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.
Roger O'Toole is the Director and Senior Clinician of the Melbourne Headache Clinic and has over 10 years experience as a physiotherapist.