Australasia Chiro and Osteo Journal 1999 (Nov): 8 (3): 8590 ~ FULL TEXT
Peter Cattley B.Sc. ,Peter J. Tuchin B.Sc., Grad.Dip.(Chiro), Dip.OHS.
Objective: To assess the response of a patient with chronic migraines to a short program of chiropractic care (diversified technique).
Method: The study was run over a 13 week period with chiropractic spinal manipulative therapy (CSMT) on a once weekly schedule for 5 weeks, followed by an 8 week re-evaluation.
Outcome measures: To measure the effect of treatment, a previously reported diary system was used which noted the intensity of a range of symptoms that are recorded following each migraine episode.
Results: The results attained showed there was a marked improvement in the migraine symptoms following the chiropractic care. The patient reported an improvement in frequency, intensity, duration and use of medication. These findings appear to also confirm other evidence which documented similar changes following a large randomised controlled trial of chiropractic treatment of migraine.
Discussion: The case is presented as further support for CSMT in the treatment of migraine. The outcome of this case is also discussed in relation to recent research that concludes that CSMT is a very effective treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It now appears clear that chiropractic care may be used to assist patients with migraine. Research is currently being undertaken to investigate the potential mechanisms of chiropractic in the treatment of migraine. This research should also assess what (if any) prognostic signs can be identified to assist practitioners making a more informed decision on the treatment of choice for migraine.
MeSH Keywords: Classic Migraine; chiropractic; manipulation, spinal; case report.
From the FULL TEXT Article
Descriptions of migraine can be traced from the ancient
civilisations of Mesopotamia through to medieval times
and the 17th century, when European physicians first gave
full case reports . Gobel et al contend that in the Bible
(Acts 9) the conversion of Saul to Paul, where a flashing
light caused Saul to fall down with additional symptoms
of "not seeing", or photophobia, and anorexia, was an
illustration of a migraine episode which fulfils the current
classification for migraine with aura .
Migraine is a common condition where prevalence is
influenced by gender, nationality, race and possibly
socioeconomics. In the USA migraine affects 6% of males
and 18% of females , in Canada 8% of males and 25%
of females  and Denmark 6% of males and 15% of
females . In the United States, migraine prevalence is
highest in Caucasians, followed by African Americans,
then Asian Americans . This is supported by a study
showing that migraine in Ethiopia affects 2% of males
and 4% of females . Stewart et al reported the incidence
of migraine to be greater in lower socioeconomic groups
in the USA . However, this was challenged by a
subsequent Canadian study .
criteria for migraine is vital for correct diagnosis and for
research in this area. There were no internationally
accepted classification or diagnostic criteria until the
1960s. An ad hoc committee of the United States National
Institutes of Health then produced a classification of
headache disorders. However, descriptions were adopted
rather than definitions and were therefore open to
interpretation . In 1988 the International Headache
Society (IHS) published an internationally accepted
classification of headaches including diagnostic criteria.
The first four categories cover primary headaches (those
without association to organic disease) and of these
migraine forms Category 1 .
Migraine is a recurrent and debilitating condition. The
IHS classification for migraine describes a headache
lasting 4 to 72 hours, having at least two of the following
features: unilateral location, pulsating, inhibiting daily
activity and aggravated by daily activity. The person must
experience nausea and/or vomiting, or, photophobia and
phonophobia . Prior to the headache the person may
experience visual disturbances (aura), tingling or
Numerous factors are implicated in triggering migraine
Emotional stress excitement, expectation, sudden
news, relaxation after stress;
Physical stress exercise, sudden exertion, head
trauma, heat, bright lights, weather change,
Foods alcohol, chocolate, cheese, citrus fruit, food
Drugs oestrogen, contraceptives containing
oestrogen, nitrates, monosodium glutamate ;
Even rubbing the eyes has been identified as a trigger .
For decades, migraines have been understood as vascular
events resulting from vasoconstriction or vasodilation.
Aura is related to cerebral vasoconstriction followed 30
to 60 minutes later by vasodilation in vessels that are pain
sensitive, culminating in headache . It is now more
widely accepted that migraine is a result of a variety of
aetiological factors: autonomic/vascular, biochemical/
psycophysiological, neurogenic and somatic .
Vernon stated that individual susceptibility, symptoms an
progression of migraine results from a combination of
these factors and also proposed the concept of
vertebrogenic migraine. The vertebrogenic migraine
model links somatic dysfunction of the cervico-thoracic
spine, disturbance of autonomic tone (leading to
vasoconstriction and de-stabilisation of central aminergic
system) and the migraine cascade of symptoms. Somatic
dysfunction of C7T4 causes joint pain and fixation
resulting in sustained discharge from the sympathetic chain
leading to transient cerebral ischaemia which reaches
threshold levels to create cerebral ischaemia which then
activates the migraine cascade. Increased catecholamine
levels would result from the sub-threshold central
excitation leading to destabilisation of platelet membranes.
Somatic dysfunction of atlanto-occipital and the atlanto-
axial joints also results in pain and fixation. This facilitates
upper neurons reducing the inhibitory effect of descending
pain pathways (at least one of which arises from the locus
ceruleus) and increasing facilitation of neurons of the
spinal tract of the trigeminus. Transient stimulation of
the locus ceruleus results in focal and spreading
vasoconstriction in intracerebral circulation leading to
vasodilation of extracarotid circulation with cranial pain
mediated by the ipsilateral trigeminal nerve. Based on
this model, three categories of migraine sufferers can be
described, those where vertebrogenic migraine is
aetiological, the second group where the vertebrogenic
component is secondary and a group where the
vertebrogenic component is not present. The first two
categories of migraine sufferers would probably benefit
from chiropractic spinal manipulative therapy .
According to Nelson there exists both diagnostic and
therapeutic overlap between migraine and tension
headaches and that they do not exist as discrete
pathophysiologic entities but form a continuum. Nelson's
continuum model has at its centre the trigeminocervical
nucleus. Headache pain is a function of the spinothalamic
tract activity that arises from this nucleus. Three
components influence activity, somatic source of pain from
pain sensitive tissue innervated by C1C3, vascular source
of pain from intracranial and extracranial blood vessels
innervated by the trigeminal nerve and disinhibition of
headache pain, mediated through the serotonin system.
The serotoninergic system is regulated by and influences
autonomic control centres. This model defines a two
dimensional continuum with a somatic (tension headache)
dimension and biochemical (migraine headache)
dimension. The spectrum of headaches may include
individuals on either extreme or individuals where one
dimension may predominate but the other dimension may
also be present. Based on the continuum model, the
effectiveness of spinal manipulation therapy may be
determined by the predominance of the somatic dimension
of the headache or migraine .
In the clinical situation a reliable and cost effective method
for determining the outcome of chiropractic treatment for
migraine is required. This may be achieved by the patient
using a migraine/headache diary to record date, headache
score, other symptoms, duration, disability, medication,
medication relief score and possible triggers. In addition,
practitioners will record their examination findings.
Research of chiropractic treatment for migraine could
benefit from independent objective measurements for
treatment outcomes. Emerging and established methods
are available to test saliva [12, 13], blood [14, 15], cerebral
blood flow [16, 17] and muscle tone [18, 19]. Saliva could
represent a fluid particularly suitable to the study migraine
as serum cortisol levels are increased by stress as in
migraine and are reflected in salivary cortisol levels .
In addition, Gamma-aminobutyric acid (GABA) levels in
saliva have also been shown to increase during migraine
. Studies have shown that platelet levels of cyclic
adenosine-3, 5-monophosphate (AMP) increase during
migraine  and the plasma level of some Th2-type
cytokines are elevated in the interictal period of migraine
. The use of transcranial doppler ultrasound on
migraine patients with aura during the interictal period
has shown that measuring mean flow velocity change and
resistance index change in the middle cerebral artery could
be used to detect patients with aura symptoms .
Positron Emission Tomography (PET) allows the
quantitative measurement of regional cerebral blood flow and has been used to monitor blood flow during the aura
and headache phase of migraine . Electromyographic
(EMG) readings of neck and temporal muscles during
headaches have shown increases in EMG activity .
Therefore, EMG is a potentially effective way of analysing
the effects of spinal manipulative therapy in the treatment
of migraine .
A 41 year old male presented with a major complaint of
headaches and migraines. The headaches occurred every
two weeks, usually early on Saturday mornings. Every
two months the headache escalated into migraine with
nausea and vomiting. The headache/migraine episodes
lasted for 18 hours and up to 6 paracetamol (Panadol)
were taken during that period. These episodes have been
occurring for two years. The patient worked as a massage
therapist and was also a university student and felt the
episodes were due to physical stress. He reported no other
The pain was located unilaterally in the suboccipital area
and behind the eye. He described the pain as intense '...as
though a steel spike was being driven into the base of my
skull and out through my eye'. During an episode the
location may change to the other side. The migraine
episodes caused nausea and vomiting. At the initial visit
he rated the headache 5 on a visual analogue scale (VAS),
where 1 indicated "no pain" and 10 indicated "terrible
pain". The VAS was 9 for the migraine. He reported that
between episodes he experienced a slight but constant dull
ache and stiffness in the suboccipital area.
Motion palpation revealed restricted movement at the
atlanto-occipital facet joint (OccC1), between the second and third cervical vertebra (C2C3) and the third and fourth
thoracic vertebra (T3T4) with hypertonicity in the
suboccipital, levator scapulae and upper trapezius
muscles. In addition, he had a functional scoliosis
(negative on Adam's Test) in the thoracic and lumbar
The patient received chiropractic adjustments to OccC1,
C2C3 and T3T4. Massage was applied to the
suboccipital, levator scapulae and upper trapezius
muscles. Home stretching of the suboccipital and
trapezius muscles was also advised.
The patient was seen a total of 5 times over a period of 5
weeks. The patient kept a migraine/headache diary during
the course of treatment. For each migraine/headache
episode the following was recorded:
VAS score (1 = slight to 10 = terrible), duration, disability
(time unable to undertake normal daily routine),
medication (type and number of tablets) and other
The patient reported having had one tension-type headache
which lasted three days (rated 3 on a VAS 1-10) during
the five week treatment period. He had not experienced a
migraine. He noted that the dull ache and stiffness in the
suboccipital area was no longer present.
At an informal follow up eight weeks after completion of
treatment the patient reported no migraine episodes. The
migraine/headache diary was not thoroughly kept during
this period, as there had been few symptoms relevant to
headaches or migraines.
Results of Treatment
Headache 1 every 2 weeks
Migraine 1 every 8 weeks
Headache 1 only
No headache details
Headache 18 hours
Migraine 18 hours
Migraine 12 hours
Headache 4 Panadol
Migraine 6 Panadol
The patient noted he had a decrease in the frequency of
headaches and migraine following the chiropractic
treatment (Table 1). It appears that there was somatic
dysfunction at C0C1, C2C3 and T3T4. Therefore, the
patient's condition fits into categories within both the
vertebrogenic migraine and headache continuum models
that could respond to spinal manipulation therapy. The
condition appeared to be aggravated by massage work
and postures where the patient bent forward for long
periods of time, predisposing the thoracic spine to
restrictions. This was coupled with a decrease in the lower
cervical curve and an increase in extension of the upper
cervical spine with forward head carry predisposing this
area to restrictions. The patient was advised to seek further
chiropractic treatment to assess and correct any cervical
and thoracic dysfunctions, and myalgia in the neck and
In 1995, Vernon  reviewed the literature on outcome
studies of chiropractic manipulation for tension-type and
migraine headaches. He concluded that there existed only
a modest body of clinical studies, only three of which
dealt with the treatment of migraine. However, well
controlled studies in migraine were definitely warranted
and should include:
Precision in classifying headaches
Use of a waiting-list control group
Large sample sizes to detect clinically important
Refinement of diagnostic and assessment procedures
for cervicogenic dysfunction
Exploration of different modes of chiropractic
A series of studies on chiropractic treatment for migraine
have been presented by Tuchin . The conclusion
from a case study of a patient with chronic headaches was
that the patient was originally misdiagnosed with migraine,
highlighting the importance of correct diagnosis of patients
participating in clinical trials . Correct diagnosis of
migraine was examined in a subsequent retrospective study
and confirmed that patients were being incorrectly
diagnosed with migraine . In addition, the current
migraine classification system resulted in the patients
falling into more than 1 category. Also, the review of
treatment outcomes suggested that chiropractic spinal
manipulation techniques (SMT) may reduce both the
disability associated with migraine and the frequency of
migraine. Tuchin's larger prospective clinical trial on the
efficacy of SMT in the treatment of migraine  using
32 migraineur volunteers showed the treatment to be
effective for migraine without aura. Tuchin noted that the study had a small sample size which necessitated the
recording of the number of associated symptoms rather
than the actual symptoms and the lack of a control group,
although he argued that the participants acted as their own
control because they participated in 2 months of pre-
treatment. The strength of this study was the 6 month
period used to allow for the cyclical nature of migraines.
A further case series by Tuchin reported on the dramatic
lessening of disability of 4 participants in the previous
trial . These patients experienced significant reduction
in both the frequency of migraines and use of medication.
Due to the small number of cases, it cannot be concluded
that this would be the case for all migraineurs.
A recent prospective, randomised, parallel group
comparison trial involving 218 migraine suffers concluded
that spinal manipulation seemed to be as effective as the
well established, efficacious treatment, amitriptyline, and
on the basis of a benign side effects profile, it should be
considered as a treatment option for patients with frequent
migraines . This study is significant due to the large
number of participants and the 4 month period of the trial.
Another, randomised controlled trial involving 127
migraine suffers has also been recently concluded .
The results confirmed that spinal manipulation is an
effective treatment, which appears to have few benign side
effects. The evidence appears now strong enough to state
that chiropractic should be considered as a treatment
option for patients with frequent migraines. This study is
also very significant due to the long period of the trial (6
months) and the number of participants.
Many other studies have assessed the effects of
manipulation in "type O" conditions including
dysmenorrhea, colic, asthma, hypertension, as well as
migraines . The evidence for CSMT in "type O"
conditions is limited and no strong conclusions can be
drawn, however, case studies such as this as some weight
to the scientific knowledge about the condition .
The "Philosophy of Chiropractic" hypothesises a
relationship between the integrity or health of the nervous
system and the resultant integrity and health in the
individual . The effects of vertebral dysfunction have
also been substantiated with alteration in the autonomic
nervous system and associated changes in physiology or
homeostasis [30, 42, 44].
It should also be noted that the improvements observed
in this case could also be explained through other potential
mechanisms. For example, changes may have occurred
through psychological factors, climactic cycles, stress
changes, dietary alteration, etc. However, it should be
noted that this case study was a patient with a chronic
history of migraine and therefore the symptomatic
improvement gained following chiropractic care was possibly independent of the other factors.
CSMT appeared to decrease the frequency of headaches
and migraines for this patient. The informal follow-up
undertaken eight weeks after treatment ceased provided a
period of time sufficient to permit assessment for the
cyclical nature of migraine. However, the controlled 5
week period of this study was insufficient and confirms
the need to conduct these types of studies over an
appropriate time period.
Initially there was a paucity of clinical studies for
chiropractic and migraine. However, the work by Vernon,
Tuchin and Nelson are important steps towards the ability
to undertake further trials on the potential mechanisms of
CSMT for migraine [20, 25, 26]. It can be argued that to
date trials have used only subjective measures but where
these measures are well established, such as the visual
analogue scale and headache diary, they remain suitable.
Further research into independent objective measures must
continue and it appears that substances within saliva may
prove suitable for such measures.
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