Headaches. Just about everyone has experienced them at some point, and many people are afflicted with them on a recurring basis.
The popular solution when confronted with a headache is to opt for a quick fix in the form of a pill, an approach that follows an alarming nationwide trend of opioid overuse and abuse. Fortunately, chiropractors are adopting treatment strategies that rely less on medication to address the pain and more on a holistic approach that seeks out and corrects the root of the problem.
And in the growing realm of treatment options, DCs have gained some new tools to help their patients feel better.
The challenge of diagnosis
But before you can hope to address a patient’s headache pain, you must first determine what type of headache the patient is experiencing. Guy Annunziata, DC, BCN, is a specialist in the use of neurofeedback, and says, “The task of getting the right diagnosis is difficult,” given the more than 150 different types of headaches diagnosable, according to ICD-10 codes. Patients may report they suffer from migraines, but DCs have to do their own investigation to be sure the diagnosis is accurate. “For example, when we examine the patient and take a good history, we may discover they aren’t migraines but are instead tension headaches,” Annunziata says.
With an estimated 38 million migraine sufferers in the U.S., according to figures compiled by the Migraine Research Foundation, there’s a veritable laundry list of factors that could be behind any one patient’s headaches.1 Some triggers are entirely under a patient’s control, while others stem from happening in the world around them and may not be obvious—even to the sufferer.
“Migraines are notoriously difficult to diagnose, and there could be other causes to rule out,” says Peter J. Levy, DC. Stroke, sinus blockages, and brain tumors sit on the list of potential underlying causes, alongside concerns such as alcohol abuse and carbon monoxide poisoning.
Kelly Lott, LMT, specializes in treating headaches, and has identified four primary migraine triggers through her research into the condition. “The No. 1 reason is stress, along with food allergies, environmental agitation, and hormone imbalance,” she says. Other reasons occasionally crop up, but issues such as allergies and environmental factors—gluten, pollen, flashing lights—are so pervasive that they dominate the headache landscape.
They may also impact and be impacted by issues within the more traditional chiropractic realm.
“A person could be out of alignment, such as from a car accident,” Lott says. “If they never get a massage or see a chiropractor or do physical therapy, they might be more triggered by that stress.”
Everything in the patient’s medical and surgical background should be factored into the initial diagnosis and resulting treatment plan, says John Matthew Upledger, a craniosacral therapy expert. “Consider if there are any chemical or emotional stressors that may be triggering it.” In addition, he encourages DCs to include in their examination any data on past accidents or injuries the patient experienced, along with previous pain treatments they may have undergone. Any of these factors could be causing or exacerbating the patient’s condition.
Roger L. Turner, DC, who specializes in cranial adjustment, points to the increasing number of concussions seen in patients today, and says it’s a common cause behind many headaches and similar complaints. Previously lumped under the more generic “brain injury” term, head trauma can set off a storm of physical problems, not just headaches.
“There are a lot of other symptoms,” Turner says. “Brain fog, blurred vision, memory problems, and emotional upsets—they’re all associated with head injury.” Sifting through the patient’s concerns and identifying which are causes and which are symptoms will give you the right information to develop an effective treatment plan.
The evolution of treatment
Headache patients that come to see Upledger’s group first undergo a broad evaluation. “Their entire system is analyzed for any restrictions of tissues that surround the brain and spinal cord,” says Lynn K. Mabry, DC, who works with Upledger. The premise behind this approach is that structure equals function, and she explains that when the structure is evened out, the function returns. “We look for restric- tions anywhere in the body. We don’t confine ourselves to the area of complaint.”
With craniosacral therapy, practitioners employ light-touch techniques to gauge how the craniosacral system, which encompasses the cerebrospinal fluid as well as the membranes that surround the brain and spinal cord, is responding. “We’re not just looking at the head or neck, but the entire body using the light-touch technique,” Upledger says. “We can then tell where, within the craniosacral system, there might be restrictions in the tissues that could have an effect on the head and neck area.”
Because headache sufferers may have other conditions tied to their head pain, the services of other providers could be used to augment chiropractic care. This is particularly important when potentially serious medical issues are present.
For example, Levy says that patients will typically be able to tell their chiro- practor if they’ve suffered a concussion, but other medical causes may not be as obvious. Headache pain could also be triggered by glaucoma but, “They might not know that unless they’ve gone to the eye doctor,” Levy says.
Coordinating visits with other profes- sionals helps to winnow down potential causes and resolve other issues that may be contributing to the patient’s concerns.
Once the course of treatment has been developed, Levy’s technique for headache and migraine sufferers is cranial facial release, which involves balloon-assisted cranial manipulation. Levy describes the purpose of the skull as twofold. “It protects the brain but it also acts as a pump for cerebral spinal fluid,” he explains. “I put balloons in the passages depending on what the skull looks like, inflate the skull, stress the sutures in the skull and manipulate the cranial bones.”
The actual inflation takes only a second or two and the process is repeated two or three times during each visit. After treatment, the skull resettles itself and it can then reestablish normal function.
Addressing lifestyle triggers is among Turner’s initial priorities when working with headache patients. Nutrition in particular is a primary issue for many people, he says, adding that the standard American diet is a common factor behind headaches. “We address diet on the case history form. We ask about milk, sugar, and wheat, plus smoking and drinking.” Turner has deep expertise in nutritional matters but he also refers patients out to other specialists for supportive care when appropriate, so his team can be more specific in their approach to treatment.
Turner’s school of cranial adjusting focuses on manually adjusting the 22 cranial bones above the atlas. He has discovered that many migraines are linked to the sphenoid bone. One traditional method of addressing headache pain involved adjusting the upper cervicals, but he as explains, “That doesn’t correct the migraines because the sphenoid is out of place.”
His team examines the skull, looking for misalignments. “Headaches are usually the result of trauma to the head,” Turner says. The sphenoid as well as the frontal bone may be involved and a thorough exam, along with input from the patient on the location of the headache, shows Turner where the skull may be out of place. Targeted adjustments can then be used to treat the condition.
Like many treatment scenarios, a diary is an important component in Lott’s drive to ensure the best outcome for her headache patients. “I ask them to document things they’re doing in their life,” she explains. “How much stress are they experiencing? How much caffeine have they taken in? Are they drinking water? What are they eating?”
Aromatherapy blends are also presented to patients during the initial exam so Lott can determine what’s causing their migraines. She then helps them adjust their lifestyle to avoid triggers. Patients’ diaries are reviewed during each visit, where they’re also exposed again to their particular aromatherapy blend to continue narrowing down the field of potential triggers.
With insight into likely causes behind migraines, Lott begins each visit by applying essential oils to patients and using pressure point massage techniques. “Within seconds to minutes, those help to calm their brain and relax them,” she says. She then places cold marble stones at strategic locations based on the patient’s particular type of headache. “Because the brain swells during migraines, the cold stones reduce inflammation of the blood vessels in the head and neck,” Lott says. The combination strategy not only helps patients avoid things that could trigger future headaches, but it’s also useful in interrupting active migraines.
Along with eliminating likely trigger elements from the patient’s environment and addressing other general chiropractic issues, such as the biomechanics of the spine, Annunziata’s approach incorporates a technique that leverages neurofeedback (NFB). “It has been found to be extremely beneficial for headaches— tension and cluster—as well as migraines,” he says. But sinus headaches, unfortunately, often don’t respond as well.
Annunziata’s patients undergo a quantitative EEG, also known as a brain map. “It shows us different patterns of brainwave activity,” he explains. If patients exhibit specific brainwave patterns, they may be more prone to headaches. “If a patient is diagnosed with headache and their brain map fits the pattern with migraine, then we initiate neurofeedback protocols to reestablish a normal brainwave pattern.”
This process often results in the elimination of patients’ migraine complaints.
Subjective vs. objective analyses
No matter the strategy used when treating patients with headaches, assessing the progress of that treatment is paramount to providing patients with relief. Mabry says the primary indicators she uses to determine how well a patient is doing are changes in headache frequency, duration, and severity. Some long-time migraine sufferers achieve significant improvement after only a few sessions, while others follow a slower track.
“I’ve seen patients who have experienced migraines for 20 years progress to where they never have one again,” Mabry says. Treatment plans may also take longer if other factors need to be weeded out of the patient’s environment, such as a poorly fitting chair that creates tension, or hormonal imbalances, which can take time to address.
And though some patients see only minor changes after several craniosacral therapy treatments, Mabry finds that a high percentage of patients find relief.
Annuziata uses headache questionnaires every 8 or 10 visits to see how things are going. “It’s very useful in tracking the progress of patients with headaches,” he says. His team then conducts routine pain evaluations and asks patients to fill out a daily diary. “If we have a patient where we have identified abnormal brainwave activity, we’ll also do another brain map after 10 neurofeedback session” Annunziata says.
That map serves as an objective tool to help determine if progress has been made in reversing the abnormal brainwave patterns.
Along with a subjective assessment, where patients rate their various symptoms during the initial visit on a scale of 1 to 10 and then repeat the process every 10 to 12 visits, Turner employs his own objective analysis to gauge progress. “I test the patient’s misalignments in the spine and the skull every time,” he explains. Intensive treatment protocols can be carried out up to three times per day.
With data on the amount of misalignment at the onset of treatment, Turner says, “I can tell how people are doing in the course of the day and over the week.” Pre- and post-treatment X- rays are also used to measure the amount of any misalignment and to determine how much improvement has been achieved. “That’s very closely related to how much their symptoms have changed,” Turner says.
Headaches with a purely mechanical cause may show improvement relatively quickly—sometimes after just a handful of visits. But, Levy warns, “If it’s a migraine it’s a longer process, because there’s so much information that’s necessary but I may not have it.” It sometimes takes longer to zero-in on the cause of migraines and, as Levy explains, the patients themselves may not know how to (or may not choose to) contribute fully to the process.
“With migraines, treatment compliance may be high because the patient wants relief—quick.”
Julie Knudson is a freelance business writer with a background in the life sciences industry. She specializes in healthcare and technology, with a focus on where those disciplines intersect. Her work has also appeared in publications covering retail, hospitality, risk management, and the commercial building sector, and she develops thought-leadership content for businesses in those same industries. She can be contacted through julieknudson.com.