By Dr. Chloe Lightner, D.C.
Migraines are a chronic neurologic condition, associated with peripheral and central dysfunction, and classified as a primary headache. This neurologic disease affects ten percent of the adult population worldwide and affects women 2 to 4 times more than men. Migraines are the third most disabling disease in the world, and the U.S.A. health care alone spends an average of $5-$17 billion dollars per year on this disease. [1, 5].
The diagnosis for a migraine includes throbbing pain lasting 4-72 hours with at least five attacks and including two of the following: unilateral location, pulsating quality, moderate to severe pain, and aggravated by physical activity (i.e. climbing stairs).  A classic migraine “with aura” also includes photophobia or phonophobia, which are triggers of short-lived visual, sensory, motor, or other focal neurological symptoms. Migraines are differentiated from other types of headaches because they include nausea, vomiting, or sensitivity to both light and/or sound. 
The cause for migraines is widely circulated. Treatment is targeted to prevent an attack or relive symptoms during an episode, but there is no known cure. The Vascular Theory first proposed that migraines were caused by intracranial arterial vasoconstriction. The narrowing of blood vessels causes blood flow to the visual cortex to decrease and extra-cranial blood vessels to vasodilate. Pain is referred from the dura mater and blood vessels. In more recent years, the Neurogenic Inflammation Theory correlates migraines to activation of the Trigeminovascular system. Essentially, there is a genetic mutation in the brain that leads to neurological abnormalities.  Specific stressors activate trigeminovascular neurons to release Substance P and other inflammatory neurotransmitters. These inflammatory agents encounter sensory fibers that innervate meninges, and their chemical properties cause cutaneous allodynia. The inflammatory chemical released may come from the brain, blood, or meningeal tissues. 
Migraines are often provoked by “triggers”, which include stress, lack of sleep, weather change, environmental pollutants, head trauma, hormonal changes, medications (vasodilators), or odors/scents. Migraines can also be triggered by vasoactive foods, such as foods rich in tyramine (red wine, cheese, chocolate), histamine (coffee, alcohol), processed foods (nitrates, MSG, preservatives).
Migraines present unilaterally in the frontotemporal, occicipto-orbital, or orbital regions. They often occur upon awakening or timed around specific events like a woman’s menstrual cycle or buildup of work-related stress. Adolescents under 18 years old often experience symptoms bilaterally in the frontotemporal region. Palliative actions for patients include avoiding triggers, taking analgesics, or laying down in a cold, dark room.
Migraines progress through a series of four phases. The first stage is prodrome. Approximately 50% of migraineurs experience prodrome 2 – 48 hours before aura. Prodromal symptoms include food cravings, repetitive yawning, fatigue, neck pain, and hyper/hypo-activity . The second stage is aura, where patients encounter visual, sensory, or motor disturbances for less than one hour. Visual aura, known as scintillating scotoma, is the most common type of aura, occurring in over 90% of patients and described as “flashing lights, zig-zag lines, or loss of vision.” Stage three is the headache, or pain phase, lasting 4-72 hours, and accompanied with vomiting, nausea, or sensory sensitivity. The final stage, postdrome, referred to as the “migraine hangover phase”, which follows for a few days after. Some patients express feeling drained, while others are re-energized and elated. 
While patients are under care, it is important to evaluate for any secondary causes to migraines and to regularly check vitals for red flags. Patients should be immediately referred out when they complain of having the “worst headache of their life”, accompanied with confusion, weakness, and double vision. Numerous studies have shown that migraine with aura has been associated with ischemic stroke . Neck stiffness (meningitis) and high blood pressure should also warrant a referral to another health discipline. The practitioner should be concerned for a more threatening diagnosis if the patient reports headaches becoming more severe, progressively worse, or a more sudden onset. Other red flags to look out for are unexplained weight loss, nuchal rigidity, dysphagia, presence of a fever, difficulty walking, or nystagmus.
The American Headache Society uses the acronym “SNOOP” to identify headache red flags: Systemic symptoms (fever, weight loss), Neurologic signs (confusion, impaired alertness), Onset (sudden/ abrupt headache), Older (new headaches for patients over 50 years old), Previous headache history (new pattern of headache) . The practitioner should be aware of this acronym and refer out when red flags are present.
Chiropractic Treatment Approach
Since migraines are a primary neurologic condition, it is imperative to consider musculoskeletal, environmental, and emotional influences. As a Doctor of Chiropractic, it is valuable to take an integrative approach of assessing the patient’s history for traumas and finding patterns of migraine triggers. A primary objective is to focus on the musculoskeletal component by delivering specific chiropractic adjustments, either with NUCCA care or HVLA adjustments to the cervical and upper thoracic spine . Incorporating cranial or soft tissue work may reduce any build up of intracranial pressure and help the Cerebral Spinal Fluid (CSF) to better circulate. Allowing the patient time to rest and incorporating rehab protocols such as superficial heat and EMS for muscle spasms may also be warranted. Additionally, specific vitamins and wholefood supplements may be needed to balance the body’s chemistry. Mindfulness based stress reduction techniques and a headache journal may also be provided for patients .
While there is no known cure for migraines, it is important to coordinate an interdisciplinary team to best overcome the debilitating disease that people experience. Studies have shown that acupuncture has helped with long-term reduction in migraine recurrence since they specialize in assessing local cervical and cranial points . A naturopath specializing in nutrition and gut health is another holistic doctor to include. There has been growing research of correlation of migraines to the gut-brain-axis, and it would be beneficial to evaluate if there are proinflammatory molecules causing hyperactivity to the HPA axis . A naturopath may also provide a more in-depth herbal and nutritional support beyond my care plan. Another interdisciplinary consideration to include when a patient is undergoing a migraine attack is massage therapy, targeted towards upper thoracic, cervical, and head myofascial release and trigger points.
Expected Treatment Results
Current research reveals that migraines are a neurologic condition caused by an overstimulation of the brainstem. Patients who experience migraines should have their nervous systems regularly checked through chiropractic care to assess for any autonomic nervous system imbalances. Spinal manipulation has been scientifically proven to inhibit pain pathways, reduce mechanical triggers, and elevate levels of endorphins . Chiropractic adjustments helps to reduce stress, anxiety, and depression, which can all be triggers for migraines. Allopathic treatment for migraines includes medications and anti-inflammatory drugs, which may cause additional side effects. Although more research is being done to understand the effect of chiropractic care for migraineurs, there are no negative side effects to Chiropractic care other than potential neck soreness from adjustments . Patients who regularly integrate chiropractic and rehabilitative care have a positive outcome on treatment results. Although chiropractic care does not guarantee curing this neurologic condition, research and clinical experience show that care helps improve the body’s structure and function thus helping to reduce recurrence of migraines.
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