.
The second area we can adopt a healthy routine is good neck health.
The science is patently clear now, that the area housing the trigeminal and upper cervical nerves is the ‘powder keg’ in all primary headache types including migraine. Sitting there on a daily basis, bubbling away waiting for a ‘spark’ (aka trigger) to blow it up.
It is not hard to believe that the neck is a driving source of this problem. Not only does the research show that treating the neck decreases trigeminal nucleus activity, but the stresses we put on our neck are almost universal.
Take a look around you at work, school, or the next time you are on a bus and count how many people are looking down or sitting slouched with their head forward of their body.
Now bend your index finger right back on itself and hold it their for 20 seconds.
The postures you are seeing are doing exactly the same thing to the top of your neck as what you have just done to your index finger, but because it builds up slowly and is relatively constant most of us we don’t notice it as much.
Imagine now how often we sit with our head forward or look down. In fact even when we go to sleep on our side we tend to curl forwards, and on our back tend to use a pillow pushing the head forward.
Our poor neck doesn’t get much respite other than when we are standing and looking straight ahead. Not a big percentage of anyone’s day.
The fact is we look down a lot because that’s where our ands are and that’s where we interact mostly commonly with our world.
Take another look around in your home or office and you will see that all the things we use most often we place between hip and shoulder height – hand height. So we have to look down.
What then can we do?
There are times when we look down and don’t need to. From the position of your car seat, to the location of the television in relation to your couch, working on a laptop instead of a desktop – there a numerous areas we can easily change with little or no expense in many cases.
A phone can be held at eye level by folding one arm across your stomach to support the elbow of the hand holding the phone.
Heavier tablets can’t be held for as long. If your routine is to read/watch tv from a tablet for long periods of time consider buying a tablet holder on a stand (often sold for musicians as a music stand). This can be adjusted to any height, easily packed away, and saves your neck an hour or so of being squeezed forwards.
Lastly, have an expert examine your neck.
The long-term changes that occur in the neck due to looking down or the head sitting forward cause reactive spams in the top of the neck. Whilst stretching and massaging these can provide short term relief, correction of the fault that is triggering the spasm is paramount to a more sustained result.
Part of the genius of the Watson Headache Approach ® was not only to prove how much this problem irritates the brainstem, but to find a method of treating it that is long lasting and sustainable.
A combination of treating the problem combined with often small changes in posture can have a profound impact on the neck, and as a result a significant decrease in the irritation of the brainstem, directly impacting on the area known to be the problem in migraines.
Start your journey to better sleep and neck health today and make your migraine a ‘routine’ condition.
Migraine and Opioid based medication
In February 2018 medications containing codeine will no longer be available over the counter (OTC) but will require a doctors prescription. The looming move of codeine based products to prescription only in Australia may have many headache sufferers concerned about their ability to cope, however many may be unaware that the drug that they are taking to relieve pain may be making their condition worse.
The Australian Therapeutic Goods Administration said misuse of over-the-counter codeine products contributes to severe health outcomes, including "liver damage, stomach ulceration, respiratory depression and death". An Australian study using coronial data showed there had been over 1,400 deaths in a little over a decade related to codeine use.
Many headache sufferers will still be able to access codeine based products with a doctors prescription, but the question is should they?
Repeated use of opioids such as codeine don’t prevent symptoms, and in their attempt to temporarily mask pain, cause disease progression and bad clinical outcomes, in particular the transformation to daily headache. The physiologic changes occur rapidly and can be permanent, and include decreased grey matter, release of CGRP (implicated in migraine pathogenesis), dynorphin and pro-inflammatory peptides, and activation of excitatory glutamate receptors. Opioids are pro-nociceptive, prevent reversal of migraine central sensitisation and interfere with triptan effectiveness. 
One study  showed that people who suffered episodic or occasional migraine and took narcotics or barbiturates more frequently were more likely to develop transformed migraine. That means they have increased their migraine days per month to more than 15, ‘transforming’ from episodic to chronic.
Its not just headache and migraine sufferers that need to be concerned.
Opioids have been shown to be problematic in inducing headache in many chronic pain conditions such as back pain and oncologic pain. Use of opioids in non-headache chronic pain was associated with a 20% likelihood of developing headache (including migraine) in the next 11 years, compared to only 3.1% in those not using opioid-based analgesics. [3,4]
We are sympathetic to those who have tried many different forms of pain relief and find codeine-based products to be the only thing to help. However we strongly support the move to prescription based access and hope that the broader chronic pain community is successful finding alternative avenues, both pharmaceutical and non-pharmaceutical to help reduce pain and improve outcomes for sufferers.
We are also conscious that this is only one part of a much bigger picture, both within migraine health and outside.
Inside the 'migraine bubble' factors relating to diet, sleep, and daily activities are always part of the picture, and recent research is indicating the issues run a lot deeper than many people will understand. Through this year we will be looking more deeply into the research outside of our own neck based treatment to try and broaden the understanding of factors influencing migraine in the hope of getting the best possible result for those in our care.
 Tepper, SJ 2012 Opioids Should not be used in Migraine Headache, 54 (S1) pp 30-34
 Bigal, M.E. and Lipton, R. A. (2008) Excessive acute migraine medication use and migraine progression. Neurology, 71 (22); 1821-8.
 Johnson, J. L., et al. “Medication-overuse headache and opioid-induced hyperalgesia: a review of mechanisms, a neuroimmune hypothesis and a novel approach to treat- ment.” Cephalalgia 33 (2012): 52–64
 Zwart, J.-A., et al. “Analgesic use: a predictor of chronic pain and medication overuse headache: The Head–HUNT Study.” Neurology 61(2) (2003): 160–164.
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.
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.
Reason 5 - Our guarantee.
We have heard this story so often it makes me feel a little ill. I have been seeing my (insert one of chiro, physio, osteo, masseur, etc) once a week for 6 months - and it seems to help for a day or so.
This is not helping. It is treating the symptoms, and because it is not getting at the underlying cause it is ultimately ineffective, expensive, and treatment without an endpoint.
Our guarantee has 2 parts. The aim is to minimise the risk of treating people who either don't have a neck problem relating to their head pain, or not continuing to treat people who are getting no more than short term relief.
Firstly we don't book everyone that calls for an appointment. We conduct a phone interview lasting approximately 10-15 minutes seeking information that may save you the time and money of an initial consult. Some people from the phone interview will be referred back to their GP or specialist for further investigation or referred back to their local health professional (Physio/Chiro/Osteo) for follow up.
Those that are accepted will then book an initial assessment. Here we look for clear signs that your neck is related to your condition. By very selectively and precisely stressing the joints in the top of the neck we look to temporarily reproduce the area of your usual symptoms (i.e. push pain up into your head behind the eye). If we can reproduce these symptoms we sustain the pressure and look for the referred pain to ease after 30-40 seconds.
If this "reproduction and resolution" of familiar symptoms occurs (and it does in approx. 80% of initial assessments) we accept the person into the initial treatment block.
If we cannot reproduce familiar symptoms, or we can but they do not subside then it is unlikely the treatment we use will be effective, so rather than try and convince you to get a treatment that will ultimately provide short term or no relief and little else, we set ourselves apart from the crowd and decide not to treat you.
Secondly, if you are accepted into the initial treatment block, then we expect there to be significant changes in your condition within 2-3 weeks. That is not to say that you will be "cured" in 2 weeks. If we get to the end of the second treatment week after the initial assessment, and there is no sign of significant change we stop.This is a protection for the 10% of cases who start treatment, and their condition does not respond preventing the cycle described above of "endless" treatment programs with no goals. This number is relatively low, indicating over 90% of people respond. The reason for such a high success rate is due in part to screening out 20% from the initial assessment, but unfortunately there are some whose necks will not respond to treatment in the long term - we will not continue to treat if you are not improving.
We would love to be able to help everyone, and we would love everyone to respond well to treatment. The reality is that only 80% have treatable problems related to their neck, and approximately 90% of these will respond to treatment. The difference is we are upfront about these numbers, and open about every step of the process to minimise the risk of receiving treatment that is ultimately not effective.
The improvement in the first few weeks is why this clinic can effectively run outreach services to regional areas. Those that do respond, respond quickly and are able to manage with self treatment soon thereafter.
Reason 4: The figure 80%.
What could 80% have to do with the neck and headaches?
Now before you click the next button thinking I’ve lost the plot, let me explain.
In 2009 Headache Australia (in conjunction with pharmaceutical company MSD) ran a survey with over 500 migraine sufferers trying to assess the impact of migraine on people’s lives. The press release for the study was titled “Migraine misery spiraling out of control”.
Given the title, it’s not hard to guess the results were not particularly good, and at the same time not all that surprising.
Quite disturbingly this study found that 81% of migraineur’s were looking for a better, more effective treatment for their migraines. Even worse, 83% didn’t expect their condition to improve.
This sounds like a lot I know. It must lead to the question, with all the billions of dollars that have been poured into (largely pharmaceutical) research………are they missing something?
Professor of Anatomy at Newcastle University, and world-renowned spine anatomist, Nick Bogduk thinks it’s fairly obvious what the missing link is:
"People in control of the headache field seemingly have not, cannot, or will not recognize that this model for cervicogenic [neck based] headache is not only the best evolved of all headaches but is testable in vivo, in patients with headache complaints. No other form of headache has that facility."
Officially, headache coming from the neck (cervicogenic) is reported to represent between 0.1% and 4% of all headache cases.
Approximately 80% of the people assessed in the Melbourne Headache Centre have testable and reproducible headpain coming from the upper cervical spine. Almost all of these would not fit the diagnostic criteria for cervicogenic headache, but are mostly tension type headache (TTH) or migraine. Many of them do not believe they have specific problems with their necks.
So what you say. I could make that number up right? Sure, but we are not alone. Dr Rothbart, an Canadian anaesthesiologist and head of the Rothbart Pain Management clinic has published his findings widely:
“Approximately 800 new headache patients per year are examined at our clinic. An estimated 80% of these patients are diagnosed with cervicogenic headache. Of these patients, almost none are referred with this diagnosis. Physicians are not taught to consider or explore neck structures when investigating headaches. This results in a rarely diagnosed but common condition”. Rothbart P. The cervicogenic headache: A pain in the neck. Can J Diagnos 1996; 13: 64–71.
That number again. 80%.
Using the same techniques as the Melbourne Headache Centre, Drummond and Watson investigated tension headache and migraine sufferers, and found that ALL of the TTH sufferers had their usual headpain reproduced during assessment, and 95% of the migraine sufferers had their usual headpain reproduced with manual examination of the upper part of the neck.
Watson, D.H. and Drummond P. D. (2012) Head Pain Referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache: The Journal of Head and Face Pain, Vol 52, (8), pp 1226–1235.
The anatomical links between the neck and the “headache/migraine centre” in the brainstem are obvious. The numbers are becoming overwhelming.
Over 80% are looking for something better. Is it a coincidence that almost all of them will not have had their upper neck assessed using headache specific assessment techniques?
80% of headache sufferers have necks that are causing a problem, but as a source of the problem the neck is largely ignored? I don’t think it’s any coincidence at all , that he same number are unhappy with their current treatment options.
Many will have tried treatment using general neck therapy from physiotherapists, chiropractors and osteopaths, without success.
It is time to try headache specific techniques and see if you too are in the majority of suffers who are needlessly putting up with treatable problems in the upper part of the neck causing so much misery.
Reason 3 - The benefit of dedicated techniques
In reason 1 we saw that there are a lot of similarities in the way that the different headaches present. Their symptoms overlap significantly. This is because, as described in Reason 2, ALL major headache types have an overactive brainstem - with the neck having direct input into this area.
So why then if all this is so obvious, is the neck not the first port of call when someone presents with a new headache or migraine?
Quite simply, the reason why the neck is often ignored is because the traditional modalities (physiotherapy, chiropractic, osteopathy and massage) have rarely offered more than short term relief. Of course there are exceptions, and no doubt there will be plenty of people willing to offer their testimonial for their local therapist who has "cured" them. For each of these there are 10 times the number who not been helped, been made worse, or had short term relief.
Traditional manual therapy approaches to the neck focus on local problems - muscle and joint dysfunction. The theory being, if it is coming from the neck, and you improve the neck problems it should get better. It often lacks the understanding of the nature of the problem, and treats symptoms rather than the underlying problem.
The techniques employed by the Melbourne Headache Centre have been developed SOLELY for the purpose of evaluating and treating the relationship between the structures in the neck and the headache/migraine. We don't treat neck pain as such.
The techniques allow us to very specifically and selectively stress each of the joints in the top part of the neck. As stress is applied we aim to temporarily reproduce the area of typical headpain. As the referred pain is produced the pressure is sustained, and after a short period of time the referred pain starts to ease off. This confirms the relevancy of the neck to the headache disorder, and the ability of the techniques to desensitise the neck. This is found in 80% of cases. Unlike traditional methods - we don't treat everyone that is assessed hoping they might get better. The 20% that do not have a clear association between the neck and symptoms are not offered treatment as they are unlikely to respond to it.
By working in a systematic way and using special movements we can not only pinpoint the exact level involved (i.e. C1, C2, C3) but the exact point on that vertebrae that is connected with the head pain. This allows great precision in application of techniques, rather that just stretch anything that is tight and loosen any joint that is stiff.
Not only do you get the benefit of dedicated headache specific techniques, but they are delivered by therapists who only treat headache and migraine. Using the same techniques all day just on headache and migraine conditions allows highly developed skill in the application of the techniques. This is as opposed to a therapist who spends half their day treating backs, knees, elbows, doing pilates etc, and then sometimes treating the odd headache.
What are you waiting for (apart from reasons 4 and 5!).
Check your neck. Call 03 8648 6487 today for your free phone consultation.
Roger O'Toole is the Director and Senior Clinician of the Melbourne Headache Clinic and has over 10 years experience as a physiotherapist.