This poster presents the successful evidence-based diagnosis and management of a patient with migraine headaches in a chiropractic setting. Migraine headaches are 19th worldwide among diseases causing disability. Prevalence of migraine is estimated at 15% in women and 6% in men, peaking at 40 years of age

Funk, Matthew F.

Whipple, Cortnee

UB ScholarWorks

IntroductionChiropractic clinical reasoning ina patient with migraine headachesCortnee Whipple, B.S. (4th year, Doctor of Chiropractic Program)Matthew F. Funk, D.C. (Associate Professor of Clinical Services)College of ChiropracticUniversity of Bridgeport, Bridgeport, CTThis poster presents the successful evidence-based diagnosis and management of a patient with migraine headaches in a chiropractic setting.Migraine headaches are 19th worldwide among diseases causing disability. [1] Prevalence of migraine is estimated at15% in women and 6% in men, peaking at 40 years of age. [2] Clinical features of migraine:• Episodic, often unilateral pulsating headache that may be associated with a prodrome or “aura”; described as blurred or spotty vision, light and sound sensitivity and/or nausea/vomiting. [1]• Triggered by stress, schedule changes, some foods like chocolate, cheese and wine. [3]• Presence of nausea, light and sound sensitivity and pain worsening with activity have been shown to increase the likelihood of a correct diagnosis. [2]Currently there are no specific examination or imaging findings to help diagnose migraine headaches.It is diagnosed by excluding serious secondary headaches from other sources and recognizing migraine’s stereotypical clinical presentation.1. Moloney MF, Johnson CJ. Migraine headaches:   diagnosis and management. J Midwifery WomensHealth 2011;56:282-92.2. Ebell MH. Diagnosis of migraine headache. Am Fam Physician 2006;74(12):2087-2088.3. Souza TA. Differential diagnosis and management for the chiropractor. Fifth ed. Massachusetts: Jones & Bartlett Learning; 2016.4. Murphy DR, Hurwitz EL. Application of a diagnosis-based clinical decision guide in patients with neck pain. Chiropr Man Therap. 2011;19(1):19.5. Bryans R et al. Evidence-based guidelines for the chiropractic treatment of adults with headache. J Manipulative Physiol Ther. 2011;34(5):274-89.Patient’s History31 year old male presented to the UBCC Clinic with a chief complaint of chronic “migraine headache”.Onset circa 2010 with no inciting incident or traumatic event.HA progressively worsening from a frequencyof 1 headache per month to 1 per week.HA described as pulsating pressure behind the eyes and tightness in the neck accompanied by an exacerbating light sensitivity. Relief reported with sleep and rest.He denied any temporal pattern, known trigger, dizziness, double vision, or trouble speaking.No difficulty swallowing, no drop attacks, numbness or radiation of pain into the upper extremity, face or jaw. He denied nauseaor vomiting.Previous treatment included nutritional recommendations by a Naturopathic Doctorto increase intake of magnesium rich foods, which he believed to be beneficial.Pertinent medical history includes a concussion after an MVA in 2013 with no known sequelae or a change in migraine pattern.Sleep disturbances reported by patient;he stops breathing during sleep which will frequently awaken him.Patient's mother also reportedly suffers from migraine as well.Treatment / ManagementCurrent evidence gives the following practice recommendations: [5]1. Spinal manipulation for patients with episodic or chronic migraine with or without aura. Treatment frequency 1-2 times/week for 8 weeks (moderate level of evidence)2. Weekly massage therapy for reducing intensity and frequency (moderate levelof evidence)3. Multimodal multidisciplinary care: exercise, relaxation, stress and nutritional counseling (moderate level of evidence)Our treatment included:Spinal manipulation of cervical spinePost-isometric andtrigger point pressurerelease ofsuboccipital andupper trapezius mm.Magnesium(400 mg/day)Results: Patient was seen 1x/week forfour weeks. He reported no migraineheadaches after the 1st treatment.By 5th visit he stated he was able to return tothe gym and workout 5x/week now that themigraines have ceased.HDI final score of 0% (100% improvement)!Common FeaturesThe following are commonly found in migraine sufferers:[3]▪75% report associated neck pain▪70%  of migraine sufferers have a family history (1.9 fold increased risk of migraine without aura if found in 1st degree relatives) ▪50% report known triggers (such as a change in weather, stress, lack of sleep/fatigue, alcohol or food)▪46% report tearing or nasal congestionDiagnostic Criteria:History of at least 5 attacks lasting 4-72 hours with at least 2 of the following 4:1. Unilateral location (59%)2. Pulsating quality (85%)3. Disabling intensity of headache 4. Aggravated by or causing avoidance of routine physical activities And at least 1 of the following 2:1. Associated nausea (73%) and vomiting 2. Light sensitivity (80%) and sound sensitivity(76%). [1]Physical ExaminationFirst goal is to rule out serious causessuch as masses, vision disordersand/or vascular events. Exam procedures included:▪ Cerebral, cerebellar, peripheral and cranial nerve testing: no abnormalities▪ Eyes, Ears, Nose, Throat: no abnormalities▪ Heart/Circulatory: No abnormalities detected▪Orthopedic/provocative testing: Cervical compression and distraction both pain free. Valsalva negative for pain. Gross active and passive cervical range of motion was full and pain free in all directions. Chiropractic analysis:▪Tender trigger points notedin the bilateral suboccipitaland bilateral upper trapezius muscles▪Pain reported upon provocative palpation of C1/2 right sided facets when brought into leftrotation.▪These reproduced the patient’s headache symptoms.Outcome Assessment tools:Headache Disability Index (HDI)Baseline score of 60% (disabling headaches)Diagnostic Reasoning [4]1. We first ruled out serious pathologythrough history and examination.• No “red flags” from historyand no neurological abnormalities.2. The second step was to determinewhich structures may be contributing to symptoms.• Cervical spine and associated muscle palpation provoked symptoms.3. The final step was to determine if any other factors may be contributing to the perpetuation of symptoms.• Fatigue, stress and nutritional deficiencies may be implicated here.References

Chiropractic clinical reasoning in a patient with migraine headaches

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Chiropractic clinical reasoning in a patient with migraine headaches

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