Physical Therapy II Presentation

MIGRAINE HEADACHES
Headache that lasts 4 to 72h, is throbbing, is moderate to severe in intensity, is
unilateral, becomes worse with exertion, and is associated with nausea, vomiting, or
sensitivity to light, sound, or smell. Only three or four of the above criteria must be
present for accurate diagnosis. (Merck Manual of Diagnosis and Therapy Sect. 14.
Neurologic Disorders Chapter 168)

Etiology:
Cause is currently unknown, although some theories attribute it to be neurogenic in
nature. Changes in arterial blood flow are seen, however whether vasodilation or
vasoconstriction are a cause or effect of the condition remains to be seen. Inflammation
due to a wave of hyperpolarization followed immediately by depolarization (changes
within the brain cortex), lead to an irritation of perivascular trigeminal sensory fibers.
The result is a lowered pain threshold and convergence of nerve tracts leading to a
referred headache phenomenon. Vascular theories attribute a resultant alteration in blood
flow as the cause of severe headache.

Classification and Patient Presentation and Diagnosis:

Classic: A short prodromal or period of warning signs including depression, irritability,
restlessness or anorexia precedes the headache by approximately 1hr. The above signs
may be accompanied by visual disturbances including flashing lights and scotomas, this
may also be complicated by transient, reversible somatosensory, motor or language
deficits. Collectively this collection of symptoms is referred to as an aura. 80-85% of all
migraines are of this nature, which accounts for 10-15% of all headaches.
Common: There is no prodrome associated with these kinds of migraines.
Generally patients are female and will present with a unilateral, pulsatile, severe
headache. The headaches are recurrent and become much more prevalent in females
during puberty (related to estrogens role as a trigger for the condition). Most often
patients will avoid light and food; many times they will also vomit. Patients who suffer
from Common Migraines may be able to aptly continue their daily activities.
The diagnosis of migraine is more likely when patients present with a family history. Lab
tests and other diagnostic procedures are done only to rule out any underlying pathology
(i.e. tumor, lesions or infections, obvious trauma).

Triggers:
Although the underlying mechanism is ill defined, several things are recognized as
triggering migraine headaches. Environmental and physical factors such as pollutants,
weather, smoke/smog, noise, light, odors or heat, certain foods (chocolate, alcohol,
coffee/black tea, cheese, salt or tomatoes) and sleep schedules, exercise habits, stress,
hormones can all play a role in the onset of an episode. Medications especially those

containing estrogen (hormone replacement therapies and oral birth control) are also
implicated.

So Now What? :
Treatment is dependent on the severity and number of attacks; they are generally
classified as prophylactic, abortive or analgesic. The presence of other pathologies
must first be ruled out or addressed in the treatment regime. Several medications
including OTC NSAIDs, Sumatriptan, Beta-blockers, Calcium Channel blockers
and Amitriptyline are used.
Adjusting as indicated as well the patient may use hot or cold packs according to their
personal comfort and the desired effect. Several articles discussed the positive
outcomes reported by patients using acupuncture for treatment.
Although Im sure that some form of subthreshold motor stimulus could be used to
stimulate endorphin (1-10cps) or enkephalin (80-120cps) release, I was unable to
find any supportive data. Only one article that discussed the use of thermal
biofeedback reported that PT alone is not effective in reducing headache, Due to
the contraindications of pad placement over the eyes or through the brain careful
consideration would be required.
Gentle exercise (yoga, stretching etc) will alleviate muscle tension and aid in relaxation;
it may also be desirable for helping the patient deal with their stress levels.

Stuff I read:

Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation of chronic
headache: a systematic review. J Manipulative Physiol Ther. 2001 Sep; 24(7):457-66.
Feahterstone Harvey J, M.D. Migraine and Muscle Contractions Headaches: a Continuum. Headache.
1985; 25:194-198
Johnson GD. Medical management of migraine-related dizziness and vertigo. Laryngoscope. 1998
Jan;108 (1Pt 2):1-28.
Marcus DA, Scharff L, Mercer S, Turk DC. Nonpharmacological treatment for migraine: incremental
utility of physical therapy with relaxation and thermal biofeedback. Cephalgia. 1998 Jun;18(5):26672; discussion 242.
Nelson CF, et al. The efficacy of spinal manipulation, amitriptyline and the combination of both
therapies for the prophylaxis of migraine headache. J Manipulative Therapy. 1998 Oct. 21(8):511519.
Parker GB, Pryor DS, Tupling H. Why does migraine improve during a clinical trial? Further results
from a trial of cervical manipulation for migraine. Aust N Z J Med. 1980 Apr; 10(2):192-8
Silberstein SD, Silberstein MM. Headaches. Evaluation and thearpy. Int J Dermatol. 1987 Sep;
26(7):469-471
Whitney SL, Wrisley DM, Brown KE, Furman JM. Physical therapy for migraine-related
vestibulopathy and vestibular dysfunction with history of migraine. Laryngoscope. 2000 Sep;
110(9):1528-34.