Non-pharmacologic Treatment for a Patient with Migraine Headaches

In 2017 The Lancet - Global Burden of Disease study, listed migraine headaches as one of the leading cause of disability worldwide (GBD Neurological Disorders Collaborator Group 2017).

Globally physicians, now more than ever are recommending complementary treatment options (ie. manual therapy, acupuncture, mindfulness stress based reduction (MSBR), pain neuroscience education and exercise) as part of a multi-modal approach to decrease the individual’s headache frequency, intensity, duration and acute medication requirements.

It is encouraging to see so many medical centers and clinical practice guidelines embracing a non-pharmacological approach for migraines

For migraine suffers soft tissue irritation and subsequent nerve sensitization may be a contributor to symptoms (Ferracini et al. 2017, Palacios-Ceña et al. 2017). This is where gentle manual therapy and acupuncture of the upper cervical spine may help avoid ongoing nociceptive input into the trigeminocervical complex (Luedtke et al. 2017).

Acupuncture: An Introduction

If a patient is interested in using acupuncture to manage migraine symptoms there is supporting evidence from The Cochrane Collaborative (Linde et al. 2016), Canadian Medical Association (Busse et al. 2017) and other high quality Systematic Reviews (Yang et al. 2016) and Randomized Control Trials (Zhao et al. 2017).

Medical acupuncture is an approach that is based upon a theory that is inline current scientific understanding of how the body works. Using occam's razor the insertion of an acupuncture needle is a form of novel stimuli, that functions by sending anti-nociceptive input to the neuroimmune system.

Preferential sites for acupuncture stimulation are associated with areas rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). All of these areas are highly innervated and as a result there are a number of physiological responses that help modulate the experience of pain (Chen et al. 2017).

Massage Therapy: An Introduction

The responses to massage therapy are multifactorial - physiological and psychological factors interplay in a complex manner. The biopsychosocial model provides a practical framework for investigating the complex interplay between massage therapy and clinical outcomes.

Based off the biopsychosocial model, investigation into mechanisms of action should extend beyond local tissue changes and include peripheral and central endogenous pain modulation. An observed favorable outcome may be explained by a number of overlapping mechanism in the periphery, spinal cord, and brain represented in the image below.

Treatment Plan Based on Patient Tolerance

My first recommendation for those who suffer from migraines is to work with a physician to develop strategies to manage symptoms. Then a treatment plan can be implemented based on patient-specific assessment findings and patient tolerance.

Structures to keep in mind while assessing and treating patients suffering from migraine headaches may include neurovascular structures and investing fascia of:
• Upper Cervical Spine (Upper Trapezius, Splenius Cervicis, Splenius Capitis)
• Suboccipitals
• Levator Scapula
• Rhomboids
• Temporalis
• Occipitofrontalis
• Corrugator Supercilii
• Masseter
• Sternocleidomastoid
• Temporomandibular Joint
• Scalene Muscle Group

More to Explore

Books
Migraine Brains and Bodies - C.M. Shifflett
Migraines: More than a headache - Elizabeth Leroux
The Migraine Brain - Carolyn Bernstein

Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia.
https://www.ichd-3.org/

Research

Berchtold et al. (2017). The supraorbital region revisited: An anatomic exploration of the neuro-vascular bundle with regard to frontal migraine headache. J Plast Reconstr Aesthet Surg.
https://www.ncbi.nlm.nih.gov/pubmed/28712884/

Brennan, K.C. & Pietrobon, D. (2018). A Systems Neuroscience Approach to Migraine. Neuron.
https://www.ncbi.nlm.nih.gov/pubmed/29518355

Burstein et al. (2015). Migraine: multiple processes, complex pathophysiology. J Neurosci.
https://www.ncbi.nlm.nih.gov/pubmed/25926442

Busse et al. (2017). Guideline for opioid therapy and chronic noncancer pain. CMAJ.
https://www.ncbi.nlm.nih.gov/pubmed/28483845

Chen, L. & Michalsen, A. (2017). Management of chronic pain using complementary and integrative medicine. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28438745

Coeytaux, R. R. & Befus, D. (2016). Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache.
https://www.ncbi.nlm.nih.gov/pubmed/27411557

Courtney et al. (2017). Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther.
https://www.ncbi.nlm.nih.gov/pubmed/28694674

Dodick, D.W. (2018). Migraine. Lancet.
https://www.ncbi.nlm.nih.gov/pubmed/29523342

Fernández-de-Las-Peñas, C. (2015). Myofascial Head Pain. Curr Pain Headache Rep.
https://www.ncbi.nlm.nih.gov/pubmed/26049772

Ferracini et al. (2017). Musculoskeletal disorders of the upper cervical spine in women with episodic or chronic migraine. Eur J Phys Rehabil Med.
https://www.ncbi.nlm.nih.gov/pubmed/28118694

Ford et al. (2017). A Real-World Analysis of Migraine: A Cross-Sectional Study of Disease Burden and Treatment Patterns. Headache.
https://www.ncbi.nlm.nih.gov/pubmed/28984356

GBD 2015 Neurological Disorders Collaborator Group. (2017). Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol.
https://www.ncbi.nlm.nih.gov/pubmed/28931491

GBD 2016 Headache Collaborators. Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol.
https://www.ncbi.nlm.nih.gov/pubmed/30353868

Giamberardino et al. (2007). Contribution of myofascial trigger points to migraine symptoms. J Pain.
https://www.ncbi.nlm.nih.gov/pubmed/17690015

Happe et al. (2016). The efficacy of lymphatic drainage and traditional massage in the prophylaxis of migraine: A randomized, controlled parallel group study. Neurological Sciences.
https://www.ncbi.nlm.nih.gov/pubmed/27338942

Horwitz, S. & Stewart, A. (2015). An Exploratory Study to Determine the Relationship between Cervical Dysfunction and Perimenstrual Migraines. Physiother Can.
https://www.ncbi.nlm.nih.gov/pubmed/25931651

Iyengar et al. (2017). The role of calcitonin gene-related peptide in peripheral and central pain mechanisms including migraine. Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28301400

Landgraf et al. (2018). Children with migraine: Provocation of headache via pressure to myofascial trigger points in the trapezius muscle? - A prospective controlled observational study. Eur J Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28952174

Lemmens et al. (2019). The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/30764753

Li et al. (2017). Acupuncture modulates the abnormal brainstem activity in migraine without aura patients. Neuroimage Clin.
https://www.ncbi.nlm.nih.gov/pubmed/28580293

Lim et al. (2016). Anti-Inflammatory Effects of Acupuncture Stimulation via the Vagus Nerve. PLoS ONE.
http://www.ncbi.nlm.nih.gov/pubmed/26991319

Lin et al. (2017). Using integrative medicine in pain management: an evaluation of current evidence. Anesth Analg.
https://www.ncbi.nlm.nih.gov/pubmed/29189365

Linde et al. (2016). Acupuncture for the prevention of episodic migraine. Cochrane Database of Systematic Reviews.
https://www.ncbi.nlm.nih.gov/pubmed/27351677

Luedtke et al. (2016). International consensus on the most useful physical examination tests used by physiotherapists for patients with headache: A Delphi study. Manual Therapy.
http://www.ncbi.nlm.nih.gov/pubmed/27183831

Luedtke et al. (2017). Musculoskeletal dysfunction in migraine patients. Cephalalgia.
https://www.ncbi.nlm.nih.gov/pubmed/28641450

Luedtke, K. & May, A. (2017). Stratifying migraine patients based on dynamic pain provocation over the upper cervical spine. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28952052

MacPherson et al. (2017). Acupuncture for chronic pain and depression in primary care: a programme of research. Southampton (UK): NIHR Journals Library.
https://www.ncbi.nlm.nih.gov/pubmed/28121095

Millstine et al. (2017). Complementary and integrative medicine in the management of headache. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/28512119

Murakami et al. (2017). Ear Acupuncture for Immediate Pain Relief-A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Med.
https://www.ncbi.nlm.nih.gov/pubmed/28395101

Nahin et al. (2016). Evidence-Based Evaluation of Complementary Health Approaches for Pain Management in the United States. Mayo Clinic Proceedings.
https://www.ncbi.nlm.nih.gov/pubmed/27594189

Negro et al. (2017). Headache and pregnancy: a systematic review. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/29052046

Orr et al. (2018) Paediatric migraine: evidence-based management and future directions. Nat Rev Neurol.
https://www.ncbi.nlm.nih.gov/pubmed/30038237

Palacios-Ceña et al. (2017). The Number of Active But Not Latent Trigger Points Associated with Widespread Pressure Pain Hypersensitivity in Women with Episodic Migraines. Pain Med.
https://www.ncbi.nlm.nih.gov/pubmed/29016874

Probyn et al. (2017). Non-pharmacological self-management for people living with migraine or tension-type headache: a systematic review including analysis of intervention components. BMJ Open.
https://www.ncbi.nlm.nih.gov/pubmed/28801425

Schwedt, T. J. (2014). Chronic migraine. BMJ.
https://www.ncbi.nlm.nih.gov/pubmed/24662044

Sollmann et al. (2019). Quantitative magnetic resonance imaging of the upper trapezius muscles - assessment of myofascial trigger points in patients with migraine. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/30658563

Tassorelli et al. (2017). Assessing and treating primary headaches and cranio-facial pain in patients undergoing rehabilitation for neurological diseases. J Headache Pain.
https://www.ncbi.nlm.nih.gov/pubmed/28963668

Vickers et al. (2018). Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. The Journal of Pain.
https://www.ncbi.nlm.nih.gov/pubmed/29198932

Watson, D. H. & 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.
https://www.ncbi.nlm.nih.gov/pubmed/22607581

Yang et al. (2016). Verum versus sham manual acupuncture for migraine: a systematic review of randomised controlled trials. Acupunct Med.
https://www.ncbi.nlm.nih.gov/pubmed/2671800

Yin et al. (2017). Acupuncture for chronic pain: an update and critical overview. Curr Opin Anaesthesiol.
https://www.ncbi.nlm.nih.gov/pubmed/28719458

Zhao et al. (2017). The Long-term Effect of Acupuncture for Migraine Prophylaxis A Randomized Clinical Trial. JAMA Intern Med.
https://www.ncbi.nlm.nih.gov/pubmed/28241154

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