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Migraine headache
CLINICAL PERSPECTIVES
Migraine headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Charna Rosenholtz, Douglas Nelson, Terry Hambrick, Gina Makris
Case study details Charna Rosenholtz
Charna Rosenholtz BA, NCTMB 420 S. Howes, Suite 102, Fort Collins, CO 80521, USA Correspondence to: Charna Rosenholtz Tel.: +1-970-221-2903; Fax: +1-970-221-0773; E-mail: [email protected] Received April 2002 Revised June 2002 Accepted July 2002 ........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 30^45 r 2003 Elsevier Science Ltd. All rights reserved. doi:10/1016/S1360-8592(02)00063-3 S1360-8592/03/$ - see front matter
Shelly is a 53-year-old-stock broker, living in a moderate-sized city in America. She spends her 50–56 hour work week at the computer and telephone, while spending the other half moving in and out of her car, meeting with clients. Shelly complains of severe headaches, which have been diagnosed as migrainous. Typically Shelly’s headaches come in the third week of the month and last for 72 hours. They begin in the upper trapezius muscle and follow up the occiput, the parietal bone, moving lateral to the temporal bone, culminating above the eyebrow. They are often right-sided and occasionally move bilaterally. The headaches follow the traditional Chinese medicine gall bladder meridian. Her pain has a searing knife-like quality that pounds from the inside out. Shelly’s headaches began in high school, with no known etiology, although her mother, daughter and aunt also suffer from this pain. She was physically active in high school and rode motorcycles, however, there is no recollection of crashing the bike before the headaches began.
Further inquiry shows an unspectacular medical history which includes inguinal hernia surgeries in 1955 and 1966. She has had several motorcycle falls during the 1960s and a 1974 car accident, which involved a minor whiplash. She had a complete hysterectomy in 1991. The headaches decreased in length at that time but not in intensity. Shelly also suffers from allergies that do not seem to be food or seasonally related. She has experienced constipation for as long as she can remember (bowel movements are at times only once a week). Shelly’s medication is an estrogen patch (0.025 estrogen), Clariden for her hay fever and Excedrin when the headaches start. She takes vitamin E, niacin, calcium, a multi-vitamin, fish oil capsules, phyto-vitamins and garlic. Her diet seems adequate, low in fried and fatty foods, but with minimal quantities of fresh food. There are a variety of concomitants to her pain, including sound sensitivity, fatigue, neck pain and food cravings. In particular, she craves chocolate during the third week of her monthly cycle. Shelly experiences nausea when her
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J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Migraine headache
headache is present and this can be debilitating. The pain and discomfort is felt in her stomach and the nausea comes in waves. Muscular palpation exam indicates hypertonicity of the bilateral scalenes, trapezius, posterior cervicals (especially C1–C4, erector spinae muscle group, suboccipitals, infraspinatus and right triceps). A closer examination of Shelly reveals an overall restricted breathing pattern with a tendency toward upper chest breathing and strong utilization of her accessory respiratory muscles. It is hard for her to ‘get a good breath’, and very difficult for her to fully exhale. Posturally there is a ‘collapse’ at the
diaphragm area, which shortens the abdominal muscles. Her shoulders are rounded, with a classic forward head posture. Her eyes are dull, with limited facial expression. She is living a societally successful life yet really wants to live in a small farm town living the simple life. Few people know that she is unhappy with her present life circumstances. Although Shelly does not drink alcohol due to her migraines, alcoholism seems to haunt her. She is in a good second marriage, while there are unresolved issues from her alcoholic first husband. Her brother is a functioning alcoholic and her stepson is a non-functional
alcoholic. She tends to deal with these relationships with frustration, impatience and avoidance. She has excellent relationships with her two children and grandchildren as well as several close friends. Shelly experienced some relief of her headaches between 1966 and 1974, but they came back with a vengeance in 1974, not long after she was rear-ended in a motor vehicle accident. The nausea and vomiting began at this time. Once a headache commences, the only thing that helps is sleep and darkness. Ice directly on the pain areas lessens the intensity. If Shelly takes Excedrin at the very beginning of the headache, it dulls the pain.
Precision neuromuscular therapy treatment perspective Douglas Nelson Migraine headaches affect nearly one in five women and about one in 20 men (Lipton & Stewart 1993). With this prevalence, migraine is responsible for billions of dollars in lost productivity and direct medical costs not to mention untold personal suffering (Lipton & Stewart 1993, Stewart et al. 1992). In fact, most migraine sufferers never are formally diagnosed by a physician or treated with prescription medication (Celentano et al. 1992). Even those who are, are quite dissatisfied with the results Douglas Nelson NCBTMB, CWMT Precision Neuromuscular Therapy Institute, 407 West Windsor Road, Champaign, IL 61820, USA Tel.: +1-217-363-3866; Fax: +1-217-366-0049; E-mail: [email protected], www.nmtmidwest.com ........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 31^37 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00064-5 S1360-8592/03/$ - see front matter
(Edmeads et al. 1993). The pounding searing pain described by Shelly in addition to her light sensitivity and nausea are typical and help to discriminate migraine from other types of headache. Discerning whether headaches are of migraine type or of cervicogenic type is not an easy call to make. The evidence in Shelly’s case points to headache of a migraine origin. Our task is to negate any somatic/mechanical influence that could exacerbate her headaches. This is certainly best approached as a team effort with other healthcare practitioners who are addressing other causative factors. Shelly’s struggle with headaches represents a clear example of the constellation of influences that can be a causative factor for migraine headaches. The most difficult endeavor is to decide which influences are the most important, and which have a low degree of likelihood of leading to successful
treatment. In our scenario, there are many such influences, and not all of them may be primary. When seeing a client for the first time, a very good approach is to determine a marker, a benchmark for the judgment of success. In Shelly’s case, that marker is the existence of her headaches that coincide with what was her menstrual cycle with a duration of approximately 72 h. These have been diagnosed as a true migraine. There is no mention of headaches at any other time. In the headache realm, the markers are frequently: . intensity, . frequency.
To grade intensity, a scale suggested by Edeling (1994) is as follows: 1/5 mild pain, 2/5 more than mild, but tolerable, 3/5 moderately severe pain,
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J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Migraine headache . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Charna Rosenholtz, Douglas Nelson, Terry Hambrick, Gina Makris
Case study details Charna Rosenholtz
Charna Rosenholtz BA, NCTMB 420 S. Howes, Suite 102, Fort Collins, CO 80521, USA Correspondence to: Charna Rosenholtz Tel.: +1-970-221-2903; Fax: +1-970-221-0773; E-mail: [email protected] Received April 2002 Revised June 2002 Accepted July 2002 ........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 30^45 r 2003 Elsevier Science Ltd. All rights reserved. doi:10/1016/S1360-8592(02)00063-3 S1360-8592/03/$ - see front matter
Shelly is a 53-year-old-stock broker, living in a moderate-sized city in America. She spends her 50–56 hour work week at the computer and telephone, while spending the other half moving in and out of her car, meeting with clients. Shelly complains of severe headaches, which have been diagnosed as migrainous. Typically Shelly’s headaches come in the third week of the month and last for 72 hours. They begin in the upper trapezius muscle and follow up the occiput, the parietal bone, moving lateral to the temporal bone, culminating above the eyebrow. They are often right-sided and occasionally move bilaterally. The headaches follow the traditional Chinese medicine gall bladder meridian. Her pain has a searing knife-like quality that pounds from the inside out. Shelly’s headaches began in high school, with no known etiology, although her mother, daughter and aunt also suffer from this pain. She was physically active in high school and rode motorcycles, however, there is no recollection of crashing the bike before the headaches began.
Further inquiry shows an unspectacular medical history which includes inguinal hernia surgeries in 1955 and 1966. She has had several motorcycle falls during the 1960s and a 1974 car accident, which involved a minor whiplash. She had a complete hysterectomy in 1991. The headaches decreased in length at that time but not in intensity. Shelly also suffers from allergies that do not seem to be food or seasonally related. She has experienced constipation for as long as she can remember (bowel movements are at times only once a week). Shelly’s medication is an estrogen patch (0.025 estrogen), Clariden for her hay fever and Excedrin when the headaches start. She takes vitamin E, niacin, calcium, a multi-vitamin, fish oil capsules, phyto-vitamins and garlic. Her diet seems adequate, low in fried and fatty foods, but with minimal quantities of fresh food. There are a variety of concomitants to her pain, including sound sensitivity, fatigue, neck pain and food cravings. In particular, she craves chocolate during the third week of her monthly cycle. Shelly experiences nausea when her
30
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3
Migraine headache
headache is present and this can be debilitating. The pain and discomfort is felt in her stomach and the nausea comes in waves. Muscular palpation exam indicates hypertonicity of the bilateral scalenes, trapezius, posterior cervicals (especially C1–C4, erector spinae muscle group, suboccipitals, infraspinatus and right triceps). A closer examination of Shelly reveals an overall restricted breathing pattern with a tendency toward upper chest breathing and strong utilization of her accessory respiratory muscles. It is hard for her to ‘get a good breath’, and very difficult for her to fully exhale. Posturally there is a ‘collapse’ at the
diaphragm area, which shortens the abdominal muscles. Her shoulders are rounded, with a classic forward head posture. Her eyes are dull, with limited facial expression. She is living a societally successful life yet really wants to live in a small farm town living the simple life. Few people know that she is unhappy with her present life circumstances. Although Shelly does not drink alcohol due to her migraines, alcoholism seems to haunt her. She is in a good second marriage, while there are unresolved issues from her alcoholic first husband. Her brother is a functioning alcoholic and her stepson is a non-functional
alcoholic. She tends to deal with these relationships with frustration, impatience and avoidance. She has excellent relationships with her two children and grandchildren as well as several close friends. Shelly experienced some relief of her headaches between 1966 and 1974, but they came back with a vengeance in 1974, not long after she was rear-ended in a motor vehicle accident. The nausea and vomiting began at this time. Once a headache commences, the only thing that helps is sleep and darkness. Ice directly on the pain areas lessens the intensity. If Shelly takes Excedrin at the very beginning of the headache, it dulls the pain.
Precision neuromuscular therapy treatment perspective Douglas Nelson Migraine headaches affect nearly one in five women and about one in 20 men (Lipton & Stewart 1993). With this prevalence, migraine is responsible for billions of dollars in lost productivity and direct medical costs not to mention untold personal suffering (Lipton & Stewart 1993, Stewart et al. 1992). In fact, most migraine sufferers never are formally diagnosed by a physician or treated with prescription medication (Celentano et al. 1992). Even those who are, are quite dissatisfied with the results Douglas Nelson NCBTMB, CWMT Precision Neuromuscular Therapy Institute, 407 West Windsor Road, Champaign, IL 61820, USA Tel.: +1-217-363-3866; Fax: +1-217-366-0049; E-mail: [email protected], www.nmtmidwest.com ........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 31^37 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00064-5 S1360-8592/03/$ - see front matter
(Edmeads et al. 1993). The pounding searing pain described by Shelly in addition to her light sensitivity and nausea are typical and help to discriminate migraine from other types of headache. Discerning whether headaches are of migraine type or of cervicogenic type is not an easy call to make. The evidence in Shelly’s case points to headache of a migraine origin. Our task is to negate any somatic/mechanical influence that could exacerbate her headaches. This is certainly best approached as a team effort with other healthcare practitioners who are addressing other causative factors. Shelly’s struggle with headaches represents a clear example of the constellation of influences that can be a causative factor for migraine headaches. The most difficult endeavor is to decide which influences are the most important, and which have a low degree of likelihood of leading to successful
treatment. In our scenario, there are many such influences, and not all of them may be primary. When seeing a client for the first time, a very good approach is to determine a marker, a benchmark for the judgment of success. In Shelly’s case, that marker is the existence of her headaches that coincide with what was her menstrual cycle with a duration of approximately 72 h. These have been diagnosed as a true migraine. There is no mention of headaches at any other time. In the headache realm, the markers are frequently: . intensity, . frequency.
To grade intensity, a scale suggested by Edeling (1994) is as follows: 1/5 mild pain, 2/5 more than mild, but tolerable, 3/5 moderately severe pain,
31
J O U R NAL O F B O DY WO R K A N D MOV E M E N T TH E R API E S JANUARY 20 0 3