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Migraines: Presentation, Mechanisms, and Management

Migraines: Presentation, Mechanisms, and Management

Migraines remain an important public health issue that can significantly affect one’s daily activities and quality of life. The prevalence of migraines in the US adult population is quite high, affecting 15.3% of individuals. Relative to the general population, the prevalence is higher for those with disabilities (16.4%), aged 18-44 (17.9%), and on low income (19.9%). Additionally, the prevalence in women (20.7%) is much higher than in men (9.7%). Annually, migraines account for 3% of all visits to the emergency department, consistently among the top four or five leading causes.1

Symptomatically, migraines progress through four stages: prodrome, aura, attack, and post-drome. One to two days before a migraine –  i.e. prodrome – subtle changes warn of an upcoming attack, including constipation, mood changes, food cravings, neck stiffness, increased thirst, and frequent yawning. As a migraine progresses, individuals may experience auras, or reversible symptoms of the nervous system that begin gradually and last 20 to 60 minutes. Examples of auras include visual phenomena (e.g. bright spots, shapes, and flashes), vision loss, pins and needles in the arms and legs, facial numbness, difficulty speaking, hearing noises, and uncontrollable jerking movements. During an attack, which can last 4 to 72 hours if untreated, individuals may experience pain on one or both sides of the head, throbbing sensations, sensitivity to light and sound, nausea, and vomiting. After an attack – i.e. post-drome – individuals may feel drained and confused for up to a day.2

Over the past few decades, our understanding of the pathophysiology of migraines has improved considerably. Previously, the vascular theory was the leading explanation for migraines; however, a series of imaging studies demonstrated that vascular changes were neither necessary nor sufficient for attacks.3-4 From vascular theories, researchers moved to neuronal theories involving the peripheral and central nervous systems. Initially, researchers attempted to localize a single structure as the source of migraines; but it is now clear that migraines are a complex brain network disorder with a genetic basis that involves multiple cortical, subcortical, and brainstem regions.4-6

The trigeminovascular system is a key actor and its activation is thought to initiate the cascade of events resulting in migraines due to its direct connection with the diencephalic and brainstem nuclei.7-8  The literature also supports the involvement of the hypothalamus in migraines. For example,several studies demonstrate hypothalamic connections to the thalamus, trigeminovascular system, and brainstem nuclei, supporting the role of the hypothalamus in pain modulation in patients with migraines.9-11 The involvement of the hypothalamus may explain some of the early symptoms of migraines, such as food cravings, mood swings, and yawning. Additionally, the thalamus may play a role in migraines. The thalamus is a nociceptive relay station that conveys information from the dura mater and cutaneous areas to second-order trigeminovascular areas. Several studies report structural and functional thalamic alterations in patients with migraines.12-13 Furthermore, changes in the structure and function of key cortical areas were demonstrated in migraineurs, such as the insular, somatosensory, prefrontal, and cingulate cortex.14 Lastly, a variety of factors may trigger migraines, including hormonal changes in women, alcohol, coffee, stress, sensory stimuli, sleep changes, weather changes, medication, and processed foods.

Chiropractic spinal manipulative therapy (CSMT) is supported by numerous studies as an effective treatment option for migraines. In a randomized controlled trial of 172 patients, Tuchin et al demonstrated that patients receiving CSMT reported a significant improvement in migraine frequency, duration, disability, and medication use. A more recent study by Chaibi et al involved a 52 year old woman suffering from migraines once per month, with pain scored as an 8 out of 10. After CSMT treatment, the patient reported a complete elimination of migraines. At a follow up 6 months later, the patient did not report a single migraine episode during the intervening period.16 Overall, evidence suggests that CSMT can alleviate pain from migraines, making chiropractic care a viable option for individuals suffering from migraines.

References

1) Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache: The Journal of Head and Face Pain. 2018;58(4):496–505.

2) Mayo Clinic Staff. Migraine. Mayo Foundation for Medical Education and Research. Nov. 2019.

3) Amin FM, Asghar MS, Hougaard A, Hansen AE, Larsen VA, de Koning PJ, Larsson HB, Olesen J, Ashina M. Magnetic resonance angiography of intracranial and extracranial arteries in patients with spontaneous migraine without aura: a cross-sectional study. Lancet Neurol. 2013;12:454–461.

4) Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman S. Pathophysiology of migraine—a disorder of sensory processing. Physiol Rev. 2017;97(2):553–622.

5) Charles A. Migraine: a brain state. Curr Opin Neurol. 2013;26:235–239.

6)  Ferrari MD, Klever RR, Terwindt GM, Ayata C, van den Maagdenberg AM. Migraine pathophysiology: lessons from mouse models and human genetics. Lancet Neurol. 2015;14:65–80.

7) Goadsby PJ, Charbit AR, Andreou AP, Akerman S, Holland PR. Neurobiology of migraine. Neuroscience. 2009;161:327–341.

8) Akerman S, Holland PR, Goadsby PJ. Diencephalic and brainstem mechanisms in migraine. Nat Rev Neurosci. 2011;12:570–584.

9)  Kagan R, Kainz V, Burstein R, Noseda R. Hypothalamic and basal ganglia projections to the posterior thalamus: possible role in modulation of migraine headache and photophobia. Neuroscience. 2013;248:359–368.

10) Abdallah K, Artola A, Monconduit L, Dallel R, Luccarini P. Bilateral descending hypothalamic projections to the spinal trigeminal nucleus caudalis in rats. PLoS One. 2013;8:e73022.

11) Robert C, Bourgeais L, Arreto CD, Condes-Lara M, Noseda R, Jay T, Villanueva L. Paraventricular hypothalamic regulation of trigeminovascular mechanisms involved in headaches. J Neurosci. 2013;33:8827–8840.

12) Magon S, May A, Stankewitz A, Goadsby PJ, Tso AR, Ashina M, Amin FM, Seifert CL, Chakravarty MM, Muller J, Sprenger T. Morphological abnormalities of thalamic subnuclei in migraine: a multicenter MRI study at 3 tesla. J Neurosci. 2015;35:13800–13806.

13) Hodkinson DJ, Wilcox SL, Veggeberg R, Noseda R, Burstein R, Borsook D, Becerra L. Increased amplitude of thalamocortical low-frequency oscillations in patients with migraine. J Neurosci. 2016;36:8026–8036.

14) Sprenger T, Borsook D. Migraine changes the brain: neuroimaging makes its mark. Curr Opin Neurol. 2012;25:252–262.

15) Tuchin P, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migrain. J Manip Physio Therap. 2000;23:91-95.

16) Chaibi A, Tuchin PJ. Chiropractic spinal manipulative treatment of migraine headache of 40-year duration using Gonstead method: a case study. J Chiropr Med. 2011;10(3):189–193.

Rehabilitation after Motor Vehicle Injuries

Motor vehicle collisions (MVC) are a known cause of poly-trauma in multiple age groups. According to the CDC, MVC claimed the lives of approximately 35,000 Americans in 2015 and account for 2.3 million visits to the hospital yearly. Injuries sustained in MVC can vary based on the mechanism of collision, speed, site of impact as well as other variables including seat belt use, air bag deployment, and others. Due to this, there are many types of injuries that can be sustained in MVC. A common injury seen in the setting of MVC is cervical whiplash injury. This article will discuss the general principles as it pertains to rehabilitation management of cervical whiplash injury. We expect that the general points discussed below can also apply to other MVC injuries.

Whiplash injury from MVC is caused by a sudden change in vehicle velocity causing a flexion/extension movement to the cervical spine. Symptoms of whiplash injury can include prolonged/persistent neck pain, pain with movement, range of motion restriction, headache, and neurological symptoms (weakness, numbness, balance disturbance). It is important to note that symptoms may not present at time of impact. Diagnosis is made with history and physical examination with supporting evidence provided by imaging. Rehabilitation treatment is directed towards reducing pain, improving range of motion, and mitigating disability. Due to the significant psychosocial factors associated with this condition, the goal of therapy is to improve function while also avoiding exacerbation of psychological, social, and legal stressors.

Rehabilitation of cervical whiplash injury is often performed under the coordinated care of a skilled therapist and medical professional (e.g., Rehabilitation Medicine Physician). Initial management is directed towards patient education, postural modification and neck range of motion. The goal of therapy is to educate towards independent practice of learned exercises at home. Most prescriptions for physical therapy are approximately two times per week for four to six weeks. If needed, therapy may be extended if the patient is obtaining benefit from treatment and gains are made.

Therapists will demonstrate and practice exercises including neck rotation, neck tilting and neck bending with the goal of teaching the patient a comprehensive home exercise program. Specific therapies include tissue manipulation. A cervical collar may also be given for comfort however prolonged or continuous use is not recommended. Modalities such as heat, ultrasound and massage may also be employed. Transcutaneous electrical nerve stimulation may also provide benefit. Rest breaks are used to mitigate pain exacerbation and are less frequent as time elapses from initial injury. While cervical traction may be employed, there is no evidence to suggest that traction provides superior management than the above treatments. The patient is educated on symptoms to monitor for and to present for medical evaluation if concerning symptoms arise during therapy and after. As the patient completes the rehabilitation

In conclusion, MVC are associated with a significant number of death and medical evaluations annually. There are many types of injuries associated with MVC due to the mechanism of injury as well as mitigating factors. A common injury seen from MVC is cervical whiplash injury. Rehabilitation of whiplash injury is directed towards reducing pain and improving range of motion with patient education towards an independent home exercise program. The above points highlight the general treatment principles for injury after MVC with cervical whiplash injury used as an example. It is important to determine the specific treatment needs for the injuries sustained and this care should be directed under the watch of a skilled medical professional.

References:

Motor Vehicle Injuries: Winnable Battles. Center for Disease Control. Accessed online on October 11th, 2019. https://www.cdc.gov/winnablebattles/report/motor.html

Cohen SP. Epidemiology, diagnosis, and treatment of neck pain. Mayo Clin Proc 2015; 90:284.

Grubb SA, Kelly CK. Cervical discography: clinical implications from 12 years of experience. Spine (Phila Pa 1976) 2000; 25:1382.

Slipman CW, Plastaras C, Patel R, et al. Provocative cervical discography symptom mapping. Spine J 2005; 5:381.

Bronfort G, Evans R, Anderson AV, et al. Spinal manipulation, medication, or home exercise with advice for acute and subacute neck pain: a randomized trial. Ann Intern Med 2012; 156:1.

Mealy K, Brennan H, Fenelon GC. Early mobilization of acute whiplash injuries. Br Med J (Clin Res Ed) 1986; 292:656.

Rosenfeld M, Gunnarsson R, Borenstein P. Early intervention in whiplash-associated disorders: a comparison of two treatment protocols. Spine (Phila Pa 1976) 2000; 25:1782.

Verhagen AP, Peeters GG, de Bie RA, Oostendorp RA. Conservative treatment for whiplash. Cochrane Database Syst Rev 2001;CD003338.