- Email: [email protected]
Alternative therapies in the management of headache and facial pain
Otolaryngol Clin N Am 36 (2003) 1221–1230
Alternative therapies in the management of headache and facial pain Collin S. Karmody, MD, FRCS, FACS Department of Otolaryngology, Tufts University School of Medicine, New England Medical Center, 750 Washington Street, Boston, MA 02111, USA
Western medicine does not have the answer to everything. Even though our armamentarium of medications is expanding at an unprecedented rate, increasingly our patient population is turning to alternative forms of therapy for a number of reasons. The most frequent reason is probably failure of our therapeutic attempts to relieve or cure their problems, followed by easier accessibility and lower cost of the alternatives [1]. In 1996, random samples of adult primary care physicians, obstetricsgynecology physicians, nurse practitioners, and adult members of a large northern California group practice model health maintenance organization (HMO) were surveyed to assess the use of alternative therapies and the extent of interest in having them incorporated into HMO-delivered care. During the previous 12 months, 25% of adults reported using alternative therapy and nearly 90% of adult primary care physicians and obstetrics-gynecology clinicians reported recommending at least one alternative therapy, primarily for pain management. Chiropractic, acupuncture, massage, and behavioral medicine techniques, such as meditation and relaxation training, were most often cited [2]. The inherent belief in most societies that natural substances are better and less harmful to the system because of the perception of their lower toxicity is also a factor. Alternative therapy has been defined as an approach to treatment that is not usually taught in medical schools or provided by most medically trained personnel. Some of the alternative therapies (such as biofeedback) have solid evidence supporting their usefulness; others are controversial because of the lack of evaluation by standard methods. Determining the efficacy of
E-mail address: [email protected] (C.S. Karmody). 0030-6665/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0030-6665(03)00119-1
1222
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
any medical treatment, especially one designed for pain relief, is a complex and difficult exercise because about 20% to 30% of patients will improve with any form of treatment. The tremendous psychological overlay of pain adds to the difficulty of assessment of therapeutic regimens. For instance, no rigorously controlled large trials have been conducted for most nonmedication therapies of tension-type headache, although many modalities, such as biofeedback, relaxation training, self-hypnosis, and cognitive therapy, are frequently employed. In looking into alternative treatments, physicians and patients especially must be informed consumers. We must be wary of products that claim to be panaceas for everything from migraines to cancer. It is dangerous to assume that all nondrug or ‘‘natural’’ treatments are safe, as has recently been shown with the natural diet substance ephedra. Combinations of some natural herbs with certain medications can also be dangerous. The physician therefore must have a working knowledge of the alternative therapies and patients have a responsibility to inform their physician about their use of other treatments. This article cannot fully cover the numerous alternative therapies that are available to the public. Instead, it provides an overview of the more frequently used modalities based on a review of the scientific literature. Acupuncture, biofeedback-relaxation, manipulation, physical therapy/massage, herbal substances, and hypnosis are among the most popular forms of alternative therapies. Acupuncture The FDA estimated in May 1993 that there were 9 to 12 million patient visits each year for acupuncture. The 1997 National Institutes of Health Consensus Conference on Acupuncture stated: ‘‘The data in support of acupuncture are as strong as those for many accepted Western medical therapies. One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same conditions’’ [3]. What is acupuncture? Traditional Chinese medicine treats disease and controls pain by the skilled placement of small needles in special acupuncture points along the body. Chinese medicine teaches that the needles restore the balance of Chi, or energy, in the body, and western researchers have found that the acupuncture needles stimulate the release of endorphins and the response of the immunologic system, probably substantially mediated through central mechanisms [4–7]. The benefit of acupuncture is that it avoids the problem of one or more doctors treating different areas of the body with conflicting drugs. It
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1223
assumes that a trained acupuncturist can accurately localize the affected channels that lead to headache, for example, and thereby apply effective treatment. Because correction of a channel disorder always affects other areas of the body as well as the patient’s emotional balance, associated symptoms are being treated simultaneously. The goal is less frequent, less severe, and ultimately total elimination of headaches. Manias, Tagaris, and Karageorgiou [8] reviewed abstracts of papers on the effect of acupuncture on headache. Using a set of quality criteria, their objective was to evaluate the efficacy of acupuncture in the treatment of primary headaches. They concluded that the use of acupuncture for the treatment of headache seems promising because the majority of the clinical trials (23 of 27) report positive conclusions regarding its effectiveness. However, additional clinical research is necessary to confirm the efficacy of acupuncture and to clarify its indications. Beppu and colleagues [9] studied 10 patients with trigeminal neuralgia aged 26 to 67 years who were treated with meridian acupuncture or acupuncture combined with moxibustion. Half of their patients were rendered pain-free; the other half had a decrease in but not complete amelioration of pain. They concluded that meridian acupuncture is useful and can be one therapeutic approach in the management of trigeminal neuralgia. Johansson et al [10] randomly divided 45 individuals with long-standing facial pain or headache of muscular origin into three groups. The first group was treated with acupuncture, the second group received an occlusal splint, and the third group served as controls. Acupuncture and occlusal splint therapy significantly reduced subjective symptoms and clinical signs. They concluded that acupuncture is an alternative method to conventional stomatognathic treatment for individuals with craniomandibular disorders of muscular origin [10]. Irnich et al [11] in a randomized trial of acupuncture compared with conventional massage and ‘‘sham’’ laser acupuncture concluded that acupuncture is an effective short-term treatment for patients with chronic neck pain, but there is only limited evidence for long term effects after five treatments. Drug therapy also creates the risk of developing ‘‘rebound’’ headaches, which occur when the drugs wear off. These can be difficult to treat because the patient must be withdrawn from the headache drugs. As most physicians have nothing other than more drugs to offer, an endless cycle of complications result. Acupuncture promises to be a useful adjunctive therapy for these patients. Behavioral and educational modalities There is now universal agreement that behavioral and educational modalities are useful and effective in the management of chronic pain. These forms of treatment are now increasingly important parts of virtually all programs for the treatment of chronic pain. The methods emphasize
1224
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
self-control and self-management of pain symptoms as well as their cognitive meanings and the maintenance of a productive level of social function. A substantial number of different treatment modalities fall under the umbrella of biobehavioral/mind-body medicine (MBM) treatments. Of these, the most frequently studied are biofeedback, stress management, relaxation, hypnosis, and education. A number of clinical trials suggest that some MBM therapies are effective in improving the quality of life, anxiety, and the intensity of pain for various conditions, such as chronic pain, headache, insomnia, and even coronary artery disease and cancer. Most of these methods are used as stand-alone or adjunctive therapy and have the potential for producing long-term benefits [12,13]. Biofeedback Biofeedback is a technique that helps a person to become more aware of and learn to deal with the body’s response to pain by learning to develop conscious control of vital functions. It emphasizes relaxation and stressreduction techniques. The sympathetic nervous system is a protective network that prepares humans for stressful situations (eg, to stand and fight or to flee). By using various visual projections of his or her bodily functions, such as electroencephalograms, electrocardiograms, blood pressure monitors, muscle tension gauges, and thermometers, biofeedback demonstrates to the patient their responses to stress, so they can consciously attempt to change their behavior. Guided imagery is a relaxation technique that is frequently used in conjunction with biofeedback. In guided imagery, a person concentrates on peaceful mental images, such as ocean waves, as a calming maneuver to control responses to the stresses of pain. Vasudeva and colleagues [14] treated 20 migraineurs with 12 sessions of biofeedback/relaxation therapy, while 20 controls relaxed on their own. The biofeedback group showed significant (P \ .05) reductions in pain, depression, and anxiety compared with the control group. Patients with and without aura did equally well. They concluded that the positive response to biofeedback/relaxation in migraine headache was not related to the presence of aura or to changes in blood flow velocity, but may be associated with reduction in anxiety and depression [14]. Myers et al [15] reviewed the literature on reports of the prevalence of and randomized clinical trials on the use of complementary and alternative medicine to treat chronic facial pain. They found that acupuncture, biofeedback, and relaxation were comparable to conservative treatment and warranted further study. Grazzi et al [16] treated 61 patients with transformed migraine and analgesic overuse with pharmacologic therapy alone or with pharmacologic therapy combined with biofeedback-assisted relaxation. Both groups had
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1225
similar levels of improvement immediately and for 1 year after treatment. At 3 years, the combined treatment group had more sustained improvement with fewer days of headache and reduced consumption of analgesics. Additionally, a greater number of the pharmacologic treatment alone relapsed. They concluded that a combination of pharmacologic and behavioral treatment is more effective than drug therapy alone in the long-term management of migraine with analgesic overuse. Alternatively, Barton and Blanchard found that self-regulatory management was ineffective in chronic daily headache [17]. Ilacqua [18] compared the effectiveness of guided imagery and biofeedback in the treatment of migraine headache in 40 subjects. There was no significant reduction in migraine activity in the treatment groups and no differences in the use of medication. Objective measures did not indicate changes in migraine activity. The findings did not support either biofeedback or guided imagery training as being more effective in counteracting migraines, although, subjectively, guided imagery seemed to have a positive influence on the perception of migraine pain [18].
Cognitive-behavioral therapy Cognitive behavior therapy (CBT) combines two kinds of psychotherapycognitive therapy and behavior therapy. Cognitive therapy teaches how certain patterns of thought cause symptoms by distorting the true picture of events, thereby generating anxiety, depression, or anger, which might lead to illogical actions. Cognitive therapy therefore seeks to alter the patientÕs thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and thereby to develop methods for channeling his or her attention to be more positive. The combination of behavior therapy and cognitive therapy into CBT provides the patient with powerful tools for controlling even somatically based symptoms and returning to a more satisfying and productive lifestyle. Behavior therapy helps the patient to control their habitual reactions, such as fear, depression, or rage, and self-defeating or self-damaging behavior, to unwanted annoying situations. It also teaches how to achieve peace of mind and body, which promotes clearer thinking and decision making, and then taking actions that are likely to have positive results. In other words, CBT focuses on exactly what traditional therapies tend to leave out—how to achieve beneficial change, as opposed to mere explanation or insight. What happens in cognitive-behavioral therapy? There are several kinds of cognitive-behavioral therapies, but all are based on the same premise that with conscious efforts people are capable of making changes in their lives. All cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, reducing pain-related
1226
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
disability, affective distress, reducing reliance on medication, and improving quality of life. In cognitive-behavior therapy the patient usually must do a lot of work themselves, such as keeping a pain diary and other assignments and must practice the techniques taught. These therapies therefore usually take much less time and are less costly. Cognitive behavioral therapy and migraine triggers Cognitive behavioral therapy requires migraineurs to keep a headache diary. In the diary is noted the timing of attacks, daily activities, foods consumed, weather conditions, possible migraine triggers, and any other information that might relate to headaches, which sometimes leads to identification of migraine triggers. Then patient and therapist can jointly devise lifestyle changes that will reduce the frequency and severity of headaches. Some triggers, such as the weather, are out of the individual’s control, but other triggers, such as diet, stress, and sensory phenomena, can be avoided or minimized. Migraine prevention and behavior modification Changes in lifestyle and behavior patterns can significantly lower the frequency and severity of migraines in some people. Stress management, relaxation techniques, and cognitive behavioral therapy are not successful in all patients for the prevention of migraine, but they are options that can be pursued without fear of unwanted side effects. Lipchik and Nash [19] report that first-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of chronic daily headaches (CHD). However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. For cognitivebehavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance. Lake [20] also found that CBT (cognitive-behavioral therapy) has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache, but the combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time [20].
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1227
Manipulation (chiropractic) and massage Chiropractic, currently the most widely used alternative therapy in the United States, focuses on manipulation of the spine and other joints to treat various problems, primarily those involving bones, joints, muscles, ligaments, and tendons. Chiropractors use their hands, primarily, to manipulate a joint or group of joints. (The term ‘‘chiropractic’’ is derived from Greek, meaning ‘‘done by hand.’’) The aim of using manipulation is to provide relief from pain by improving the function of joints, muscles, and nerves. Jull et al [21] conducted a multicenter, randomized controlled trial to determine the effectiveness of manipulative therapy and a low-load exercise program in 200 subjects with cervicogenic headache when used alone and in combination, as compared with a control group. The treatment period was 6 weeks with follow-up assessment. Participants were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. At the 12-month follow-up, manipulative therapy and specific exercise had significantly reduced frequency and intensity of headaches and the neck pain (P \ 0.05 for all). They concluded that manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained [21]. In a randomized controlled trial of 127 patients with migraine, Tuchin et al [22] found that 22% of participants reported more than a 90% reduction of migraines after 2 months of spinal manipulative therapy. Approximately 50% more participants reported significant improvement in the morbidity of each episode. A high percentage (>80%) of participants, however, reported stress as a major factor for their migraines. The authors postulated that in patients with reduction in migraine symptoms, chiropractic care primarily affected the physical conditions that are related to stress [22]. Bronfort et al [23] reviewed nine trials involving 683 patients with chronic headache. Their conclusion was that spinal manipulative therapy (SMT) appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications, such as amitriptyline, for tensiontype headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length [23]. However, Bove and Nilsson [24] found in a study of 75 patients with episodic tension-type headaches divided into two groups (one treated by manipulation and the other group as a control) no significant differences as observed by three outcome measures. Astin and Ernst [25] in a review of randomized clinical trials of the effectiveness of spinal manipulation for the treatment of headache disorders stated, ‘‘Despite claims that spinal manipulation is an effective treatment for headache, the data available to
1228
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (eg, of personal attention, patient expectation). Whether manipulation produces any long-term changes in these conditions is also uncertain. Future studies should address these two crucial questions and overcome the methodological limitations of previous trials’’ [25]. In a review of publications on the use of manipulative therapy for the treatment of chronic pain, Mior also concluded that ‘‘for chronic post-traumatic headache, evidence of effectiveness of manipulation and mobilization is limited’’ [26]. Haldeman et al [27] warns that stroke should be considered a random and unpredictable complication of cervical manipulation. The sudden onset of acute and unusual neck or head pain may represent a vertebrobasilar dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to cerebral ischemia and stroke [27]. There is a dearth of rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length. The efficacy and safety of manipulation for the treatment of chronic headache and facial pain is therefore still in question. Combination therapy Combinations of different modalities have become the rule rather than the exception in treatment of headache pain, which makes assessment of any single modality difficult. There are infinite numbers of combinations possible, some seemingly rational and others without scientific basis. Marcus et al [28] investigated the efficacy of physical therapy as a treatment for migraine and investigated the usefulness of PT as an adjunct treatment in patients who fail to improve with relaxation training/ thermal biofeedback (RTB).They found that PT alone is not effective in reducing headache. However, physical therapy was a useful adjunct to relaxation/thermal biofeedback, with 47% of a group of 11 subjects who had failed to improve with RTB reporting improvement with the addition of PT. It is recommended that RTB remain the nonmedical treatment of choice for migraine, and PT used as an adjunct for patients who failed to improve. There is also an increasingly popular trend to combine standard medication regimens with alternative treatments. Holyroyd et al [29] studied 33 patients who were randomized to relaxation-biofeedback training alone or to relaxation-biofeedback training accompanied by long-acting propranolol of varying dosages. They found that concomitant propranolol therapy significantly enhanced the effectiveness of relaxation-biofeedback training as assessed by either recordings of daily headaches or clinical evaluations by a neurologist. However, use of propranolol was accompanied by more side effects.
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1229
Summary Complementary therapies are now becoming the rule rather than the exception in the management of headache and facial pain. It is incumbent on physicians to be aware of and to have a working knowledge of these increasingly popular modalities.
References [1] Mauskop A. Alternative therapies in headache. Is there a role? Med Clin North Am 2001;85:1077–84. [2] Gordon NP, Sobel DS, Tarazona EZ. Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 1998;169(3):153–61. [3] NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518–24. [4] Shen J. Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. Altern Complement Med 2001;7(Suppl 1):S121–7. [5] Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998;44:129–38. [6] Pintov S, Lahat E, Alstein M, Vogel Z, Barg J. Acupuncture and the opioid system: implications in management of migraine. Pediatr Neurol 1997;17:129–33. [7] Petti F, Bangrazi A, Liguori A, Reale G, Ippoliti F. Effects of acupuncture on immune response related to opioid-like peptides. J Tradit Chin Med 1998;18:55–63. [8] Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain 2000;16:334–9. [9] Beppu S, Sato Y, Amemiya Y, Tode I. Practical application of meridian acupuncture treatment for trigeminal neuralgia. Headache 2000;40:311–5. [10] Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontol Scand 1991;49:153–8. [11] Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, et al. Randomised trial of acupuncture compared with conventional massage and ‘‘sham’’ laser acupuncture for treatment of chronic neck pain. BMJ 2001;322(7302):1574–8. [12] Dworkin SF. Behavioral and educational modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:128–33. [13] Barrows KA, Jacobs BP. Mind-body medicine. An introduction and review of the literature. Med Clin North Am 2002;86(1):11–31. [14] Vasudeva S, Claggett AL, Tietjen GE, McGrady AV. Biofeedback-assisted relaxation in migraine headache: relationship to cerebral blood flow velocity in the middle cerebral artery. Headache 2003;43:245–50. [15] Myers CD, White BA, Heft MW. A review of complementary and alternative medicine use for treating chronic facial pain. J Am Dent Assoc 2002;133:1189–96. [16] Grazzi L, Andrasik F, D’Amico D, Leone M, Usai S, Kass SJ, et al. Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: outcome at 3 years. Headache 2002;42:483–90. [17] Barton KA, Blanchard EB. The failure of intensive self-regulatory treatment with chronic daily headache: a prospective study. Appl Psychophysiol Biofeedback 2001;26:311–8. [18] Ilacqua GE. Migraine headaches: coping efficacy of guided imagery training. Headache 1994;34:99–102. [19] Lipchik GL, Nash JM. Cognitive-behavioral issues in the treatment and management of chronic daily headache. Curr Pain Headache Rep 2002;6:473–9. [20] Lake AE III. Behavioral and nonpharmacologic treatments of headache. Med Clin North Am 2001;85:1055–75.
1230
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
[21] Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;1;27:1835–43. [22] Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther 2000;23:91–5. [23] Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001;24:457–66. [24] Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA 998;280:1576–9. [25] Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalalgia 2002;22:617–23. [26] Mior S. Manipulation and mobilization in the treatment of chronic pain. Clin J Pain 2001;17(Suppl):S70–6. [27] Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol 2002;249:1098–104. [28] Marcus DA, Scharff L, Mercer S, Turk DC. Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia 1998;18(5):266–72. [29] Holroyd KA, France JL, Cordingley GE, Rokicki LA, Kvaal SA, Lipchik GL, McCool HR. Enhancing the effectiveness of relaxation-thermal biofeedback training with propranolol hydrochloride. J Consult Clin Psychol 1995;63(2):327–30.
Alternative therapies in the management of headache and facial pain Collin S. Karmody, MD, FRCS, FACS Department of Otolaryngology, Tufts University School of Medicine, New England Medical Center, 750 Washington Street, Boston, MA 02111, USA
Western medicine does not have the answer to everything. Even though our armamentarium of medications is expanding at an unprecedented rate, increasingly our patient population is turning to alternative forms of therapy for a number of reasons. The most frequent reason is probably failure of our therapeutic attempts to relieve or cure their problems, followed by easier accessibility and lower cost of the alternatives [1]. In 1996, random samples of adult primary care physicians, obstetricsgynecology physicians, nurse practitioners, and adult members of a large northern California group practice model health maintenance organization (HMO) were surveyed to assess the use of alternative therapies and the extent of interest in having them incorporated into HMO-delivered care. During the previous 12 months, 25% of adults reported using alternative therapy and nearly 90% of adult primary care physicians and obstetrics-gynecology clinicians reported recommending at least one alternative therapy, primarily for pain management. Chiropractic, acupuncture, massage, and behavioral medicine techniques, such as meditation and relaxation training, were most often cited [2]. The inherent belief in most societies that natural substances are better and less harmful to the system because of the perception of their lower toxicity is also a factor. Alternative therapy has been defined as an approach to treatment that is not usually taught in medical schools or provided by most medically trained personnel. Some of the alternative therapies (such as biofeedback) have solid evidence supporting their usefulness; others are controversial because of the lack of evaluation by standard methods. Determining the efficacy of
E-mail address: [email protected] (C.S. Karmody). 0030-6665/03/$ - see front matter Ó 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0030-6665(03)00119-1
1222
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
any medical treatment, especially one designed for pain relief, is a complex and difficult exercise because about 20% to 30% of patients will improve with any form of treatment. The tremendous psychological overlay of pain adds to the difficulty of assessment of therapeutic regimens. For instance, no rigorously controlled large trials have been conducted for most nonmedication therapies of tension-type headache, although many modalities, such as biofeedback, relaxation training, self-hypnosis, and cognitive therapy, are frequently employed. In looking into alternative treatments, physicians and patients especially must be informed consumers. We must be wary of products that claim to be panaceas for everything from migraines to cancer. It is dangerous to assume that all nondrug or ‘‘natural’’ treatments are safe, as has recently been shown with the natural diet substance ephedra. Combinations of some natural herbs with certain medications can also be dangerous. The physician therefore must have a working knowledge of the alternative therapies and patients have a responsibility to inform their physician about their use of other treatments. This article cannot fully cover the numerous alternative therapies that are available to the public. Instead, it provides an overview of the more frequently used modalities based on a review of the scientific literature. Acupuncture, biofeedback-relaxation, manipulation, physical therapy/massage, herbal substances, and hypnosis are among the most popular forms of alternative therapies. Acupuncture The FDA estimated in May 1993 that there were 9 to 12 million patient visits each year for acupuncture. The 1997 National Institutes of Health Consensus Conference on Acupuncture stated: ‘‘The data in support of acupuncture are as strong as those for many accepted Western medical therapies. One of the advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for the same conditions’’ [3]. What is acupuncture? Traditional Chinese medicine treats disease and controls pain by the skilled placement of small needles in special acupuncture points along the body. Chinese medicine teaches that the needles restore the balance of Chi, or energy, in the body, and western researchers have found that the acupuncture needles stimulate the release of endorphins and the response of the immunologic system, probably substantially mediated through central mechanisms [4–7]. The benefit of acupuncture is that it avoids the problem of one or more doctors treating different areas of the body with conflicting drugs. It
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1223
assumes that a trained acupuncturist can accurately localize the affected channels that lead to headache, for example, and thereby apply effective treatment. Because correction of a channel disorder always affects other areas of the body as well as the patient’s emotional balance, associated symptoms are being treated simultaneously. The goal is less frequent, less severe, and ultimately total elimination of headaches. Manias, Tagaris, and Karageorgiou [8] reviewed abstracts of papers on the effect of acupuncture on headache. Using a set of quality criteria, their objective was to evaluate the efficacy of acupuncture in the treatment of primary headaches. They concluded that the use of acupuncture for the treatment of headache seems promising because the majority of the clinical trials (23 of 27) report positive conclusions regarding its effectiveness. However, additional clinical research is necessary to confirm the efficacy of acupuncture and to clarify its indications. Beppu and colleagues [9] studied 10 patients with trigeminal neuralgia aged 26 to 67 years who were treated with meridian acupuncture or acupuncture combined with moxibustion. Half of their patients were rendered pain-free; the other half had a decrease in but not complete amelioration of pain. They concluded that meridian acupuncture is useful and can be one therapeutic approach in the management of trigeminal neuralgia. Johansson et al [10] randomly divided 45 individuals with long-standing facial pain or headache of muscular origin into three groups. The first group was treated with acupuncture, the second group received an occlusal splint, and the third group served as controls. Acupuncture and occlusal splint therapy significantly reduced subjective symptoms and clinical signs. They concluded that acupuncture is an alternative method to conventional stomatognathic treatment for individuals with craniomandibular disorders of muscular origin [10]. Irnich et al [11] in a randomized trial of acupuncture compared with conventional massage and ‘‘sham’’ laser acupuncture concluded that acupuncture is an effective short-term treatment for patients with chronic neck pain, but there is only limited evidence for long term effects after five treatments. Drug therapy also creates the risk of developing ‘‘rebound’’ headaches, which occur when the drugs wear off. These can be difficult to treat because the patient must be withdrawn from the headache drugs. As most physicians have nothing other than more drugs to offer, an endless cycle of complications result. Acupuncture promises to be a useful adjunctive therapy for these patients. Behavioral and educational modalities There is now universal agreement that behavioral and educational modalities are useful and effective in the management of chronic pain. These forms of treatment are now increasingly important parts of virtually all programs for the treatment of chronic pain. The methods emphasize
1224
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
self-control and self-management of pain symptoms as well as their cognitive meanings and the maintenance of a productive level of social function. A substantial number of different treatment modalities fall under the umbrella of biobehavioral/mind-body medicine (MBM) treatments. Of these, the most frequently studied are biofeedback, stress management, relaxation, hypnosis, and education. A number of clinical trials suggest that some MBM therapies are effective in improving the quality of life, anxiety, and the intensity of pain for various conditions, such as chronic pain, headache, insomnia, and even coronary artery disease and cancer. Most of these methods are used as stand-alone or adjunctive therapy and have the potential for producing long-term benefits [12,13]. Biofeedback Biofeedback is a technique that helps a person to become more aware of and learn to deal with the body’s response to pain by learning to develop conscious control of vital functions. It emphasizes relaxation and stressreduction techniques. The sympathetic nervous system is a protective network that prepares humans for stressful situations (eg, to stand and fight or to flee). By using various visual projections of his or her bodily functions, such as electroencephalograms, electrocardiograms, blood pressure monitors, muscle tension gauges, and thermometers, biofeedback demonstrates to the patient their responses to stress, so they can consciously attempt to change their behavior. Guided imagery is a relaxation technique that is frequently used in conjunction with biofeedback. In guided imagery, a person concentrates on peaceful mental images, such as ocean waves, as a calming maneuver to control responses to the stresses of pain. Vasudeva and colleagues [14] treated 20 migraineurs with 12 sessions of biofeedback/relaxation therapy, while 20 controls relaxed on their own. The biofeedback group showed significant (P \ .05) reductions in pain, depression, and anxiety compared with the control group. Patients with and without aura did equally well. They concluded that the positive response to biofeedback/relaxation in migraine headache was not related to the presence of aura or to changes in blood flow velocity, but may be associated with reduction in anxiety and depression [14]. Myers et al [15] reviewed the literature on reports of the prevalence of and randomized clinical trials on the use of complementary and alternative medicine to treat chronic facial pain. They found that acupuncture, biofeedback, and relaxation were comparable to conservative treatment and warranted further study. Grazzi et al [16] treated 61 patients with transformed migraine and analgesic overuse with pharmacologic therapy alone or with pharmacologic therapy combined with biofeedback-assisted relaxation. Both groups had
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1225
similar levels of improvement immediately and for 1 year after treatment. At 3 years, the combined treatment group had more sustained improvement with fewer days of headache and reduced consumption of analgesics. Additionally, a greater number of the pharmacologic treatment alone relapsed. They concluded that a combination of pharmacologic and behavioral treatment is more effective than drug therapy alone in the long-term management of migraine with analgesic overuse. Alternatively, Barton and Blanchard found that self-regulatory management was ineffective in chronic daily headache [17]. Ilacqua [18] compared the effectiveness of guided imagery and biofeedback in the treatment of migraine headache in 40 subjects. There was no significant reduction in migraine activity in the treatment groups and no differences in the use of medication. Objective measures did not indicate changes in migraine activity. The findings did not support either biofeedback or guided imagery training as being more effective in counteracting migraines, although, subjectively, guided imagery seemed to have a positive influence on the perception of migraine pain [18].
Cognitive-behavioral therapy Cognitive behavior therapy (CBT) combines two kinds of psychotherapycognitive therapy and behavior therapy. Cognitive therapy teaches how certain patterns of thought cause symptoms by distorting the true picture of events, thereby generating anxiety, depression, or anger, which might lead to illogical actions. Cognitive therapy therefore seeks to alter the patientÕs thoughts, beliefs, ideas, attitudes, assumptions, mental imagery, and thereby to develop methods for channeling his or her attention to be more positive. The combination of behavior therapy and cognitive therapy into CBT provides the patient with powerful tools for controlling even somatically based symptoms and returning to a more satisfying and productive lifestyle. Behavior therapy helps the patient to control their habitual reactions, such as fear, depression, or rage, and self-defeating or self-damaging behavior, to unwanted annoying situations. It also teaches how to achieve peace of mind and body, which promotes clearer thinking and decision making, and then taking actions that are likely to have positive results. In other words, CBT focuses on exactly what traditional therapies tend to leave out—how to achieve beneficial change, as opposed to mere explanation or insight. What happens in cognitive-behavioral therapy? There are several kinds of cognitive-behavioral therapies, but all are based on the same premise that with conscious efforts people are capable of making changes in their lives. All cognitive-behavioral therapies focus on preventing mild pain from becoming disabling pain, reducing pain-related
1226
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
disability, affective distress, reducing reliance on medication, and improving quality of life. In cognitive-behavior therapy the patient usually must do a lot of work themselves, such as keeping a pain diary and other assignments and must practice the techniques taught. These therapies therefore usually take much less time and are less costly. Cognitive behavioral therapy and migraine triggers Cognitive behavioral therapy requires migraineurs to keep a headache diary. In the diary is noted the timing of attacks, daily activities, foods consumed, weather conditions, possible migraine triggers, and any other information that might relate to headaches, which sometimes leads to identification of migraine triggers. Then patient and therapist can jointly devise lifestyle changes that will reduce the frequency and severity of headaches. Some triggers, such as the weather, are out of the individual’s control, but other triggers, such as diet, stress, and sensory phenomena, can be avoided or minimized. Migraine prevention and behavior modification Changes in lifestyle and behavior patterns can significantly lower the frequency and severity of migraines in some people. Stress management, relaxation techniques, and cognitive behavioral therapy are not successful in all patients for the prevention of migraine, but they are options that can be pursued without fear of unwanted side effects. Lipchik and Nash [19] report that first-line drug or cognitive-behavioral therapies administered alone have minimal impact on reducing the frequency or severity of chronic daily headaches (CHD). However, combined drug and cognitive-behavioral therapy shows promise in providing the most benefit for this often intractable condition. For cognitivebehavioral therapies to be effective, it is important to address complicating factors, including medication overuse, psychiatric comorbidity, stress and poor coping, and sleep disturbance. Lake [20] also found that CBT (cognitive-behavioral therapy) has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache, but the combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time [20].
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1227
Manipulation (chiropractic) and massage Chiropractic, currently the most widely used alternative therapy in the United States, focuses on manipulation of the spine and other joints to treat various problems, primarily those involving bones, joints, muscles, ligaments, and tendons. Chiropractors use their hands, primarily, to manipulate a joint or group of joints. (The term ‘‘chiropractic’’ is derived from Greek, meaning ‘‘done by hand.’’) The aim of using manipulation is to provide relief from pain by improving the function of joints, muscles, and nerves. Jull et al [21] conducted a multicenter, randomized controlled trial to determine the effectiveness of manipulative therapy and a low-load exercise program in 200 subjects with cervicogenic headache when used alone and in combination, as compared with a control group. The treatment period was 6 weeks with follow-up assessment. Participants were randomized into four groups: manipulative therapy group, exercise therapy group, combined therapy group, and a control group. The primary outcome was a change in headache frequency. At the 12-month follow-up, manipulative therapy and specific exercise had significantly reduced frequency and intensity of headaches and the neck pain (P \ 0.05 for all). They concluded that manipulative therapy and exercise can reduce the symptoms of cervicogenic headache, and the effects are maintained [21]. In a randomized controlled trial of 127 patients with migraine, Tuchin et al [22] found that 22% of participants reported more than a 90% reduction of migraines after 2 months of spinal manipulative therapy. Approximately 50% more participants reported significant improvement in the morbidity of each episode. A high percentage (>80%) of participants, however, reported stress as a major factor for their migraines. The authors postulated that in patients with reduction in migraine symptoms, chiropractic care primarily affected the physical conditions that are related to stress [22]. Bronfort et al [23] reviewed nine trials involving 683 patients with chronic headache. Their conclusion was that spinal manipulative therapy (SMT) appears to have a better effect than massage for cervicogenic headache. It also appears that SMT has an effect comparable to commonly used first-line prophylactic prescription medications, such as amitriptyline, for tensiontype headache and migraine headache. This conclusion rests upon a few trials of adequate methodological quality. Before any firm conclusions can be drawn, further testing should be done in rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length [23]. However, Bove and Nilsson [24] found in a study of 75 patients with episodic tension-type headaches divided into two groups (one treated by manipulation and the other group as a control) no significant differences as observed by three outcome measures. Astin and Ernst [25] in a review of randomized clinical trials of the effectiveness of spinal manipulation for the treatment of headache disorders stated, ‘‘Despite claims that spinal manipulation is an effective treatment for headache, the data available to
1228
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
date do not support such definitive conclusions. It is unclear to what extent the observed treatment effects can be explained by manipulation or by nonspecific factors (eg, of personal attention, patient expectation). Whether manipulation produces any long-term changes in these conditions is also uncertain. Future studies should address these two crucial questions and overcome the methodological limitations of previous trials’’ [25]. In a review of publications on the use of manipulative therapy for the treatment of chronic pain, Mior also concluded that ‘‘for chronic post-traumatic headache, evidence of effectiveness of manipulation and mobilization is limited’’ [26]. Haldeman et al [27] warns that stroke should be considered a random and unpredictable complication of cervical manipulation. The sudden onset of acute and unusual neck or head pain may represent a vertebrobasilar dissection in progress and be the reason a patient seeks manipulative therapy that then serves as the final insult to the vessel leading to cerebral ischemia and stroke [27]. There is a dearth of rigorously designed, executed, and analyzed trials with follow-up periods of sufficient length. The efficacy and safety of manipulation for the treatment of chronic headache and facial pain is therefore still in question. Combination therapy Combinations of different modalities have become the rule rather than the exception in treatment of headache pain, which makes assessment of any single modality difficult. There are infinite numbers of combinations possible, some seemingly rational and others without scientific basis. Marcus et al [28] investigated the efficacy of physical therapy as a treatment for migraine and investigated the usefulness of PT as an adjunct treatment in patients who fail to improve with relaxation training/ thermal biofeedback (RTB).They found that PT alone is not effective in reducing headache. However, physical therapy was a useful adjunct to relaxation/thermal biofeedback, with 47% of a group of 11 subjects who had failed to improve with RTB reporting improvement with the addition of PT. It is recommended that RTB remain the nonmedical treatment of choice for migraine, and PT used as an adjunct for patients who failed to improve. There is also an increasingly popular trend to combine standard medication regimens with alternative treatments. Holyroyd et al [29] studied 33 patients who were randomized to relaxation-biofeedback training alone or to relaxation-biofeedback training accompanied by long-acting propranolol of varying dosages. They found that concomitant propranolol therapy significantly enhanced the effectiveness of relaxation-biofeedback training as assessed by either recordings of daily headaches or clinical evaluations by a neurologist. However, use of propranolol was accompanied by more side effects.
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
1229
Summary Complementary therapies are now becoming the rule rather than the exception in the management of headache and facial pain. It is incumbent on physicians to be aware of and to have a working knowledge of these increasingly popular modalities.
References [1] Mauskop A. Alternative therapies in headache. Is there a role? Med Clin North Am 2001;85:1077–84. [2] Gordon NP, Sobel DS, Tarazona EZ. Use of and interest in alternative therapies among adult primary care clinicians and adult members in a large health maintenance organization. West J Med 1998;169(3):153–61. [3] NIH Consensus Conference. Acupuncture. JAMA 1998;280:1518–24. [4] Shen J. Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. Altern Complement Med 2001;7(Suppl 1):S121–7. [5] Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application. Biol Psychiatry 1998;44:129–38. [6] Pintov S, Lahat E, Alstein M, Vogel Z, Barg J. Acupuncture and the opioid system: implications in management of migraine. Pediatr Neurol 1997;17:129–33. [7] Petti F, Bangrazi A, Liguori A, Reale G, Ippoliti F. Effects of acupuncture on immune response related to opioid-like peptides. J Tradit Chin Med 1998;18:55–63. [8] Manias P, Tagaris G, Karageorgiou K. Acupuncture in headache: a critical review. Clin J Pain 2000;16:334–9. [9] Beppu S, Sato Y, Amemiya Y, Tode I. Practical application of meridian acupuncture treatment for trigeminal neuralgia. Headache 2000;40:311–5. [10] Johansson A, Wenneberg B, Wagersten C, Haraldson T. Acupuncture in treatment of facial muscular pain. Acta Odontol Scand 1991;49:153–8. [11] Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, et al. Randomised trial of acupuncture compared with conventional massage and ‘‘sham’’ laser acupuncture for treatment of chronic neck pain. BMJ 2001;322(7302):1574–8. [12] Dworkin SF. Behavioral and educational modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:128–33. [13] Barrows KA, Jacobs BP. Mind-body medicine. An introduction and review of the literature. Med Clin North Am 2002;86(1):11–31. [14] Vasudeva S, Claggett AL, Tietjen GE, McGrady AV. Biofeedback-assisted relaxation in migraine headache: relationship to cerebral blood flow velocity in the middle cerebral artery. Headache 2003;43:245–50. [15] Myers CD, White BA, Heft MW. A review of complementary and alternative medicine use for treating chronic facial pain. J Am Dent Assoc 2002;133:1189–96. [16] Grazzi L, Andrasik F, D’Amico D, Leone M, Usai S, Kass SJ, et al. Behavioral and pharmacologic treatment of transformed migraine with analgesic overuse: outcome at 3 years. Headache 2002;42:483–90. [17] Barton KA, Blanchard EB. The failure of intensive self-regulatory treatment with chronic daily headache: a prospective study. Appl Psychophysiol Biofeedback 2001;26:311–8. [18] Ilacqua GE. Migraine headaches: coping efficacy of guided imagery training. Headache 1994;34:99–102. [19] Lipchik GL, Nash JM. Cognitive-behavioral issues in the treatment and management of chronic daily headache. Curr Pain Headache Rep 2002;6:473–9. [20] Lake AE III. Behavioral and nonpharmacologic treatments of headache. Med Clin North Am 2001;85:1055–75.
1230
C.S. Karmody / Otolaryngol Clin N Am 36 (2003) 1221–1230
[21] Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for cervicogenic headache. Spine 2002;1;27:1835–43. [22] Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic spinal manipulative therapy for migraine. J Manipulative Physiol Ther 2000;23:91–5. [23] Bronfort G, Assendelft WJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther 2001;24:457–66. [24] Bove G, Nilsson N. Spinal manipulation in the treatment of episodic tension-type headache: a randomized controlled trial. JAMA 998;280:1576–9. [25] Astin JA, Ernst E. The effectiveness of spinal manipulation for the treatment of headache disorders: a systematic review of randomized clinical trials. Cephalalgia 2002;22:617–23. [26] Mior S. Manipulation and mobilization in the treatment of chronic pain. Clin J Pain 2001;17(Suppl):S70–6. [27] Haldeman S, Kohlbeck FJ, McGregor M. Stroke, cerebral artery dissection, and cervical spine manipulation therapy. J Neurol 2002;249:1098–104. [28] Marcus DA, Scharff L, Mercer S, Turk DC. Nonpharmacological treatment for migraine: incremental utility of physical therapy with relaxation and thermal biofeedback. Cephalalgia 1998;18(5):266–72. [29] Holroyd KA, France JL, Cordingley GE, Rokicki LA, Kvaal SA, Lipchik GL, McCool HR. Enhancing the effectiveness of relaxation-thermal biofeedback training with propranolol hydrochloride. J Consult Clin Psychol 1995;63(2):327–30.