Fit and Well - Melbourne Headache Centre interview on Watson Headache Approach
SEN Fit and Well Interview: Roger O'Toole with Paul Coburn and Tony Schibeci - 27/06/2012
TONY SCHIBECI: One man that will never give up on you too soon is Paul Coburn. How are ya Cobes?
PAUL COBURN: Very well, very well.
TONY SCHIBECI: Excellent mate, of course brought to us by the Mill Park Physiotherapy group – 9436 9666 if you want to check out Cobes or any of the other physiotherapists there for a bit of advice.
PAUL COBURN: I’ve got a traffic alert.
TONY SCHIBECI: Tell me.
PAUL COBURN: Down at Rod Laver Arena, I thought, geez the Wimbeldon fans have gone and slipped something in the cucumber sanwhiches, and I thought hell, they’ve really gone right off, with what they’re wearing and the looks, etc. But I guess on reflection its probably a Lady GaGa concert down there
TONY SCHIBECI: Oh yes there is of course, so all the ‘little monsters’ were down there…….
PAUL COBURN: Yes, so just if your driving past there, just a warning…….
TONY SCHIBECI: There’s some weird people……..
PAUL COBURN: Yeah there sure is…
TONY SCHIBECI: You’ve brought in a very special topic today Cobes. We’re talking headaches/migraines.
PAUL COBURN: Yeah today were going to cover migraine headaches. There’s some established views on how to treat headaches, but we’ve got a special guest that might have an insight into a new technique that’s being used at the moment.
TONY SCHIBECI: We have to, and lets introduce him now, we have Roger O’Toole from the Melbourne Headache Centre, G’day Roger.
ROGER O’TOOLE: Hi Tony, thanks for having me
TONY SCHIBECI: Welcome aboard, it is a really serious topic because there’s nothing more debilitating than a nasty headache, and even moreso a shocking migraine.
ROGER O’TOOLE: Yeah definitely. I’d refer to it as maybe the silent epidemic. There’s a lot of people out there, so 3 million Australians suffering migraine and if we add in Tension-Type headache there’s another 7 million suffering with that, and absolutely it can knock you out. Typically people with a migraine are out for a day, but then for a couple of days after they’ve usually got what they refer to as the hangover where they are still not productive.
PAUL COBURN: O.k. so Rog could you explain to us from the start, or actually define for us the difference between a severe headache and a migraine headache?
ROGER O’TOOLE: It’s a curly question Paul because there’s a lot of conflicting ideas and when it comes down to it, it can be difficult to distinguish between the two. A severe Tension-Type headache can mimic or be very similar to a severe migraine, but really the definition is that a migraine is usually one sided, moderate to severe in intensity, often with a throbbing or pulsatile nature to it, but also associated with nausea or vomiting, and/or sensitivity to light and sound.
PAUL COBURN: So what’s the aura thing that they talk about?
ROGER O’TOOLE: That’s a visual disturbance that can precede or accompany their migraine, and people can in fact have an aura without headpain. The way that it has been traditionally looked at is that these are independent beings or entities, but what the research is starting to suggest now is that they are more a continuum, so there’s no ………
PAUL COBURN: So they might all have a relationship between them.
ROGER O’TOOLE: Yeah that there’s a common underlying issue in Tension-Type headache, Migraine, Menstrual migraine, and cluster headache. So there’s a lot of these sub-types.
PAUL COBURN: So traditionally what have been thought to be the triggers for migraine headache?
ROGER O’TOOLE: That’s probably as varied as we look. Stress, hormones with menstrual migraine, people have chocolate as a trigger. So traditionally the medical approach might be to do a diary of what you have eaten or what you have done during the day, to see if you can identify something that commonly precedes your migraine. For the lucky ones they might be able to pick something out, and say “oh great I’ve just got to avoid chocolate and I don’t get my migraine anymore” but often there might be two or three different things, and that can be really hard to nut down.
PAUL COBURN: So people having their headaches, the first step is to go to their GP and get everything cleared, because, off air Schibecs, you were saying that once you had a migraine after a concussion.
TONY SCHIBECI: Yeah heads collided on a footy field. We were both running for the mark and ‘bang’ we were both knocked out. I remember the next day, and it’s the only time I reckon I’ve ever had a migraine…….I’ve had bad headaches, but the only time I’ve ever had a migraine because everything, every sound was amplified by about a thousand, light was just…….I couldn’t stand light I had to be in total darkness for the day and it was the day after the concussion, and I felt really crook and really bad. I can understand and feel sorry for people that suffer hat on a regular basis. For me the trigger was I would say, the concussion.
ROGER O’TOOLE: Yeah look its not uncommon in what’s being referred to now as post concussion syndrome, where people might then have chronic headaches or migraines. Certainly in your case you’d want to know that you are ok, so the first step would be to see your GP to get cleared. Anyone that contacts our clinic, we do a phone screen initially and we are really looking at is this person appropriate (for us to treat), so we are really looking at how long has this person had symptoms and has it changed significantly in the past 3 months, or is it new. So anyone that has got a new severe headache, sudden onset, and its only been 2 weeks, we’re going to send you to your GP to get checked out.
TONY SCHIBECI: Have they been able to categorize a specific group of people that suffer headaches or migraines more than anyone else?
ROGER O’TOOLE: With migraine in particular its women 3 times more than men TTH it’s a bit less of a difference, women 1.5 more, whereas with Cluster headache it’s a bit different with men slightly more than women.
PAUL COBURN: Now Rog, in the past, like when I graduated we treated headaches, we’ve always treated headaches, but we didn’t treat migraines because we didn’t feel like we had an impact. You’re working with a guy from South Australia, Dean Watson and Dean Watson has done some research into looking at migraine headaches. What’s his approach? Why is it different?
ROGER O’TOOLE: Traditionally the physio approach, the way we are trained is to look at movement and painful restriction of movement, which really feeds back into triggers. So really it’s trying to improve the movement of a joint, can we reduce the tension of the muscle and hopefully that might have an effect on their headache. Typically we don’t see migraine. Its only about 2% would typically seek treatment for their neck, it’s just not within the medical model. So what’s different about the research that’s being done, which is part of Dean’s PhD which he is just completing now, is that they took a group of TTH sufferers and migraine sufferers, and in applying pressure in really specific ways in the upper part of the neck, they were able to reproduce their typical headpain, so the pain they would suffer during their headache or their migraine in every single one of the TTH sufferers, so 100%, and all but one of the migraine sufferers they were able to reproduce that pain. So we would say not only does that suggest that the neck is involved, but its actually central to the problem.
TONY SCHIBECI: So could it have something to do with the nerves at the bottom of the brainstem?
ROGER O’TOOLE: Absolutely Tony, you’ve been reading!
TONY SCHIBECI: No, no, its just makes sense.
ROGER O’TOOLE: Well it does. What we know is, and this is not new research……
PAUL COBURN: Hang on, lets take a break. We need to say how it has an impact because it’s a bit different to the way we used to think, and so then people can think about whether it might be appropriate for them.
Now Roger before we went to the break you were starting to explain how this mechanism works, so how is pushing on the neck going to affect someone’s headaches from chocolate or stress, a migraine headache?
ROGER O’TOOLE: Sure. If we think about it in a really simple framework, that there is an input, or a ‘trigger’ so for some people that might be stress, chocolate or hormones. Something has to allow that to then become a migraine. So these inputs go into the brainstem, and the brainstem sits in the top part of the neck. Now there’s a reasonable amount of research over the past decade to suggest that there is a sensitization, or an increase of the activity levels in this part of the brainstem.
PAUL COBURN: What’s it called?
ROGER O’TOOLE: The Trigemino-cervical nucleus.
PAUL COBURN: We had to get that out there
TONY SCHIBECI: Of course it is…..(laughs)
PAUL COBURN: We all knew that, yeah, yeah (laughs) ….go on, and then what happens
ROGER O’TOOLE: SO lets say on a zero to one hundred scale that 50 is the threshold for a migraine. For you and I, I assume Paul, we are sitting somewhere under 10. We need a fair bit of input to push us up over that limit.
PAUL COBURN: Yep
ROGER O’TOOLE: For someone that sufferes say daily migraine they might be sitting at 49.
TONY SCHIBECI: Wow
ROGER O’TOOLE: So getting out of bed, just the weight of the head on their shoulders can be enough of an input to trip them over.
PAUL COBURN: So what does the neck treatment do then?
ROGER O’TOOLE: Yep, so the second part of the research that’s just been done by Dean (Watson) over in Perth with his PhD, has shown that by applying the techniques that we apply to the neck, and what we are looking for is that reproduction of their typical headpain, and as we sustain the pressure (on the neck) we then get a lessening of their usual headpain, that this is actually desentising the brainstem.
TONY SCHIBECI: I was going to say its funny you mention that, because we do have an SMS from someone in regards to something similar to that. They are saying ‘If I get migraines, if I push on a certain spot between two of the vertebrae in the back of my neck the pain goes away completely. It returns the second I take that pressure away.
ROGER O’TOOLE: He’s going to put me out of a job that bloke (laughs)
Yeah look its exactly what we do, probably in a bit more of a specific manner, but we are really identifying what segment, what joint, and its quite specific to say particular angles, or a millimeter this way or that as to whether you’re getting the exact headpain people typically suffer, and as we sustain that pressure we are then getting that resolution, so the headache starts to go away, at that point we know we are having an effect, not just on the stiffness in the neck, or the inputs if you like, but we’re actually starting to target the reason why all those inputs become a migraine.
PAUL COBURN: O.K. Rog, now how do we know that your not going to be helped by this, because its all very well to say ‘everyone with a migraine headache’ but its not going to help everyone, so how would you know if its not going to help somebody.
ROGER O’TOOLE: In the first session we get about 80% who get reproduction of their typical headpain and resolution. It can be difficult to know prior to that who we can and can’t help, but certainly within the first assessment we know that with 80%, yep we can reproduce your headpain by assessing your neck, and we have that go away, 90% of those will have a significant improvement after 5 sessions.
TONY SCHIBECI: Lets go to a caller Paul on the line, and Roger. Jamie out at Sommerville joins us, G’Day Jamie
Jamie: G’Day guys how are ya?
TONY SCHIBECI: Good
Jamie: Just for the last 3 years after every game of football I get chronic headaches. They border on migraines, and I’ve tried everything from pills and going to the doctors and everything. The only thing I can do is to take about 6 extra strength aspirin throughout the day to get rid of it and I’ve read up on this thing, and the only thing I could find was on exertion headaches. Do you know anything about that?
ROGER O’TOOLE: Yeah look, exertional headache, it’s a little bit of a mystery box, but what we think is happening with exertional headaches, is that because of the pressure that tends to build up when you are under stress, not dissimilar to when someone coughs they might hurt the disc in their lower back, we believe that the tension and pressure is applying pressure to the disc in the C2/3 area in the neck, which is the top disc in the neck.
TONY SCHIBECI: We’ve got an interesting SMS, we don’t normally get professionals send us an SMS, but Dr Ben Robbins, and Osteopath and SEN fan has sent one through though and says that if you go beyond the neck and look into the thoracic spine and the sympathetic input and mechanical base you get further with migraine treatment. So I suppose there’s a whole lot, a gamete of studies being done around the whole lot?
ROGER O’TOOLE: There is, and we know there is some sympathetic overlay, particularly with the C2 nerve……..
PAUL COBURN: So sympathetic being one of the nerve systems of the body, not something to feel sorry for…….(laughs)
ROGER O’TOOLE: No, no that’s right so sympathetic is your fight and flight responses, and responsible for sweat, tearing, runny noses, all that sort of thing. SO what we see with a lot of migraine sufferers is that many of them have chronic sinus issues, and there are particular types of headache, cluster headache falls into this category that the diagnosis is due to these additional signs. They might get tearing, they might get redness in an eye or sinus on that side.
TONY SCHIBECI: Quick break, we’ll be back to wrap up the hour in just a tick.