Headaches & Treatments: The most common cause of headaches can relate to neck complications. From spending excessive time looking down at a laptop, desktop, iPad, and even from constant texting, an incorrect posture for extended periods of time can begin to place pressure on the neck and upper back leading to problems that could cause headaches. The majority of these type of headaches occurs as a result of tightness between the shoulder blades, which in turn causes the muscles on the top of the shoulders to also tighten and radiate pain into the head. If the source of the headaches is related to a complication of the cervical spine or other region of the spine and muscles, chiropractic care, such as chiropractic adjustments, manual manipulation, and physical therapy, can be a good treatment option. Also, a chiropractor may often follow up chiropractic treatment with a series of exercises in order to improve posture as well as offering advice for future lifestyle improvements to avoid further complications. For Answers to any questions you may have please call Dr. Jimenez at 915-850-0900
The percentage of individuals that are affected by fatigue, headaches, and overall pain is continuously growing. For the most part, these symptoms can all be linked back to a hormone imbalance. Hormone imbalances are more common than individuals realize and can affect people of all ages. Originally, hormone testing was completed through a blood draw (serum testing). However, as science is improving, there are now better, more functional ways of testing.
As more and more studies are done, it is becoming more clear that salivary testing is superior to serum (blood) testing for hormones. There are two forms in which hormones exist in the human body, free (5%) and protein-bound (95%). Due to the protein-bound hormones being bound, they become too large to pass through into the salivary glands. This meaning that they are not bio-available and can not be delivered to the receptors in the tissues of the body. The unbound hormones, or free hormones, are the relevant hormones that are found in the saliva. Considering the fact that free hormones are not as abundant, the hormone levels found in saliva are significantly less than those found in serum. However, many patients who are treated with serum hormone results are often overdosed because of the lack of correlation between bio-availability.
Labrix by Doctor’s Data
Similar to the D.U.T.C.H hormone testing previously discussed, this company Labrix offers a variety of hormone testing as well.
NeuroBasic: ideal for monitoring therapeutic interventions of neurotransmitter imbalances previously tested or when symptoms are indicating an imbalance. This test measures Serotonin, Dopamine, Epinephrine, Norepinephrine, Glutamate, Glycine, Histamine, and Phenethylamine
Comprehensive Neurotransmitter: best when a comprehensive look at neurotransmitter secretion and metabolism of markers is needed. This test measures Serotonin, GABA, Dopamine, Norepinephrine, Epinephrine, Glutamate, Glycine, Histamine, and Phenethylamineand DOPAC, 3-MT, Normetanephrine, Metanephrine, 5-HIAA, Tryptamine, Tyrosine, Tyramine, and Taurine.
NeuroHormone Complete Plus: provides insight on how the HPA axis function may be contributing to patients’ symptoms, such as mood swings, fatigue, and pain. In addition, this test is ideal for those who are at risk for breast cancer, PCOS, or a strong family history of autoimmune disease. This test is recommended for women only. This test measures Estrone, Estradiol, Estriol, Progesterone, Testosterone, DHEA, Cortisol x 4, Serotonin, GABA, Dopamine, Epinephrine, Norepinephrine, Glutamate, Glycine, Histamine, Phenethylamine
NeuroHormone Complete: useful for patients (men or women) who are experiencing any type of mood disorder, addiction, fatigue, chronic illness, confusion, weight issues, low libido, PMS, or chronic pain. This test measures Estradiol, Progesterone, Testosterone, DHEA, Cortisol x 4, Serotonin, GABA, Dopamine, Epinephrine, Norepinephrine, Glutamate, Glycine, Histamine, Phenethylamine.
NeuroAdrenal: Included in this test is a full diurnal cortisol pattern, DHEA, and 6 primary neurotransmitters to help those with symptoms such as depression, anxiety, addiction, chronic illness, and low libido. This test measures DHEA, Cortisol x 4, Serotonin, GABA, Dopamine, Epinephrine, Norepinephrine, Glutamate, Glycine, Histamine, Phenethylamine
Comprehensive Plus: provides an assessment of breast cancer risk. This test is a considerationfor women only who have an increased risk for developing breast cancer, other hormonally sensitive cancers, PCOS or a family history of autoimmune disease. This test measures estrone, estriol, and Estrogen Quotient.
Women’s Helth and breast Profile: includes two risk assessment ratios, the Estrogen Quotient and the Pg/E2 ratio
Comprehensive Hormone: assessment of hormonal status and endocrine function and includes estradiol, progesterone, testosterone, DHEA and four cortisols. This profile is useful with male and female patients because it looks at the full diurnal cortisol pattern; it is especially important in patients who are experiencing the full diurnal pattern ( weight gain, high blood sugar, elevated lipids, chronic fatigue)
Short Comprehensive: useful in men and women whose primary symptoms are related to sex hormone imbalances (elevated or depressed E2, P or T)
Basic Hormone: a basic evaluation of the sex hormones and a brief glimpse at the adrenal function with the AM cortisol level. Best for men who are experiencing decreased libido, erectile dysfunction, loss os stamina, decreased mental sharpness and metabolic syndrome. Best for women who are experiencing hot flashes, anxiety, night sweats, breast tenderness, irritability, forgetfulness, and acne.
Comprehensive Adrenal Function: provides insight into the body’s stress response. This test measures sIgA
Adrenal Function: comprehensive view of adrenal function, DHEA, and cortisol levels. This is best for people who are fatigued, nervous, weak, crave sugar, have headaches, irritability, and depression
Diurnal Cortisol: Similar to the test above but for patients who do not need DHEA testing
Melatonin: Provides a snapshot of the sleep/wake cycle during a one day period
Salivary Hormone + CAR :
CAR: has the capability to test all the same markers as above but adds Cortisol Awakening Response “CAR” to all of them.
For more information regarding testing and hormones tested, please visitlabrix.com
LABRIX BASIC BOX CONTENTS:
Upon opening every box (no matter the labrix test) the patient will see a requisition form, a billable stamp, and a FedEx envelope. Under these two items, a styrofoam box (insulated cooler) with the imprint “doctorsdata.com” will be present. Once the patient lifts the lid off of the styrofoam box, they will see two more pieces of paper. The first being a list of symptoms (patient survey) on a white sheet of paper that the patient is to fill out and place back in the styrofoam box and the second a small instruction manual.
Neurotransmitter Tests Breakdown
For the Neurotransmitter Tests, the patient is provided with the basic kit described above. The only sample type required for the neurotransmitter tests is urine.
The contents of the styrofoam box include a small plastic cup, a clear plastic bag consisting of a white tube, a dropper, an absorbent pad, and a Lab-Brix ice pack. The first step is to freeze the ice-pack and keep it frozen until ready to ship.
In order for this test to have proper results, the patient should collect their sample with their first or second-morning urine upon waking. Then, select on the requisition form which urine ( first or second ) the sample was collected from. It is also important to note on the requisition form what time the patient woke and what time the sample was collected. The urine sample should be collected midstream. Patients will collect their sample in the plastic cup provided, not directly in the tube. Next, the patients will use the dropper provided to transfer 10 ml of the sample from the cup into the tube. Ensure the lid is screwed on tightly and gently rock the tube back and forth for 3-5 seconds to mix the urine with the preservative. The patients will then wrap the absorbent pad around the tube (not inside the tube), and place the sample tube back in the plastic bag. The bag is then to be placed in the freezer for 4-6 hours, and is to be kept frozen until ready to ship!
Neurotransmitter + Hormone Tests Breakdown
The Neurotransmitter + Hormone analysis tests consist of urine and saliva samples. This basic test kit includes everything above. However, upon opening this styrofoam box the patient will find two plastic bags. The first being a plain plastic clear bag with a dropper, white test tube, and absorbent pad. The second plastic bag is a biohazard bag that has multiple colors on the outside and consists of 4 clear small straws, an absorbent pad, and 4 small saliva collection tubes of various colors.
The urine sample is instructed to be taken the same way as the neurotransmitter test.
The patient should collect their sample with their first or second-morning urine upon waking. Then, select on the requisition form which urine ( first or second ) the sample was collected from. (Remember, the individual is to note on the requisition form time they woke and what time the sample was collected). Patients will collect their sample mid-stream in the plastic cup provided, not directly in the tube. Next, use the dropper provided to transfer 10 ml of the sample from the cup into the tube. Be sure to check that the lid is screwed on tightly and gently rock the tube back and forth for 3-5 seconds to mix the urine with the preservative. The patients will then wrap the absorbent pad around the tube (not inside the tube), and place the sample tube back in the plastic bag. The bag is then to be placed in the freezer for 4-6 hours, and is to be kept frozen until ready to ship!
The salivary collection has a few more steps considering it is 4 samples rather than one. The timing for the salivary testing is critical, so timers are encouraged. As the patient wakes up, a timer should be set for 30 minutes later. This is when the first salivary sample (the pink tube) is to be collected. Before this test, the patient should not eat, drink, brush or floss. The second collection (green tube) is to be taken right before lunch, around noon. The third (orange tube), is to be collected in the evening before dinner, and the final collection (blue tube) before bed at night.
For all salivary collections, each tube needs to be 3/4 of the way full. The straws provided are the patient’s choice to be used. As soon as the tube is 3/4 of the way full, snap the saliva lid tightly, put into the bag in which it came, and freeze for 4-6 hours, until ready to ship. Patients are to record the date and times of the saliva collections on the bag and requisition form.
Considering the salivary hormone testing is done using 4 saliva samples, the instructions are the same as the saliva collection in the test mentioned above. However, to review them again, the timing for the salivary testing is critical, so timers are highly encouraged.
As the patient wakes up, a timer should be set for 30 minutes later. This is when the first salivary sample (the pink tube) is to be collected. Before this test, the patient is not to eat, drink, brush or floss. For the second collection (green tube), it should be collected right before lunch, around noon. The third (orange tube), is to be obtained in the evening before dinner, and the final sample (blue tube) before bed at night.
For all salivary collections, each tube needs to be 3/4 of the way full. The straws provided are to be used at the patient’s discretion. As soon as the tube is 3/4 of the way full, snap the saliva lid tightly, put into the bag in which it came, and freeze for 4-6 hours, until ready to ship. Patients are to record the date and times of the saliva collections on the bag and requisition form.
Salivary Hormone + CAR Breakdown
Aside from the basic components, the styrofoam box includes 6 colored salvia collection tubes, 6 straws, and an absorbent pad. The tests that fall under this category require 6 samples throughout the day. It is important to remember to write down the time the samples were collected as well as the time when the patient first woke up. The first sample (yellow tube) is to be taken as soon as the patient is awake but has not gotten out of bed. In order to accomplish this properly, it is best the patient sets the tube next to their bed the night before. This makes it easy to collect first thing in the morning. It is very important that the patient sets an alarm for 30 minutes after they wake up ( second test, pink tube)and for 1 hour after they wake up (third test, lavender tube). These tests are all to be done prior to eating breakfast, brushing and flossing teeth. The fourth collection (green tube) is to be taken before lunch and the fifth (orange tube) before dinner. The sixth and final sample (blue tube) is to be collected at least one hour after dinner. Just as the other saliva samples mentioned above, these tubes are to be filled 3/4 of the way, tightly closed, placed back in the bag they came in and frozen for 4-6 hours, or until they are ready to ship.
SHIPPING INSTRUCTIONS FOR ALL TESTS:
Shipping should be done Monday-Friday as this will ensure the sample will be delivered to the lab on time. Make sure all paperwork is filled out properly and place contents back in the styrofoam box in the following order:
sealed plastic bag with frozen specimen tubes
frozen ice pack
requisition form, symptom sheet, and payment (if applicable)
Next, place the lid back on the box and place the entire styrofoam box in the cardboard collection kit. Close the cardboard box and place it inside the FedEx shipping envelope provided. The patient will then write their name and address on the Billable Stamp and tear off the customer receipt for their records. Then, place on the FedEx envelope. The final step is to schedule a pick-up. In order to do this, the patient will call the FedEx toll-Free number at 1-800-463-3339 and select “schedule a pickup”. This MUST be a scheduled pick up from an address and NOT a dropbox.
* It is important to note that patients should avoid eating avocados, eggplant, tomatoes, bananas, melons, pineapples, plums, nuts, nut butter, wine, cheese and chocolate 48 hours before and during the testing period as these could impact the results.
* Patients should keep in mind that strenuous exercise, alcohol, coffee, tea, tobacco or any other product containing nicotine is to be avoided 24 hours before and during the collection period.
Labrix is a great company that allows patients a noninvasive way to have their hormone levels checked. Almost every patient who walks in the door can benefit from this test. I highly recommend this test because hormone levels can change based on age, PMS symptoms, fatigue, blood sugar issues, or stress! These results are accurate and have a decently quick turn around time. Gaining insight and taking control of your body is now easier than ever. – Kenna Vaughn, Senior Health Coach
The scope of our information is limited to chiropractic, musculoskeletal and nervous health issues as well as functional medicine articles, topics, and discussions. We use functional health protocols to treat injuries or chronic disorders of the musculoskeletal system. To further discuss the subject matter above, please feel free to ask Dr. Alex Jimenez or contact us at 915-850-0900.
*All information and photos/video content for this article are directly sourced from labrix. Please see labrix for more information and credit.
The effectiveness of chiropractic care for headaches has been proven by many research studies, which is good news for the 90% of Americans who suffer. Chiropractic is not only excellent for treating headaches, but is gentle, non-invasive, does not require medications, and is known for being free of side effects.
Chiropractic A Gentle, Effective Treatment
Headaches can range from mild to debilitating, and all the stages in between. Some people suffer from headaches only occasionally, while others are constantly dealing with headaches. Unfortunately, standard medical care can only do so much to treat headaches – and the treatments often come with side effects, such as those caused by pain medications.
Chiropractic takes a different approach than traditional Western medicine. Instead of treating the symptoms, chiropractic attempts to get to the source of the problem. Using non-invasive treatments, chiropractic works to help the body heal itself – which it can do surprisingly well when the conditions are right. Chiropractic strives to create these ideal conditions.
The two most common types of headaches most people suffer from include:
Tension headaches are the most common type of headache. The pain of a tension headache can range from fairly mild to severe. Although some headache sufferers describe tension headaches as similar to having a painful band around their heads, the symptoms of tension headaches can vary significantly from individual to individual. Symptoms of tension headaches include:
Pain that is constant, not throbbing
A feeling of tightness in the temples, forehead, back of the head, side of head or combination of these
Neck pain and stiffness
Tension headaches, as the name indicates, are caused by tension in the body – often in the neck and upper back.
Migraine headaches, while less common than tension headaches, are still a major issue for a large portion of Americans. It is estimated that approximately 13 percent of the population suffers from migraines.
Symptoms of migraines include:
Pain is often on one side of the head
Sensitivity to light
Migraines are still not fully understood by the medical community. Research has shown what happens in the brain during migraines, and there are a number of triggers that are known, but research is ongoing to determine exactly what is happening and what causes these debilitating headaches.
How Chiropractic Helps
Research has shown that chiropractic can help headache sufferers, particularly those that suffer from tension headaches. There are a number of ways that chiropractic can improve symptoms, including:
The spine and the muscles, ligaments, and tendons that surround it are prone to injury and misalignment, which can cause significant tension, nerve pain, and associated health issues. Subluxations, also referred to as spinal misalignments, can put pressure on nerves and cause muscles to tighten and even spasm. All of this can lead to considerable tension. Tension can result in headaches.
Chiropractic adjustments realign the spine, relieving pressure on nerves and helping muscles to relax.
While chiropractic adjustments can do a great deal to help relieve tension headaches, migraines are often most effectively treated through lifestyle adjustments. Changes in diet and avoidance of known triggers are considered the best way to avoid migraines and minimize symptoms.
Chiropractic care includes lifestyle advice to help patients navigate their health issues effectively, including migraines.
We live in a stressful world. Life happens; it moves so fast. Pressures coming at you from all directions. Eventually, it catches up with you, and it’s your body that bears the brunt of it. Tension is your body’s way of telling you that it is under stress – probably too muchstress.
It’s hard to escape stress in today’s society so if you find that you are exhibiting physical symptoms of stress, it might be time to make some changes. If tension headaches are one of those symptoms, you’re in good company – about 90% of adults in the US have headaches. Many of them are tension headaches.
Symptoms of Tension Headaches
Tension headaches are distinctive and can be very painful. The good news is, they are rarely an indication of a more serious condition – other than a stressful lifestyle. Some of the most common symptoms of tension headaches include:
Muscle tightness in the neck, jaw, and shoulders – may also be sore.
A Headache that originates at the back of the head and moves forward over the top and sides.
Squeezing pain or dull pressure in the head may also be described as a tight band or vice around the head.
Pain or pressure on both sides of the head equally.
Sometimes tension headache symptoms can occur prior to a migraine. In other words, a tension headache can turn into a migraine headache and may be considered a migraine trigger.
Causes of Tension Headaches
The actual cause of tension headaches is not known. Researchers have some idea of potential triggers, but recent advancements in medicine have debunked the belief that they are caused by the tightening of muscles in the scalp, shoulders, neck, and jaw. Scientific tests show that then a person has a tension headache, muscle tension does not increase. Newer theories indicate that a likelier cause involves changes neurotransmitters (chemicals in the brain) which includes serotonin. This is similar to a migraine.
While researchers do not know the exact levels of neurotransmitter fluctuations, they do have evidence that it activates the brain’s pain pathways. The tightness in the muscles could be part of the physiological changes that trigger the fluctuations in neurotransmitters, or the neurotransmitter fluctuations could cause muscle tightness.
Some common triggers of tension headaches include:
Clenching the jaw
Alcohol or drugs
Certain medications (even some medications for headaches which can cause rebound headaches)
Keeping your head in one position for too long (like using a cell phone or computer)
Neck or head injury (even old injuries)
Sleeping in a cold room or in an awkward position.
Sleeping on a worn-out mattress or the wrong pillow
Certain foods can also be triggers for tension headaches. Additives and preservatives in prepared foods, even high sodium, can cause a headache.
Sinus and allergy problems can also accompany or lead to tension headaches.
Tension Headache Treatment
Over the counter and prescription medication may be recommended for tension headaches, but a good portion of the treatment involves lifestyle changes. Relaxation techniques, dietary changes, and exercise are all common treatments for tension headaches. Patients may be advised to stop smoking, limit alcohol consumption, or avoid certain foods.
Many patients find that keeping a headache journal is very useful in pinpointing triggers. There are several headache tracking apps that you can install on your smartphone and use them to get a better handle on your headaches.
Chiropractic for Tension Headaches
Chiropractic is a very effective, natural treatment for tension headaches. In addition to recommended lifestyle changes, the chiropractor may also make adjustments to realign the vertebrae and spine. The chiropractor may also use massage and other treatments that encourage relaxation of the muscles and relieve stress. He or she will use spinal manipulation of the neck and upper back to bring the body back into alignment, relieving not only the pain but the tension as well.
Headaches are a real pain (insert eye-roll here). Many individuals suffer from them, and there are a variety of causes, symptoms, and treatment options. For some, they are a rare occurrence, while others deal with them on a weekly, or even daily, basis. They can range from minor inconveniences to full-fledged life-changing afflictions.
The first step in treating headaches is to understand the type of headache you are experiencing. Some people think they have a migraine, when in fact, they are suffering from a tension headache. While tension headaches are more common, it’s estimated by the Migraine Research Foundation that 1 in 4 U.S. Households include someone with a migraine.
Determining which headache being dealt with takes a bit of research. Individuals suffering from headaches need to ask themselves these questions to determine if they are having a migraine, or experiencing a tension headache.
When in life did the headaches begin? According to the Mayo Clinic, migraines start in adolescence or early adulthood. In contrast, tension headaches can start at any time in a person’s life. If an adult just began suffering from headaches, they are most likely tension headaches.
Where does it hurt? Migraines typically occur on one side of the head. Tension headaches affect both sides of the head and can produce a feeling of pressure at the forehead area. The location of the pain is a vital indicator of the type of headache.
What kind of pain is it? If it is a dull pain, a feeling of pressure, or tenderness around the scalp, it’s most likely a tension headache. If, on the other hand, the pain is throbbing or pulsing pain, it could be a migraine. Both headaches can offer up severe pain, just different types.
Are there any other symptoms?Migraines typically come with symptoms beyond head pain. Nausea, light and sound sensitivity, seeing bright flashing or sparkling lights, pins and needle sensations down one or both arms, or dizziness are common. Individuals who don’t experience any of these symptoms are most likely dealing with a tension headache.
Can you function? While painful and frustrating, many people with a tension headache can still perform their jobs, drive, read, and deal with daily life. A migraine is a different story. Lying in a dark, quiet room with a sleep mask on until the headache passes is how most people handle migraines. If the headache is life-disrupting, it could very well be a migraine.
Do regular painkillers work? Tension headaches can often be relieved by over-the-counter pain medications. Migraines don’t budge with these treatments. Once a migraine is in full force, the sufferer generally must ride it out. If a headache reacts well to a couple of non-prescription painkillers, it’s most likely a tension headache.
The majority of individuals will, unfortunately, deal with a headache at one point in their lives. It’s important to note that tension headaches are much more common than migraines, but that doesn’t rule out the possibility of a headache being a migraine. The answers to the above questions combined give insight as to the type of a headache occurring, and how best to proactively handle the treatment. No matter the type of headache, if the pain is severe, or begins after a head injury, seek medical treatment immediately.
45 million Americans suffer headaches on a regular basis. There are the traditional methods used to treat them, which include taking over the counter medications or taking pharmaceutical concoctions to eliminate pain and reduce swelling. However, none of these solutions provide permanent relief that address the core of the problem.
In recent years, people throughout the country are seeking alternative forms of therapy for all types of conditions, especially headaches. One treatment that is promising for physical and other types of pain is chiropractic treatment.
This form of alternative care has been used for over a hundred years and is a regular part of the American healthcare delivery system. Insurance providers are growing and are willing to pay for chiropractic because of its effectiveness.
Chiropractic school begins by studying human anatomy in great detail, like other medical professionals. In addition to looking at how the body works together physically, training primarily revolves around the diagnosis and treatment of misalignments in the spine known as subluxations.
Theses subluxations compress nerve tissue that affects organ function, soft tissue like muscle, ligaments and tendons and can eventually manifest as other health problems if not treated.
Once the nerves are disrupted pain will result. While it usually manifests itself as physical pain, this is not always the case. In some instances, the person may experience difficulties with sleep or other routine habits.
How Does Chiropractic Help People Who Suffer From Headaches
On the first visit with a chiropractor, a review of health history will be completed. These include x-rays (if they are needed), in order to determine the type of nerve blockage that may be occurring. They will listen to the patient, make an assessment, and determine what type/s of treatment is best.
With headaches, there is usually a misalignment (subluxation) in the cervical spine. This may be accompanied by muscles that are tight in the neck, shoulders and surrounding area. Pressure on the nerves can cause sharp stabbing pain or a continual throbbing pain in the region.
The chiropractor will assess the area and then begin treatment, known as a chiropractic adjustment. The adjustment is what relieves the pressure and pain. The relief is usually instantaneous, with an increase in positive symptoms for the following few hours.
Chiropractors don’t just focus on relieving symptoms but getting to the root cause and correcting the problem. That is why additional treatments/adjustments are often required, as one adjustment is usually not enough. A chiropractor will take time to educate patients on treatment, therapy exercises, fitness, nutrition, sleep, and regular adjustments.
If you’re tired and no longer want to suffer from headaches, see how beneficial chiropractic care can be, then please give us a call to schedule an appointment!
Injury Medical Clinic: Chiropractic Care Migraines & Headaches
My treatment with Dr. Alex Jimenez has been helping me by simply making me less tired. I’m not experiencing as many headaches. The headaches are going down dramatically and my back feels much better. I would highly recommend Dr. Alex Jimenez. He’s very friendly, his staff is very friendly and everybody goes well beyond what they can do to help you. – Shane Scott
A majority of the populations has suffered from this well-known nagging health issue, however, did you know that headaches can sometimes be caused by neck pain? While these headaches are commonly referred to as as cervicogenic headaches, other types of headaches, such as cluster headaches and even migraines, have also been determined to be caused by neck pain. Neck pain can develop due to a variety of reasons and it can vary tremendously from mild to severe.
Therefore, it’s fundamental to seek a proper diagnosis if you’ve experienced headaches or neck pain to determine the root cause of your symptoms as well as to properly determine what treatment option will be best for your specific health issue. Healthcare professionals will assess your upper back, or the cervical spine, including your neck, base of the skull and cranium, and also all the surrounding muscles and nerves to find the source of your symptoms. Before seeking help from a doctor, however, it’s important to understand how neck pain can cause headaches. Below, we will discuss the anatomy of the cervical spine, or neck, as well as demonstrate how neck pain is connected to headaches.
How Neck Pain Causes Headaches
The muscles located between the shoulder blades, upper portion of the shoulders and those surrounding the neck, or cervical spine, may all cause neck pain if they become too tight or stiff. This can generally occur due to trauma or damage from an injury, as well as in consequence to bad posture or poor sitting, lifting or work habits. The tight muscles will result in your neck joints feeling stiff or compressed and it can even radiate pain towards your shoulders. Over time, the balance of the neck muscles changes and those specific muscles which are meant to support the neck become weak and can ultimately begin to make the head start to feel heavy, increasing the risk of experiencing neck pain as well as headaches..
Furthermore, the roots of the upper 3 cervical spinal nerves, which are found at C1, C2, and C3, share a pain nucleus, which routes pain signals to the brain, along with the trigeminal nerve. The trigeminal nerve is the main sensory nerve that is in charge of carrying messages from the face to your brain. Because of the shared nerve tracts, pain is misunderstood and thus “felt” by the brain as being located in the head. Fortunately, many healthcare professionals are experienced in the assessment and correction of muscular imbalances which may lead to neck pain and headaches. Moreover, they can help to relieve muscle tension, enhance muscle length and joint mobility, and retrain correct posture.
What Causes Neck Pain and Headaches?
Cervicogenic headaches, otherwise known as “neck headaches”, are caused by painful neck joints, tendons or other structures surrounding the neck, or cervical spine, which may refer pain to the bottom of the skull, to your face or head. Researchers believe that neck headaches, or cervicogenic headaches, account for approximately 20 percent of all headaches diagnosed clinically. Cervicogenic headaches and neck pain are closely associated with each other, although other types of headaches can also cause neck pain.
This type of head pain generally starts because of an injury, stiffness or lack of proper functioning of the joints found at the top of your neck, as well as tight neck muscles or swollen nerves, which could trigger pain signals that the brain then interprets as neck pain. The usual cause of neck headaches is dysfunction in the upper three neck joints, or 0/C1, C1/C2, C2/C3, including added tension in the sub-occipital muscles. Other causes for cervicogenic headaches and neck pain can include:
Cranial tension or trauma
TMJ (JAW) tension or altered bite
The Link Between Migraines and Neck Pain
Neck pain and migraines also have an intricate connection with each other. While in some cases, severe trauma, damage or injury to the neck can lead to severe headaches like migraine, in other situations neck pain might be the result of a migraine headache. However, it’s never a good idea to assume that one is the end result of the other. Seeking treatment for neck pain when the reason for your concern is in fact a migraine, often will not lead to effective pain management or pain relief. The best thing that you can do if you’re experiencing neck pain and headaches is to seek immediate medical attention from a specialized healthcare professional in order to determine the cause of your pain, as well as to determine the root cause of the symptoms.
Unfortunately, neck pain, as well as a variety of headaches, are commonly misdiagnosed or even sometimes go undiagnosed for an extended period of time. As a matter of fact, one of the top reasons as to why neck pain may be so difficult to treat is primarily because it takes a long time for people to take this health issue seriously and seek a proper diagnosis. Waiting an extended amount of time to take care of your neck pain, especially after an injury, may lead to acute pain and it may even make the symptoms more difficult to control, turning them into chronic pain. By the time a patient seeks diagnosis for their neck pain, it may have already been a persistent problem. Also, the most frequent reasons people seek treatment for neck pain and headaches include:
Chronic migraines and headaches
Restricted neck function, including difficulties moving the head
Soreness in the neck, upper back and shoulders
Stabbing pain and other symptoms, particularly in the neck
Pain radiating from the neck and shoulders to the fingertips
Aside from the symptoms mentioned above, individuals with neck pain and headaches can also experience additional symptoms, including nausea, diminished eyesight, difficulty concentrating, severe fatigue, and even difficulty sleeping.While there are circumstances in which the cause of your headaches or neck pain may be apparent, such as being in a recent automobile accident or suffering from sport-related trauma, damage or injuries, in several instances, the cause may not be quite as obvious.
Because neck pain and headaches can also develop as a result of bad posture or even due to nutritional problems, it’s fundamental to find the origin of the pain to increase the success of treatment, in addition to enabling you to prevent the health issue from happening again in the future. It’s common for a healthcare professional to devote their time working with you to ascertain what could have caused the pain in the first place.
A Health Issue You Can’t Ignore
Neck pain is typically not a problem which should be ignored. You may think that you’re only experiencing minor neck discomfort and that it’s irrelevant to any other health issues you may be having, but more frequently than not, you can’t know for sure till you receive a proper diagnosis for your symptoms. Patients who seek immediate medical attention and treatment for their neck-centered problems are surprised to learn that some of the other health issues they may be experiencing may actually be correlated, such as in the case of neck pain and headaches. Thus, even in the event that you think you can “live with” not being able to turn your neck completely, other health issues can develop, and these problems might be more challenging to deal with.
There are circumstances in which a pinched nerve in the neck is the main reason for chronic tension headaches, where a previous sports injury that was not properly addressed before is now the cause of the individual’s limited neck mobility and in which a bruised vertebrae at the base of the neck induces throbbing sensations throughout the spine, which radiates through the shoulders into the arms, hands and fingers. You might also blame your chronic migraines on a hectic schedule and stressful conditions, however, it might truly be a consequence of poor posture and the obligated hours that you spend hunched over a computer screen. Untreated neck pain might even lead to problems you might never expect, such as balance problems or trouble gripping objects. This is because all the neural roots located on the upper ligaments of the cervical spine, or neck, are connected to other parts of the human body, from your biceps to each one of your small fingers.
Working with a healthcare professional to relieve the root cause of your neck pain and headaches may significantly enhance your quality of life and may be able to eliminate other symptoms from turning into a significant problem. While the most common causes of chronic migraines are generally caused by another health issue or nutritional deficiency, you might also be amazed to learn how often the outcome is something which may be resolved with concentrated exercises and stretches recommended by a healthcare professional, such as a chiropractor. Additionally, you may understand that the health issues you’ve been having often develop from compressed, pinched, irritated or inflamed nerves in your upper cervical nerves.
Dr. Alex Jimenez’s Insight
Although it may be difficult to distinguish the various types of headaches, neck pain is generally considered to be a common symptom associated with head pain. Cervicogenic headaches are very similar to migraines, however, the primary difference between these two types of head pain is that a migraine occurs in the brain while a cervicogenic headache occurs in the base of the skull or in the cervical spine, or neck. Furthermore, some headaches may be caused by stress, tiredness, eyestrain and/or trauma or injury along the complex structures of the cervical spine, or neck. If you are experiencing neck pain and headaches, it’s important to seek help from a healthcare professional in order to determine the true cause of your symptoms.
Treatment for Neck Pain and Headaches
Foremost, a healthcare professional must determine the cause of an individual’s symptoms through the use of appropriate diagnostic tools as well as to make sure they have the utmost success in relieving the headache and neck pain without prolonging the duration of the symptoms and extra cost of incorrect therapy. Once an individual’s source of neck pain and headaches has been diagnosed, the kind of treatment a patient receives ought to be dependent on the type of headache. As a rule of thumb, treatment starts once the diagnosis has been made. A healthcare professional will work with you to create a treatment plan that’s appropriate for your specific health issues. In your sessions, you’ll be taken through procedures that help build flexibility and strength.
Chiropractic care is a well-known, alternative treatment option which focuses on the diagnosis, treatment and prevention of a variety of musculoskeletal and nervous system injuries and/or conditions. A doctor of chiropractic, or chiropractor, can help treat neck pain and headache symptoms by carefully correcting any spinal misalignments, or subluxations, in the cervical spine or neck, through the use of spinal adjustments and manual manipulations, among other therapeutic techniques. Chiropractors, as well as physical therapists, may also utilize a combination of gentle Muscle Energy Techniques, muscle building, joint slides, cranio-sacral therapy, and specific posture and muscle re-education to lower the strain being placed on the structures surrounding the cervical spine. The staff will also help you understand how to better position yourself during your daily life to prevent relapses, like ergonomic and posture tips. Contact a healthcare professional in order for them to be able to assist you immediately.
In cases where alternative treatment options have been utilized without any results, or sometimes simply being used together with other complementary treatment approaches, pain drugs and/or medications may be contemplated, such as non-steroidal anti-inflammatory drugs (NSAIDs), anti-seizure agents such as gabapentin, tricyclic anti-depressants, or migraine prescriptions. If pain medications prove ineffective, then injections may be contemplated, including peripheral nerve blocks, atlantoaxial joint block administered at C1-C2, or aspect joint blocks administered in C2-C3. Surgical interventions may also be other treatment options, however, healthcare professionals suggest attempting all other treatment options before considering surgery. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Many headaches that people classify as migraines are actually not migraines at all. Two of the most common headaches confused with migraines are sinus headaches and occipital neuralgia.
The condition can be debilitating but there are treatments, including chiropractic, that are very effective. Understanding occipital neuralgia can help patients better manage it so they can minimize the pain and symptoms of the condition.
What Is Occipital Neuralgia?
Occipital neuralgia is a neurological condition that affects the occipital nerves which run from the top portion of the spinal cord, through the scalp, transmitting messages to and from the brain. There are two greater occipital nerves, one on each side of the head, from between the vertebrae located in the upper neck through the muscles that are located at the base of the skull and back of the head.
While they do not cover the areas on or near the ears or over the face, they can extend over the scalp as far as the forehead. When those nerves are injured or become inflamed, occipital neuralgia is the result. A person with this condition may experience pain at the base of their skull or the back of their head.
What Are The Symptoms Of Occipital Neuralgia?
Pain is the prevalent symptom of occipital neuralgia. It often mimics the pain of migraine headaches or cluster headaches and is described as throbbing, burning, and aching.
There may also be intermittent shooting or shocking pain. Typically, the pain begins at the base of the skull but may radiate along the side of the scalp or in the back of the head. Other symptoms include:
Pain is experienced on one side (but sometimes both sides)
Pain behind the eye of the side that is affected
Tenderness in the scalp
Sensitivity to light
Pain triggered by neck movement
What Causes Occipital Neuralgia?
Irritation or pressure to the occipital nerves are what actually cause the pain. This may be due to tight muscles in the neck that squeeze or trap the nerves, injury, or inflammation.
However, much of the time doctors are unable to determine the cause. There are several medical conditions linked to occipital neuralgia:
Tight neck muscles
Trauma or injury to the back of the head
Tension in the neck muscles
Inflammation of the blood vessels in and around the neck
Cervical disc disease
What Are The Treatments For Occipital Neuralgia?
Occipital neuralgia treatment focuses on pain relief. It often begins with conservative treatments that include:
In more severe cases the patient may be prescribed a stronger anti-inflammatory medication, muscle relaxants or in some cases an anticonvulsant medication.
If these therapies are not effective or do not bring about the desired level of pain relief, then doctors may recommend percutaneous nerve blocks and steroids. Sometimes surgery is recommended in cases where the pain is severe, chronic, and is unresponsive to more conservative treatments.
Chiropractic For Occipital Neuralgia
Chiropractic was once considered an “alternative” treatment for occipital neuralgia, but now it is often a regular part of recommended patient care. The advantage of chiropractic over medication or surgery is that chiropractic does not come with the side effects of drugs or the risks of surgery.
Another advantage is that chiropractic seeks to correct the root of the problem, not just manage the pain like other treatments.
Chiropractic treatment for occipital neuralgia may include lift adjustments, heat, massage, and traction. This will bring the body back into proper alignment and take the pressure off of the nerves as it loosens the neck muscles.
The patient stands a better chance of staying pain free when taking this treatment route.
Injury Medical Clinic: Doctor Of Chiropractic Near Me
CBD research currently being conducted is showing its medical potential. This has opened doors for antipsychotic, anticancer and anti-inflammatory treatmentoptions among a variety of others. Scientists from all over are publishing studies that are proving CBD is one of the most effective and favorable cannabinoids that promotes proper function of the body’s systems.
Five Properties Of CBD
CBD Medical Benefits
1. Inhibits Cancer Cell Growth
Studies have supported this claim. By way of Proapoptotic action or apoptosis, Cannabidiol, Tetrahydrocannabinol, Cannabigerol and Cannabichromene in this order are extremely effective in tumor growth reduction in rats and cancerous human prostate cells. Research is still ongoing, but understanding that these cannabinoids stimulate the body’s process of killing cells that no longer function properly or at their optimal level. In traditional chemotherapy both healthy and cancerous cells are destroyed and only works when the cancer cells are replicating more frequently than healthy cells. CBD treatment promotes the body’s natural immune response to cells that are not functioning properly, which eradicates tumors.
2. Pain Reducer
The most common reason people start using marijuana despite its psychoactive affects, is that it also functions, as a pain reliever! People with chronic pain that are tired of taking pain killing opiates, rely on cannabinoid products to deal with pain and eliminate its source, commonly inflammation. Inflammation is the body’s natural response to injury, which floods the injured area with blood and nutrients to aid in rehabilitation. But inflammation creates secondary problems, among them pain and discomfort. Through stimulation of nutrients in the area that is injured, CBD creates negative feedback to inflammatory reactions, as the nutrients that came with the inflammation are already there.
3. Treats Anxiety
Anxiety along with PTSD affects over 40 million adults in the U.S. Valium and Xanax is what is normally used to treat these conditions. However, CBD products are becoming the preferred treatment, as they have none of the side effects or dependency issues. The effects of CBD have been observed thoroughly by experts and studies have proved its effectiveness, as a dependable alternative for mental disorders. Two receptors in the human brain responsible for sending out Adrenaline and Serotonin are the α2-adrenergic receptor agonist and 5-HT1A receptor antagonist. These receptors both are related to anxiety, depression, insomnia, and other mental disorders when imbalanced.
4. Strengthens The Immune System
Phytocannabinoids are able to balance, reinforce and strengthen the immune system. Cannabinoid products taken daily, work in regulating the immune system. This increases the body’s detection of foreign and potentially dangerous organisms, which include cancer cells.
5. Prevents Muscle Spasms
CBD contains chemically antispasmodic properties. Athletes from all sports love CBD and what it can do. It is a preferred supplement and these oils have proven to prevent muscle spasms and soreness. This is done through lubricating the potassium and calcium pumps within the muscle tissue.
CBD is finding its place, slowly, but surely. It is one of natures own medicines and it is our job to discover and figure how to utilize these properties. Consult a doctor before beginning any treatment of diagnosed or undiagnosed diseases with CBD. For the more severe diseases like diabetes, schizophrenia, epilepsy, which, CBD can treat, but only when used properly.
The therapeutic effects of Cannabidiol or CBD, is often the cannabinoid’s pain soothing effect that gets talked about. Headaches are the most common source of pain for the general population. Therefore, it makes sense that CBD use for migraines and headaches is an obvious.
Migraines and headaches can be a medical mystery, but usually their causes are brought on by problems with brain stem centers. The only treatments thus far, has been painkillers i.e. paracetamol or ibuprofen. Triptan medications, which constricts the blood vessels in order to block pain pathways in the brain are used as well. But is there a better more natural way to treat headaches and migraines?
Cannabis Has Been Treating Headaches For Quite Awhile
CBD oil for headaches is not a new therapy. Cannabis is mentioned as treatment for headaches in ancient texts that go back thousands of years. However, its use didn’t become familiar in the west until the 19th century when it would be prescribed by doctors as a tincture.
Today conclusive clinical evidence is incomplete, as far as, medical cannabis and hemp oil use for headaches. But scientists do know when it comes to CBD oil use for headaches and migraines, that the endocannabinoid system is working in conjunction with the compounds.
The Endocannabinoid System & Migraines
A theory brought about a possible contributing cause of migraines is dysfunction in the endocannabinoid system or (ECS). This is the body’s network of receptors and cannabis-like chemicals that respond and regulate:
Researchers have noted ECS mechanisms that could have a connection to migraine attacks.
Anandamide (AEA) is one of the prime endocannabinoids in the body. It is both a painkiller and has been found to power the serotonin 5-HT1A receptors.
The clearest record of endocannabinoid dysfunction that contributes to migraines is from a study in 2007 at the University of Perugia and published in the Journal of Neuropsychopharmacology. Researchers measured endocannabinoid levels in the cerebrospinal fluid of patients with chronic migraines and found significantly lower amounts of Anandamide. These findings, could “reflect an impairment of the endocannabinoid system in these patients, which may contribute to chronic head pain.”
Clinical Endocannabinoid Deficiency? Migraines Could Be A Sign
The link between lower levels of endocannabinoids in migraine patients has contributed to the formulation of what has been termed Clinical Endocannabinoid Deficiency. This theory was developed by Neurologist and Cannabinoid Researcher Dr. Ethan Russo.
The theory comes from how many brain disorders are inadequate or missing neurotransmitters like acetylcholine. Russo has suggested “a comparable deﬁciency in endocannabinoid levels might manifest similarly in certain disorders that display predictable clinical features as sequelae of this deﬁciency.”
In an interview he describes how, “If you don’t have enough endocannabinoids you have pain where there shouldn’t be pain. You would be sick, meaning nauseated. You would have a lowered seizure threshold. And just a whole litany of other problems.”
Russo relates these deficiencies can be addressed through introduction to plant cannabinoids, which act almost like those found in the body, by stimulating the endocannabinoid receptors. There is CB1 agonists such as Marinol and Nabilone have been tested for migraines, Russo suggests that the ECS needs a “gentle nudge” rather than a “forceful shove” given by these synthetic alternatives. He suggests small doses of whole plant cannabis, which contain “additional synergistic and buffering components, such as CBD and cannabis terpenoids.”
Cannabidiol CBD Oil: Migraines
Russo in particular singles out CBD (Cannabidiol) in that it brings balance to the endocannabinoid system. In his interview with Martin Lee from Project CBD he says, “cannabidiol is an endocannabinoid modulator, in other words, when given chronically it actually increases the gain of the system…. So, if there’s too much activity in a system, homeostasis requires that it be brought back down. If there’s too little, it’s got to come up. And that’s what cannabidiol can do as a promoter of endocannabinoid tone.”
Scientists still are not exactly sure of how CBD interacts with the endocannabinoid system. Unlike psychoactive THC, CBD does not bind with any of the endocannabinoid receptors. Instead it activates a host of other non-endocannabinoid receptors, which work in the development and treatment of migraines, i.e. the 5-HT1A serotonin and TRPV-1 receptors.
Another possible explanation is CBD’s role as a fatty acid amide hydrolase (FAAH) inhibitor, which breaks down anandamide in the body. By inhibiting its production the theory is that it might lead to higher levels of pain relieving endocannabinoid. This is something that would benefit migraine sufferers.
Lack Of Clinical Evidence
Currently there are no gold standard, double blind, placebo clinical studies published to back up any accounts that suggest CBD or cannabis is an effective treatment for headaches and migraines.
One placebo controlled study has been conducted, documenting the safety and efficacy of synthetic THC medication Dronabinol for migraines. However, the results are still pending.
The largest study to take place was done from a retrospective basis. It was published in 2016 and found that out of 121 participants that suffer from migraines and were prescribed medical cannabis by a doctor; 103 participants found their migraine frequency reduced by half.
Can Cannabidiol Cause A Headache?
There are those who tried CBD and noted persistent headaches and even migraines. Does CBD cause headaches, even though the research suggests the contrary.
Those who reported getting headaches after taking CBD oil noted that the oil they bought was low quality, and the ingredients used included ethanol, various alcohols, preservatives and harsh chemicals.
When purchasing CBD oil for migraines or other conditions, get the best quality, not the cheapest!
How To Use CBD For Head Pain
There are different ways to apply CBD oil for headaches. If taking CBD for tension headaches, migraines or general headaches, there are many way to administer. Probably the simplest and most effective ways of using CBD is the sublingual method.
With this method one places a few drops of oil underneath the tongue. There it permeates through the membrane and makes its way to where it needs to go.
This isn’t the only method and many others can be just as effective. Make sure to do research when looking for CBD products online and the methods of administering these products.
Just like the nature of migraines, CBD for headaches and migraines is still not completely and scientifically understood. But with continued research of CBD and Cannabinoid based medicine, the future of sufferers of headaches and migraines will get better.
Injury Medical Clinic: Migraine Treatment & Recovery
Concussions are traumatic brain injuries that affect brain function. Effects from these injuries are often temporary but can include headaches, problems with concentration, memory, balance and coordination. Concussions are usually caused by a blow to the head or violent shaking of the head and upper body. Some concussions cause loss of consciousness, but most do not. And it is possible to have a concussion and not realize it. Concussions are common in contact sports, such as football. However, most people gain a full recovery after a concussion.
Blurred eyesight or other vision problems, such as dilated or uneven pupils
Ringing in the ears
Nausea or vomiting
Delayed response to questions
Continued or persistent memory loss
Irritability and other personality changes
Sensitivity to light and noise
Mood swings, stress, anxiety or depression
Disorders of taste and smell
Rigidity and inflexibility
Lack of empathy
Lack of motivation or initiative
Depression or anxiety
Symptoms In Children
Concussions can present differently in children
Loss of appetite
Loss of interest in favorite toys or activities
Unsteadiness while standing
Memory loss and failure to form new memories
Inability to remember things that happened before the injury
Due to failure in recall
Inability to remember things that happened after the injury
Due to failure to formulate new memories
Even short memory losses can be predictive of outcome
Amnesia may be up to 4-10 times more predictive of symptoms and cognitive deficits following concussion than is LOC (less than 1 minute)
Return To Play Progression
Baseline: No Symptoms
As the baseline step of the Return to Play Progression, the athlete needs to have completed physical and cognitive rest and not be experiencing concussion symptoms for a minimum of 48 hours. Keep in mind, the younger the athlete, the more conservative the treatment.
Step 1: Light Aerobic Activity
The Goal: Only to increase an athlete’s heart rate.
The Time: 5 to 10 minutes.
The Activities: Exercise bike, walking, or light jogging.
Absolutely no weight lifting, jumping or hard running.
Step 2: Moderate activity
The Goal: Limited body and head movement.
The Time: Reduced from typical routine.
The Activities: Moderate jogging, brief running, moderate-intensity stationary biking, and moderate-intensity weightlifting
Step 3: Heavy, non-contact activity
The Goal: More intense but non-contact
The Time: Close to typical routine
The Activities: Running, high-intensity stationary biking, the player’s regular weightlifting routine, and non- contact sport-specific drills. This stage may add some cognitive component to practice in addition to the aerobic and movement components introduced in Steps 1 and 2.
Step 4: Practice & full contact
The Goal: Reintegrate in full contact practice.
Step 5: Competition
The Goal: Return to competition.
After head trauma microglial cells are primed and can become over active
To combat this, you must mediate the inflammation cascade
Prevent repeated head trauma
Due to priming of the foam cells, response to follow-up trauma may be far more severe and damaging
What Is Post-Concussion Syndrome (PCS)?
Symptoms following head trauma or mild traumatic brain injury, that can last weeks, months or years after injury
Symptoms persist longer than expected after initial concussion
More common in women and persons of advanced age who suffer head trauma
Severity of PCS often does not correlate to severity of head injury
Loss of concentration and memory
Ringing in the ears
Noise and light sensitivity
Rarely, decreases in taste and smell
Concussion Associated Risk Factors
Early symptoms of headache after injury
Mental changes such as amnesia or fogginess
Prior history of headaches
Evaluation Of PCS
PCS is a diagnosis of exclusion
If patient presents with symptoms after head injury, and other possible causes have been ruled out => PCS
Use appropriate testing and imaging studies to rule out other causes of symptoms
Headaches In PCS
Often “tension” type headache
Treat as you would for tension headache
Improve stress coping skills
MSK treatment of the cervical and thoracic regions
Adrenal supportive/adaptogenic herbs
Can be migraine, especially in people who had pre-existing migraine conditions prior to injury
Reduce inflammatory load
Consider management with supplements and or medications
Reduce light and sound exposure if there is sensitivity
Dizziness In PCS
After head trauma, always assess for BPPV, as this is the most common type of vertigo after trauma
Dix-Hallpike maneuver to diagnose
Epley’s maneuver for treatment
Light & Sound Sensitivity
Hypersensitivity to light and sound is common in PCS and typically exacerbates other symptoms such as headache and anxiety
Management of excess mesencephalon stimulation is crucial in such cases
Other light blocking glasses
Cotton in ears
Treatment Of PCS
Manage each symptom individually as you otherwise would
Manage CNS inflammation
Fish oil/Omega-3s – (***after r/o bleed)
Cognitive behavioral therapy
Mindfulness & relaxation training
Brain balancing physical therapy exercises
Refer for psychological evaluation/treatment
Refer to mTBI specialist
mTBI is difficult to treat and is an entire specialty both in the allopathic and complementary medicine
Primary objective is to recognize and refer for appropriate care
Pursue training in mTBI or plan to refer to TBI specialists
“A Head for the Future.” DVBIC, 4 Apr. 2017, dvbic.dcoe.mil/aheadforthefuture.
Alexander G. Reeves, A. & Swenson, R. Disorders of the Nervous System. Dartmouth, 2004.
“Heads Up to Health Care Providers.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 16 Feb. 2015, www.cdc.gov/headsup/providers/.
“Post-Concussion Syndrome.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 28 July 2017, www.mayoclinic.org/diseases-conditions/post- concussion-syndrome/symptoms-causes/syc-20353352.
Origin: The most common cause of migraines/headaches can relate to neck complications. From spending excessive time looking down at a laptop, desktop, iPad, and even from constant texting, an incorrect posture for extended periods of time can begin to place pressure on the neck and upper back leading to problems that can cause headaches. The majority of these type of headaches occurs as a result of tightness between the shoulder blades, which in turn causes the muscles on the top of the shoulders to also tighten and radiate pain into the head.
Tension headaches are the most prevalent types of headaches, occurring more often in women than in men. Research shows that 48 percent of women and 38 percent of men suffer from tension headaches.
Each year, patients spend more than $2 billion on over the counter headache medications. In fact, people spend a lot of money and effort seeking remedies for headaches. From prescription medication to over the counter drugs to alternative headache treatments like meditation, acupuncture, and chiropractic.
In fact, chiropractic is a proven treatment for these types headaches, but there is more to it than just adjustments. Chiropractic offers a whole body approach to treatment that can not only relieve the pain of these headaches, but help prevent them as well.
What Are Tension Headaches?
The most common type of headache is the tension headache which is described as pain ranging from mild to moderate that feels like a tight band is wrapped around the head. While stress can be a factor in the cause of these headaches, it still isn’t well understood how these headaches originate. Symptoms of a tension headache include:
Aching, dull pain in the head
Sensation of pressure or tightness on the back and sides of the head or across the forehead
Tenderness in the shoulder muscles, neck, and scalp
There are two categories of tension headaches: chronic and episodic. There are two primary factors that identify each type. The length of the headache and the frequency can help you determine which type of tension headache you have.
Chronic Tension Headaches
Length of Headache – hours and can be continuous
Frequency of Headache – occur 15 days or more a month for three or more months
Episodic Tension Headaches
Length of Headache – half hour to a week
Frequency of Headache – occur less than 15 days a month for three or more months
There are two primary risk factors for tension headaches:
Women – Research shows that nearly 90 percent of women will experience tension headaches throughout the course of their life. Only 70 percent of men will experience tension headaches in their lifetime.
Middle Age – Tension headaches increase as people approach 40 and peak at middle age, or when a person is in their 40s. However, anyone can get a tension headache, regardless of age.
Lifestyle Changes To Treat Tension Headaches
A chiropractor can treat tension headaches through traditional spinal manipulation and adjustments, but they also provide advice on lifestyle and nutrition. Several things that your chiropractor may suggest include applying heat or ice to the area around your neck, shoulders, or head. A warm bath or shower may also help.
Stress management is another way that you can learn to manage and prevent tension headaches. This is typically a combination of minimizing stress in your life and learning relaxation techniques. Your chiropractor may also help you improve your posture. Poor posture is a very common contributing factor for many types of headaches.
Chiropractic for Tension Headaches
Your Doctor of Chiropractic will sit down with you to discuss your history, including your headaches. He or she will conduct diagnostic tests including x-rays, MRIs and other to determine if there are underlying causes for your headaches. They will recommend various lifestyle changes including dietary changes and exercises that you can do.
Your doctor may also perform chiropractic adjustments, or spinal manipulation which will help return the body to proper balance, improving spinal function and alleviating stress on the body and system. This helps to relieve pain as an immediate treatment, but when performed consistently, chiropractic can also help prevent tension headaches, allowing you to live pain free.
Injury Medical Clinic: Migraine Treatment & Recovery
Headaches are very common health issues, and lots of people treat themselves by using basic painkillers, drinking additional water, with rest, or by simply waiting for the headache to go away on its own. As a matter of fact, a headache is among the most common reasons for doctor office visits.
Just about everyone will experience a headache sometime during their life. Most headaches are not caused by serious or sinister conditions. However, people understandably worry if headaches feel different, whether they’re especially severe, particularly frequent or unusual in any other manner. But, the most common concern is whether the headache may be a symptom of an underlying health issue, such as a brain tumor.
The following article discusses headaches generally. It explains the various types of headaches you may experience and describes those very rare situations where a headache may be a symptom of a serious disease.
Types of Headaches
Headaches can be categorized as primary, or they can be classified as secondary, meaning they are a side-effect of another injury or condition.
A healthcare professional can usually determine the possible cause of your headaches from speaking to you and examining you. When they have found the cause then you’ll have the ability to decide the best treatment approach for your head pain symptoms. This may involve taking drugs only when you get the headaches, taking daily medication to stop them altogether, and/or even stopping medication you’re already taking. Very occasionally, headaches may need further diagnosis to rule out more serious underlying causes. Chiropractic care and physical therapy are also commonly utilized to help treat headaches. Below, we will discuss the different types of headaches.
The most common types of headaches, by far, are tension headaches and migraines.
Tension headaches are generally felt as a band around the forehead. They may last for many days. They may be tiring and uncomfortable, but they don’t normally disturb sleep. Most people can carry on working with a tension headache. These often have a tendency to worsen as the day progresses, however, they aren’t usually made worse with physical activities, though it’s not strange to be somewhat sensitive to bright light or noise.
Migraines are also very common types of headaches. A typical migraine is described as a throbbing sensation. Headaches which are one-sided, headaches which throb and headaches that make you feel sick are more inclined to be migraines compared to anything else. Migraines are often severe enough to be disabling. Some individuals will need to go to bed to sleep off their aggravation.
Cluster headaches are extremely severe headaches, sometimes called “suicide headaches”. They occur in clusters, often every day for a number of days or maybe weeks. Then they vanish for weeks on end. These types of headaches are rare and often occur particularly in adult male smokers. They’re intense, one-sided headaches, which are very disabling, meaning they stop routine activity. People often describe them as the worst pain they have ever felt. Cluster headaches are typically one-sided. Patients frequently have a red watery eye on the other hand, a stuffy runny nose and a droopy eyelid.
Chronic Tension Headaches
Chronic tension headaches (or chronic daily headache) is generally caused by muscle tension in the back of the neck and affects women more frequently than men. Chronic means that the problem is persistent and ongoing. These headaches can develop due to neck injuries or tiredness and may worsen with drug/medication overuse. A headache that occurs virtually every day for 3 weeks or more is known as a chronic daily headache or a chronic tension headaches.
Medication-overuse headaches or medication-induced aggravation, is an unpleasant and long-term headache. It’s brought on by taking painkillers usually meant for headaches. Unfortunately, when painkillers are taken regularly for headaches, the body reacts by creating additional pain sensors in the brain. Finally, the pain sensors are so many that the head becomes super-sensitive and the headache won’t go away. Individuals who have these headaches often take an increasing number of painkillers to attempt and feel much better. But, the painkillers may have regularly long ceased to work. Medication-overuse headaches are the most common cause of secondary headache.
Exertional Headaches/Sexual Headaches
Exertional headaches are headaches associated with physical activity. They may get severe very quickly following a strenuous activity like coughing, running, with intercourse, and straining with bowel movements. They’re more commonly experienced by patients that also have migraines, or who have relatives with migraine.
Headaches associated with sex particularly worry patients. They can occur as sex starts, at orgasm, or following sex. Headaches at orgasm would be the most common type. They are generally acute, at the back of the head, behind the eyes or all around. They last about twenty minutes and aren’t usually an indication of any other underlying health issues or problems.
Exertional and sexual intercourse-related headaches aren’t typically an indication of serious underlying problems. Very occasionally, they can be a sign that there is a leaky blood vessel on the surface of the brain. As a result, if they are marked and repeated, it’s sensible to talk about them with your healthcare professional.
Primary Stabbing Headaches
Primary traumatic headaches are sometimes called “ice-pick headaches” or “idiopathic stabbing headache”. The term “idiopathic” is used by doctors for something that comes without a clear cause. These are brief, stabbing headaches that are extremely sudden and severe. They generally last between 5 and 30 seconds and they occur at any time of the day or night. They feel as though a sharp object, like an ice pick, is being stuck into your head. They frequently occur in or just behind the ear and they are sometimes quite frightening. Even though they aren’t migraines they’re more prevalent in those who suffer from migraines, nearly half of individuals who experience migraines have principal stabbing headaches.
They are often felt at the place on the head where the migraines have a tendency to happen. Primary stabbing headaches are too brief to take care of, even though migraine prevention medications may reduce their number.
Hemicrania continua is a major chronic daily headache. It typically induces a continuous but shifting pain on one side of the brain. The pain is generally continuous with episodes of severe pain, which can last between 20 minutes and several days. During those episodes of severe pain there may be other symptoms, such as watering or redness of the eye, runny or blocked nose, and drooping of the eyelid, around precisely the same side as the aggravation. Similar to a migraine, there may also be sensitivity to light, feeling sick, such as nausea, and being sick, such as vomiting. The headaches do not go away but there may be periods when you don’t have any headaches. Hemicrania continua headaches respond to medicine called indometacin.
Trigeminal neuralgia causes facial pain. The pain consists of very short bursts of electric shock-like sensations in the face, particularly at the area of the eyes, nose, scalp, brow, lips or limbs. It’s usually one-sided and is more common in people over age 50. It may be triggered by touch or a light breeze on the surface area.
Occasionally, headaches have underlying causes, and treatment of the headache involves treating the cause. Individuals often fear that headaches are caused by serious illness, or by high blood pressure. Both of these are extremely uncommon causes of headache, really increased blood pressure usually causes no symptoms in any way.
Chemicals, Drugs and Substance Withdrawal
Headaches can be because of a substance, or its withdrawal, for example:
Carbon monoxide, that is made by gas heaters which aren’t properly ventilated
Drinking alcohol, with headache often experienced the morning afterwards
Deficiency of body fluid or dehydration
Headaches Due to Referred Pain
Some headaches may be caused by pain in some other portion of the head, such as ear or tooth pain, pain in the jaw joint and pain in the neck.
Sinusitis is also a frequent cause of headaches. The sinuses are “holes” in the skull which are there to stop it from becoming too heavy for the neck to transport around. They are lined with mucous membranes, such as the lining of the nose, and this creates mucus in response to colds or allergy. The liner membranes also swell and can block the drainage of the mucus out of the space. It subsequently becomes cracked and infected, resulting in headache. The headache of sinusitis is often felt at the front of the head and also in the face or teeth.
Frequently the face feels tender to tension, particularly just below the eyes beside the nose. You might have a stuffy nose and the pain is often worse when you bend forwards. Acute sinusitis is the kind that comes on fast in conjunction with a cold or abrupt allergy. You may have a temperature and be generating a lot of mucus. Chronic sinusitis may be caused by allergy, by overusing decongestants or with the acute sinusitis that doesn’t settle. The sinuses become chronically infected and the nasal linings chronically swollen. The contents of this uterus may be thick but frequently not infected.
Acute glaucoma can cause severe headaches. In this condition, the pressure inside the eyes goes up suddenly and this causes a surprisingly, very severe headache behind the eye. Even the eyeball can feel really hard to touch, the eye is red, the front part of the eye, or cornea, can seem cloudy and the eyesight is generally blurred.
What Types of Headaches are Dangerous or Serious?
All headaches are unpleasant and some, such as headache from medication abuse, are serious in the sense that if not treated correctly they might never go away. But a few headaches are indications of serious underlying issues. These are uncommon, in many cases very rare. Dangerous headaches often occur suddenly, and also eventually become increasingly worse over time. They are more common in elderly people. They comprise of the following:
Bleeding Around the Brain (Subarachnoid Haemorrhage)
Subarachnoid haemorrhage is a really serious condition which occurs when a tiny blood vessel pops on the surface of the brain. Patients develop a serious headache and stiff neck and may become unconscious. This is a rare cause of acute headache.
Meningitis and Brain Infections
Meningitis is infection of the tissues around and on the surface of the brain and encephalitis is infection of the brain itself. Brain infections can be caused by germs called bacteria, viruses or parasites and they are thankfully rare. They cause a severe, disabling headache. Normally, patients may feel sick or vomit and can’t bear bright lights, something known as photophobia. Often they have a rigid neck, too stiff for your physician to have the ability to bend the head down so that the chin touches the chest, even in the event that you attempt to relax. Patients are generally also unwell, experiencing hot, sweaty and overall sick sensations.
Giant Cell Arteritis (Temporal Arteritis)
Giant cell arteritis (temporal arteritis) is, generally, just seen in people over the age of 50. It is due to swelling, or inflammation, of the arteries at the temples and behind the eye. It causes a headache behind the forehead, also referred to as a sinus headache. Typically the blood vessels at the forehead are tender and individuals detect pain from the scalp when they comb their own hair. Frequently the pain gets worse with chewing. Temporal arteritis is severe because if it’s not treated it can cause sudden loss of eyesight. Treatment is with a course of steroids. The need to keep these steroids is generally monitored by the GP through blood tests, and they are typically needed for several months.
Brain tumors are a very uncommon cause of headache, although most patients with long-term, severe or persistent headaches start to worry that this might be the reason. Brain tumors can lead to headaches. Usually the aggravation of brain tumors exists on waking in the morning, is worse on sitting up, and becoming steadily worse in the day to day, never easing and never disappearing. It can sometimes be worse on coughing and sneezing, as may sinus headaches and migraines.
When Should I Worry About a Headache?
Most headaches do not have a serious underlying cause. However, healthcare professionals are trained to ask you about the signs and symptoms that might suggest your headache needs further diagnosis, just to make certain it’s nothing serious.
The things which would suggest to your physician and nurse that your headache may need additional evaluation include the following. They don’t mean that your headache is severe or sinister, but they imply that the healthcare professional may wish to do some additional evaluations to make sure if:
You have had a substantial head injury in the previous three months.
Your headaches are worsening and accompanied with high temperature or fever.
Your headaches begin extremely unexpectedly.
You’ve developed problems with speech and balance as well as headache.
You’ve developed problems with your memory or changes in your behavior or personality in addition to headache.
You’re confused or muddled along with your headache.
Your headache started when you coughed, sneezed or strained.
Your headache is much worse when you sit or stand.
Your headache is associated with red or painful eyes.
Your headaches are not like anything you’ve ever experienced before.
You have unexplained nausea together with the aggravation.
You have low immunity, for instance, when you have HIV, or are about oral steroid medicine or immune suppressing drugs.
You have or have had a type of cancer that can spread throughout the body.
Dr. Alex Jimenez’s Insight
Headaches are extremely common health issues which affect a wide range of the population around the world. Although frequent, a headache which is described to be like no other ever experienced before, may often become a concern. There are several types of headaches which can be caused by a variety of injuries and/or underlying conditions. As a healthcare professional, it’s essential to be able to determine between sinister or dangerous types of headaches and benign types of headaches, in order to decide the best treatment approach. By properly diagnosing the source of a patient’s headaches, both benign and sinister types of headaches can be treated accordingly.
Many headaches, whilst unpleasant, are harmless and react to a variety of treatments, including chiropractic care. Migraine, tension headaches and medication-overuse headaches are very common. The majority of the populace will experience one or more of these. Working out exactly the underlying cause of any headaches through discussion with your doctor is often the best method to resolve them. It is possible to develop a persistent or chronic and constant headache through taking drugs and/or medications that you took to get rid of your headache. Your physician can support you through the practice of quitting painkillers when that is the case.
Headaches are, quite infrequently, an indication of a serious or sinister underlying illness, and many headaches go away on their own.
If you have a headache which is uncommon for you then you need to discuss it with your doctor. You should also speak to your doctor about headaches which are particularly severe or that affect your regular activities, those that are associated with other symptoms, such as tingling or weakness, and those which make your own scalp tender, especially if you’re over 50 years old. Finally, always speak to a healthcare professional when you have an unremitting morning headache which is present for at least three days or is becoming gradually worse.
Remember that headaches are not as likely to occur in people who:
Handle their anxiety levels well.
Eat a balanced, regular diet.
Take balanced routine exercise.
Focus on posture and core muscles.
Sleep on two pillows or fewer.
Drink loads of water.
Have plenty of sleep.
Anything that you can do to enhance one or more of these aspects of your life will improve your health and well-being and cut back the number of headaches you experience. Make sure to seek the appropriate medical attention from a qualified and experienced healthcare professional in the event of a severe headache unlike anything you’ve ever experienced before. The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Back Pain
Back pain is one of the most prevalent causes for disability and missed days at work worldwide. As a matter of fact, back pain has been attributed as the second most common reason for doctor office visits, outnumbered only by upper-respiratory infections. Approximately 80 percent of the population will experience some type of back pain at least once throughout their life. The spine is a complex structure made up of bones, joints, ligaments and muscles, among other soft tissues. Because of this, injuries and/or aggravated conditions, such as herniated discs, can eventually lead to symptoms of back pain. Sports injuries or automobile accident injuries are often the most frequent cause of back pain, however, sometimes the simplest of movements can have painful results. Fortunately, alternative treatment options, such as chiropractic care, can help ease back pain through the use of spinal adjustments and manual manipulations, ultimately improving pain relief.
Suffer Migraines: If you’ve ever had a migraine you know that it’s more than just a headache. The debilitating pain can be accompanied by nausea and other symptoms – and it’s more common than you may think. Research shows that in every four American households, one person is a migraine sufferer. In fact, 12 percent of the U.S. population suffers from migraines, including children. This means migraines affect more people that asthma and diabetes combined.
It is estimated that 18 percent of women suffer from migraines while 6 percent of men are migraine sufferers. It most commonly affects people who are between the ages of 25 and 55, but even young children have been diagnosed. Migraines can stop you in your tracks, but there are treatments that can help. Chiropractic care has been shown to help ease the pain, intensity, and frequency of migraines.
Suffer From Migraines
What Is A Migraine?
Migraines are vicious headaches that can last several minutes to several hours or even days. It is characterized by intense pulsing or a throbbing sensation that is typically confined to one area of the head. It is often accompanied by vomiting, nausea, and extreme sensitivity to sound and light. The pain can be so severe that you can barely function. Many people find themselves confined to bed in a darkened room, waiting for it to pass.
Many times migraine sufferers report experiencing an aura, or sensory warning symptoms, such as strange smells, blind spots, flashes of light, or tingling in your leg or arm. They also tend to run in families. If one parent is a migraine sufferer the child has a 40 percent chance of having migraines as well. If both parents get migraines that chance jumps to 90 percent. It is the 8th most debilitating illness on a global scale.
For the most part, doctors do not know much about what causes migraines. However, there are some things that have been identified as migraine triggers:
Hormonal changes – at certain times during the month, women experience fluctuations in estrogen which can trigger migraines
Oral contraceptives – medications that change or replace hormones can make headaches worse
Certain foods – processed foods, MSG, salty foods, aged cheeses
Fasting or skipping meals
Intense physical exertion
Too much or too little sleep
How Chiropractic Care Can Help Migraine Sufferers
Many doctors believe that headaches and migraines may be caused by a spine that is out of alignment. When your spine is misaligned your entire body suffers. It can irritate the nerves that run from the brain to the spine causing a headache. Chiropractic adjustments can help relieve the pain of migraines. In fact, many people report a distinct difference after just one session.
A Doctor of Chiropractic will align your spine and work with you to create a wellness plan that includes lifestyle changes and diet. Making changes to your sleep patterns and eliminating certain foods from your diet can help prevent migraines. By creating a whole body wellness program, you and your chiropractor can not only help prevent your migraines, but other health conditions as well.
Your chiropractor may also recommend that you keep a journal to help you pinpoint your own unique migraine triggers. You will record the foods you eat, environmental factors that may affect you, stressors, and sleep patterns, as well as when you have migraines, how long they last, and their severity. By tracking these things, you can determine what may be causing your migraines and make adjustments to your lifestyle, thus preventing them. Incorporating chiropractic care as part of your whole body maintenance, as well as migraine prevention, can help you stave off these headaches so you can get on with your life.
If you or a loved one suffers from migraine headaches, make sure you give us a call. Our Doctor of Chiropractic is here to help!
Several types of headaches can affect the average individual and each may result due to a variety of injuries and/or conditions, however, migraine headaches can often have a much more complex reason behind them. Many healthcare professionals and numerous evidence-based research studies have concluded that a subluxation in the neck, or a misalignment of the vertebrae in the cervical spine, is the most common reason for migraine headaches. Migraine is characterized by severe head pain typically affecting one side of the head, accompanied by nausea and disturbed vision. Migraine headaches can be debilitating. The information below describes a case study regarding the effect of atlas vertebrae realignment on patients with migraine.
Effect of Atlas Vertebrae Realignment in Subjects with Migraine: An Observational Pilot Study
Introduction. In a migraine case study, headache symptoms significantly decreased with an accompanying increase in intracranial compliance index following atlas vertebrae realignment. This observational pilot study followed eleven neurologist diagnosed migraine subjects to determine if the case findings were repeatable at baseline, week four, and week eight, following a National Upper Cervical Chiropractic Association intervention. Secondary outcomes consisted of migraine-specific quality of life measures. Methods. After examination by a neurologist, volunteers signed consent forms and completed baseline migraine-specific outcomes. Presence of atlas misalignment allowed study inclusion, permitting baseline MRI data collection. Chiropractic care continued for eight weeks. Postintervention reimaging occurred at week four and week eight concomitant with migraine-specific outcomes measurement. Results. Five of eleven subjects exhibited an increase in the primary outcome, intracranial compliance; however, mean overall change showed no statistical significance. End of study mean changes in migraine-specific outcome assessments, the secondary outcome, revealed clinically significant improvement in symptoms with a decrease in headache days. Discussion. The lack of robust increase in compliance may be understood by the logarithmic and dynamic nature of intracranial hemodynamic and hydrodynamic flow, allowing individual components comprising compliance to change while overall it did not. Study results suggest that the atlas realignment intervention may be associated with a reduction in migraine frequency and marked improvement in quality of life yielding significant reduction in headache-related disability as observed in this cohort. Future study with controls is necessary, however, to confirm these findings. Clinicaltrials.gov registration number is NCT01980927.
It has been proposed that a misaligned atlas vertebra creates spinal cord distortion disrupting neural traffic of brain stem nuclei in the medulla oblongata encumbering normal physiology [1–4].
The objective of the National Upper Cervical Chiropractic Association (NUCCA) developed atlas correction procedure is restoration of misaligned spinal structures to the vertical axis or gravity line. Described as the “restoration principle,” realignment aims to reestablish a patient’s normal biomechanical relationship of the upper cervical spine to the vertical axis (gravity line). Restoration is characterized as being architecturally balanced, being capable of unrestricted range of motion, and allowing a significant decrease in gravitational stress . The correction theoretically removes the cord distortion, created by an atlas misalignment or atlas subluxation complex (ASC), as specifically defined by NUCCA. Neurologic function is restored, specifically thought to be in the brain stem autonomic nuclei, which affect the cranial vascular system that includes Cerebrospinal Fluid (CSF) [3, 4].
The intracranial compliance index (ICCI) appears to be a more sensitive assessment of changes made in craniospinal biomechanical properties in symptomatic patients than the local hydrodynamic parameters of CSF flow velocities and cord displacement measurements . Based on that information, previously observed relationships of increased intracranial compliance to marked reduction in migraine symptoms following atlas realignment provided incentive for using the ICCI as the study objective primary outcome.
ICCI affects the ability of the Central Nervous System (CNS) to accommodate physiologic volume fluctuations that occur, thereby avoiding ischemia of underlying neurologic structures [5, 6]. A state of high intracranial compliance enables any volume increase to occur in the intrathecal CNS space without causing an intracranial pressure increase that occurs primarily with arterial inflow during systole [5, 6]. Outflow occurs in the supine position via the internal jugular veins or when upright, via paraspinal or secondary venous drainage. This extensive venous plexus is valveless and anastomotic, allowing blood to flow in a retrograde direction, into the CNS through postural changes [7, 8]. Venous drainage plays an important role in regulating the intracranial fluid system . Compliance appears to be functional and dependent on the free egress of blood via these extracranial venous drainage pathways .
Head and neck injury could create abnormal function of the spinal venous plexus that may impair spinal venous drainage, possibly because of autonomic dysfunction secondary to spinal cord ischemia . This decreases accommodation of volume fluctuations within the cranium creating a state of decreased intracranial compliance.
Damadian and Chu describe return of a normal CSF outflow measured at mid-C-2, exhibiting a 28.6% reduction of the measured CSF pressure gradient in the patient where the atlas had been optimally realigned . The patient reported freedom from symptoms (vertigo and vomiting when recumbent) consistent with the atlas remaining in alignment.
A hypertension study using the NUCCA intervention suggests a possible mechanism underlying the blood pressure decrease could be resultant from changes in cerebral circulation in relation to atlas vertebrae position . Kumada et al. investigated a trigeminal-vascular mechanism in brain stem blood pressure control [14, 15]. Goadsby et al. have presented compelling evidence that migraine originates via a trigeminal-vascular system mediated through the brain stem and upper cervical spine [16–19]. Empirical observation reveals significant reduction of migraine patients’ headache disability after application of the atlas correction. Using migraine-diagnosed subjects seemed ideal for investigating proposed cerebral circulation changes following atlas realignment as originally theorized in the hypertension study conclusions and seemingly supported by a possible brain stem trigeminal-vascular connection. This would further advance a developing working pathophysiologic hypothesis of atlas misalignment.
Results from an initial case study demonstrated substantial increase in ICCI with decrease in migraine headache symptoms following the NUCCA atlas correction. A 62-year-old male with neurologist diagnosed chronic migraine volunteered for a before-after intervention case study. Using Phase Contrast-MRI (PC-MRI), changes in cerebral hemodynamic and hydrodynamic flow parameters were measured at baseline, 72 hours, and then four weeks after the atlas intervention. The same atlas correction procedure used in the hypertension study was followed . 72 hours after study revealed a noteworthy change in the intracranial compliance index (ICCI), from 9.4 to 11.5, to 17.5 by week four, after intervention. Observed changes in venous outflow pulsatility and predominant secondary venous drainage in the supine position warranted additional investigation further inspiring a study of migraine subjects in this case series.
The possible effects of the atlas misalignment or ASC on venous drainage are unknown. Careful examination of intracranial compliance in relation to effects of an atlas misalignment intervention may provide insight into how the correction might influence migraine headache.
Using PC-MRI, this current study’s primary objective, and primary outcome, measured ICCI change from baseline to four and eight weeks following a NUCCA intervention in a cohort of neurologist selected migraine subjects. As observed in the case study, the hypothesis supposed that a subject’s ICCI would increase following the NUCCA intervention with a corresponding decrease in migraine symptoms. If present, any observed changes in venous pulsatility and drainage route were to be documented for further comparison. To monitor migraine symptoms response, the secondary outcomes included patient reported outcomes to measure any related change in Health Related Quality of Life (HRQoL), similarly used in migraine research. Throughout the study, subjects maintained headache diaries documenting the decrease (or increase) in the number of headache days, intensity, and medication used.
Conducting this observational case series, pilot study, allowed for additional investigation into aforementioned physiologic effects in further development of a working hypothesis into the pathophysiology of an atlas misalignment. Data required for estimation of statistically significant subject sample sizes and resolving procedural challenges will provide needed information for developing a refined protocol to conduct a blinded, placebo controlled migraine trial using the NUCCA correction intervention.
This research maintained compliance with the Helsinki Declaration for research on human subjects. The University of Calgary and Alberta Health Services Conjoint Health Research Ethics Board approved the study protocol and subject informed consent form, Ethics ID: E-24116. ClinicalTrials.gov assigned the number NCT01980927 after registration of this study (https://clinicaltrials.gov/ct2/show/NCT01980927).
Subject recruitment and screening occurred at the Calgary Headache Assessment and Management Program (CHAMP), a neurology-based specialist referral clinic (see Figure 1, Table 1). CHAMP evaluates patients resistant to standard pharmacotherapy and medical treatment for migraine headache that no longer provides migraine symptom relief. Family and primary care physicians referred potential study subjects to CHAMP making advertising unnecessary.
Figure 1: Subject disposition and study flow (n = 11). GSA: Gravity Stress Analyzer. HIT-6: Headache Impact Test-6. HRQoL: Health Related Quality of Life. MIDAS: Migraine Disability Assessment Scale. MSQL: Migraine-Specific Quality of Life Measure. NUCCA: National Upper Cervical Chiropractic Association. PC-MRI: Phase Contrast Magnetic Resonance Imaging. VAS: Visual Analog Scale.
Table 1: Subject inclusion/exclusion criteria. Potential subjects, naïve to upper cervical chiropractic care, demonstrated between ten and twenty-six headache days per month self-reported over the previous four months. Requisite was at least eight headache days per month, where intensity reached at least four, on a zero to ten Visual Analog Scale (VAS) pain scale.
Study inclusion required volunteers, between the ages of 21 and 65 years, that satisfy specific diagnostic criteria for migraine headache. A neurologist with several decades of migraine experience screened applicants utilizing the International Classification of Headache Disorders (ICHD-2) for study inclusion . Potential subjects, naïve to upper cervical chiropractic care, must have demonstrated through self-report between ten and twenty-six headache days per month over the previous four months. At least eight headache days per month had to reach an intensity of at least four on a zero to ten VAS pain scale, unless treated successfully with a migraine-specific medication. At least four separate headache episodes per month separated by at least a 24-hour pain-free interval were required.
Significant head or neck trauma occurring within one year prior to study entry excluded candidates. Further exclusion criteria included acute medication overuse, a history of claustrophobia, cardiovascular or cerebrovascular disease, or any CNS disorder other than migraine. Table 1 describes the complete inclusion and exclusion criteria considered. Using an experienced board certified neurologist to screen potential subjects while adhering to the ICHD-2 and guided by the inclusion/exclusion criteria, the exclusion of subjects with other sources of headache such as muscular tension and medication overuse rebound headache would increase the likelihood of successful subject recruitment.
Those meeting initial criteria signed informed consent and then completed a baseline Migraine Disability Assessment Scale (MIDAS). The MIDAS requires twelve weeks to demonstrate clinically significant change . This allowed adequate time to pass to discern any possible changes. Over the next 28 days, candidates recorded a headache diary providing baseline data while confirming the number of headache days and intensity required for inclusion. After the four weeks, the diary check diagnostic substantiation permitted administration of remaining baseline HRQoL measures:
Migraine-Specific Quality of Life Measure (MSQL) ,
Headache Impact Test-6 (HIT-6) ,
Subject current global assessment of headache pain (VAS).
Referral to the NUCCA practitioner, to determine presence of atlas misalignment, confirmed need for intervention finalizing a subject’s study inclusion∖exclusion. Absence of atlas misalignment indicators excluded candidates. After scheduling appointments for NUCCA intervention and care, qualified subjects obtained baseline PC-MRI measures. Figure 1 summarizes subject disposition throughout the study.
The initial NUCCA intervention required three consecutive visits: (1) Day One, atlas misalignment assessment, before-correction radiographs; (2) Day Two, NUCCA correction with after-correction assessment with radiographs; and (3) Day Three, after-correction reassessment. Follow-up care occurred weekly for four weeks, then every two weeks for the remainder of the study period. At each NUCCA visit, subjects completed a current assessment of headache pain (please rate your headache pain on average over the past week) using a straight edge and pencil in marking a 100 mm line (VAS). One week after the initial intervention, subjects completed a “Possible Reaction to Care” questionnaire. This assessment has past been used for successfully monitoring adverse events related to various upper cervical correction procedures .
At week four, PC-MRI data were obtained and subjects completed an MSQL and HIT-6. End of study PC-MRI data were collected at week eight followed by a neurologist exit interview. Here, subjects completed final MSQOL, HIT-6, MIDAS, and VAS outcomes and headache diaries were collected.
At the week-8 neurologist visit, two willing subjects were offered a long-term follow-up opportunity for a total study period of 24 weeks. This involved further NUCCA reassessment monthly for 16 weeks after completion of the initial 8-week study. The purpose of this follow-up was to help determine if headache improvement continued contingent upon maintenance of atlas alignment while observing for any long-term effect of NUCCA care on ICCI. Subjects desiring to participate signed a second informed consent for this phase of study and continued monthly NUCCA care. At the end of 24 weeks from the original atlas intervention, the fourth PC-MRI imaging study occurred. At the neurologist exit interview, final MSQOL, HIT-6, MIDAS, and VAS outcomes and headache diaries were collected.
The same NUCCA procedure as previously reported was followed using the established protocol and standards of care developed through NUCCA Certification for assessment and atlas realignment or correction of the ASC (see Figures Figures22–5) [2, 13, 25]. Assessment for the ASC includes screening for functional leg-length inequality with the Supine Leg Check (SLC) and examination of postural symmetry using the Gravity Stress Analyzer (Upper Cervical Store, Inc., 1641 17 Avenue, Campbell River, BC, Canada V9W 4L5) (see Figures Figures22 and 3(a)–3(c)) [26–28]. If SLC and postural imbalances are detected, a three-view radiographic exam is indicated to determine the multidimensional orientation and degree of craniocervical misalignment [29, 30]. A thorough radiographic analysis provides information to determine a subject specific, optimal atlas correction strategy. The clinician locates anatomic landmarks from the three-view series, measuring structural and functional angles that have deviated from established orthogonal standards. The degree of misalignment and atlas orientation are then revealed in three dimensions (see Figures 4(a)–4(c)) [2, 29, 30]. Radiographic equipment alignment, reduction of collimator port size, high-speed film-screen combinations, special filters, specialized grids, and lead shielding minimize subject radiation exposure. For this study, average total measured Entrance Skin Exposure to subjects from the before-after-correction radiographic series was 352 millirads (3.52 millisieverts).
Figure 2: Supine Leg Check Screening Test (SLC). Observation of an apparent “short leg” indicates possible atlas misalignment. These appear even.
Figure 3: Gravity Stress Analyzer (GSA). (a) Device determines postural asymmetry as a further indicator of atlas misalignment. Positive findings in the SLC and GSA indicate need for NUCCA radiographic series. (b) Balanced patient with no postural asymmetry. (c) Hip calipers used to measure pelvis asymmetry.
Figure 4: NUCCA radiograph series. These films are used to determine atlas misalignment and developing a correction strategy. After-correction radiographs or postfilms ensure the best correction has been made for that subject.
Figure 5: Making a NUCCA correction. The NUCCA practitioner delivers a triceps pull adjustment. The practitioner’s body and hands are aligned to deliver an atlas correction along an optimal force vector using information obtained from radiographs.
The NUCCA intervention involves a manual correction of the radiographically measured misalignment in the anatomical structure between the skull, atlas vertebra, and cervical spine. Utilizing biomechanical principles based on a lever system, the doctor develops a strategy for proper
force vector to correct the atlas misalignment.
Subjects are placed on a side-posture table with the head specifically braced using a mastoid support system. Application of the predetermined controlled force vector for the correction realigns the skull to the atlas and neck to the vertical axis or center of gravity of the spine. These corrective forces are controlled in depth, direction, velocity, and amplitude, producing an accurate and precise reduction of the ASC.
Using the pisiform bone of the contact hand, the NUCCA practitioner contacts the atlas transverse process. The other hand encircles the wrist of the contact hand, to control the vector while maintaining the depth of force generated in application of the “triceps pull” procedure (see Figure 5) . By understanding spinal biomechanics, the practitioner’s body and hands are aligned to produce an atlas correction along the optimal force vector. The controlled, nonthrusting force is applied along the predetermined reduction pathway. It is specific in its direction and depth to optimize the ASC reduction assuring no activation in the reactive forces of the neck muscles in response to the biomechanical change. It is understood that an optimal reduction of the misalignment promotes long-term maintenance and stability of spinal alignment.
Following a short rest period, an after-assessment procedure, identical to the initial evaluation, is performed. A postcorrection radiograph examination uses two views to verify return of the head and cervical spine into optimum orthogonal balance. Subjects are educated in ways to preserve their correction, thus preventing another misalignment.
Subsequent NUCCA visits were comprised of headache diary checks and a current assessment of headache pain (VAS). Leg length inequality and excessive postural asymmetry were used in determining the need for another atlas intervention. The objective for optimal improvement is for the subject to maintain the realignment for as long as possible, with the fewest number of atlas interventions.
In a PC-MRI sequence, contrast media are not used. PC-MRI methods collected two data sets with different amounts of flow sensitivity acquired by relating gradient pairs, which sequentially dephase and rephase spins during the sequence. The raw data from the two sets are subtracted to calculate a flow rate.
An on-site visit by the MRI Physicist provided training for the MRI Technologist and a data transfer procedure was established. Several practice scans and data transfers were performed to ensure data collection succeeded without challenges. A 1.5-tesla GE 360 Optima MR scanner (Milwaukee, WI) at the study imaging center (EFW Radiology, Calgary, Alberta, Canada) was used in imaging and data collection. A 12-element phased array head coil, 3D magnetization-prepared rapid-acquisition gradient echo (MP-RAGE) sequence was used in anatomy scans. Flow sensitive data were acquired using a parallel acquisition technique (iPAT), acceleration factor 2.
To measure blood flow to and from the skull base, two retrospectively gated, velocity-encoded cine-phase-contrast scans were performed as determined by individual heart rate, collecting thirty-two images over a cardiac cycle. A high-velocity encoding (70 cm/s) quantified high-velocity blood flow perpendicular to the vessels at the C-2 vertebra level includes the internal carotid arteries (ICA), vertebral arteries (VA), and internal jugular veins (IJV). Secondary venous flow data of vertebral veins (VV), epidural veins (EV), and deep cervical veins (DCV) were acquired at the same height using a low-velocity encoding (7–9 cm/s) sequence.
Subject data were identified by Subject Study ID and imaging study date. The study neuroradiologist reviewed MR-RAGE sequences to rule out exclusionary pathologic conditions. Subject identifiers were then removed and assigned a coded ID permitting transfer via a secured tunnel IP protocol to the physicist for analysis. Using proprietary software volumetric blood, Cerebrospinal Fluid (CSF) flow rate waveforms and derived parameters were determined (MRICP version 1.4.35 Alperin Noninvasive Diagnostics, Miami, FL).
Using the pulsatility-based segmentation of lumens, time-dependent volumetric flow rates were calculated by integrating the flow velocities inside the luminal cross-sectional areas over all thirty-two images. Mean flow rates were obtained for the cervical arteries, primary venous drainage, and secondary venous drainage pathways. Total cerebral blood flow was obtained by summation of these mean flow rates.
A simple definition of compliance is a ratio of volume and pressure changes. Intracranial compliance is calculated from the ratio of the maximal (systolic) intracranial volume change (ICVC) and pressure fluctuations during the cardiac cycle (PTP-PG). Change in ICVC is obtained from momentary differences between volumes of blood and CSF entering and exiting the cranium [5, 31]. Pressure change during the cardiac cycle is derived from the change in the CSF pressure gradient, which is calculated from the velocity-encoded MR images of the CSF flow, using the Navier-Stokes relationship between derivatives of velocities and the pressure gradient [5, 32]. An intracranial compliance index (ICCI) is calculated from the ratio of ICVC and pressure changes [5, 31–33].
Statistical analysis considered several elements. ICCI data analysis involved a one-sample Kolmogorov-Smirnov test revealing a lack of normal distribution in the ICCI data, which were therefore described using the median and interquartile range (IQR). Differences between baseline and follow-up were to be examined using a paired t-test.
NUCCA assessments data were described using mean, median, and interquartile range (IQR). Differences between baseline and follow-up were examined using a paired t-test.
Depending on the outcome measure, baseline, week four, week eight, and week twelve (MIDAS only) follow-up values were described using the mean and standard deviation. MIDAS data collected at initial neurologist screening had one follow-up score at the end of twelve weeks.
Differences from baseline to each follow-up visit were tested using a paired t-test. This resulted in numerous p values from two follow-up visits for each outcome except the MIDAS. Since one purpose of this pilot is to provide estimates for future research, it was important to describe where differences occurred, rather than to use a one-way ANOVA to arrive at a single p value for each measure. The concern with such multiple comparisons is the increase in Type I error rate.
To analyze the VAS data, each subject scores were examined individually and then with a linear regression line that adequately fits the data. Use of a multilevel regression model with both random intercepts and random slope provided an individual regression line fitted for each patient. This was tested against a random intercept-only model, which fits a linear regression line with a common slope for all subjects, while intercept terms are allowed to vary. The random coefficient model was adopted, as there was no evidence that random slopes significantly improved the fit to the data (using a likelihood ratio statistic). To illustrate the variation in the intercepts but not in the slope, the individual regression lines were graphed for each patient with an imposed average regression line on top.
From initial neurologist screening, eighteen volunteers were eligible for inclusion. After completion of baseline headache diaries, five candidates did not meet inclusion criteria. Three lacked the required headache days on baseline diaries to be included, one had unusual neurological symptoms with persistent unilateral numbness, and another was taking a calcium channel blocker. The NUCCA practitioner found two candidates ineligible: one lacking an atlas misalignment and the second with a Wolff-Parkinson-White condition and severe postural distortion (39°) with recent involvement in a severe high impact motor vehicle accident with whiplash (see Figure 1).
Eleven subjects, eight females and three males, average age forty-one years (range 21–61 years), qualified for inclusion. Six subjects presented chronic migraine, reporting fifteen or more headache days a month, with a total eleven-subject mean of 14.5 headache days a month. Migraine symptom duration ranged from two to thirty-five years (mean twenty-three years). All medications were maintained unchanged for the study duration to include their migraine prophylaxis regimens as prescribed.
Per exclusion criteria, no subjects included received a diagnosis of headache attributed to traumatic injury to the head and neck, concussion, or persistent headache attributed to whiplash. Nine subjects reported a very remote past history, greater than five years or more (average of nine years) prior to neurologist screen. This included sports-related head injuries, concussion, and/or whiplash. Two subjects indicated no prior head or neck injury (see Table 2).
Table 2: Subject intracranial compliance index (ICCI) data (n = 11). PC-MRI6 acquired ICCI1 data reported at baseline, week four, and week eight following NUCCA5 intervention. Bolded rows signify subject with secondary venous drainage route. MVA or mTBI occurred at least 5 years prior to study inclusion, average 10 years.
Individually, five subjects demonstrated an increase in ICCI, three subject’s values remained essentially the same, and three showed a decrease from baseline to end of study measurements. Overall changes in intracranial compliance are seen in Table 2 and Figure 8. The median (IQR) values of ICCI were 5.6 (4.8, 5.9) at baseline, 5.6 (4.9, 8.2) at week four, and 5.6 (4.6, 10.0) at week eight. Differences were not statistically different. The mean difference between baseline and week four was −0.14 (95% CI −1.56, 1.28), p = 0.834, and between baseline and week eight was 0.93 (95% CI −0.99, 2.84), p = 0.307. These two subject’s 24-week ICCI study results are seen in Table 6. Subject 01 displayed an increasing trend in ICCI from 5.02 at baseline to 6.69 at week 24, whereas at week 8, results were interpreted as consistent or remaining the same. Subject 02 demonstrated a decreasing trend in ICCI from baseline of 15.17 to 9.47 at week 24.
Figure 8: Study ICCI data compared to previously reported data in the literature. The MRI time values are fixed at baseline, week 4, and week 8 after intervention. This study’s baseline values fall similar to the data reported by Pomschar on subjects presenting only with mTBI.
Table 6: 24-week ICCI findings showing an increasing trend in subject 01 whereas at end of study (week 8), results were interpreted as consistent or remaining the same. Subject 02 continued to show a decreasing trend in ICCI.
Table 3 reports changes in NUCCA assessments. The mean difference from before to after the intervention is as follows: (1) SLC: 0.73 inches, 95% CI (0.61, 0.84) (p < 0.001); (2) GSA: 28.36 scale points, 95% CI (26.01, 30.72) (p < 0.001); (3) Atlas Laterality: 2.36 degrees, 95% CI (1.68, 3.05) (p < 0.001); and (4) Atlas Rotation: 2.00 degrees, 95% CI (1.12, 2.88) (p < 0.001). This would indicate that a probable change occurred following the atlas intervention as based on subject assessment.
Table 3: Descriptive statistics [mean, standard deviation, median, and interquartile range (IQR2)] of NUCCA1 assessments before-after initial intervention (n = 11).
Headache diary results are reported in Table 4 and Figure 6. At baseline subjects had mean 14.5 (SD = 5.7) headache days per 28-day month. During the first month following NUCCA correction, mean headache days per month decreased by 3.1 days from baseline, 95% CI (0.19, 6.0), p = 0.039, to 11.4. During the second month headache days decreased by 5.7 days from baseline, 95% CI (2.0, 9.4), p = 0.006, to 8.7 days. At week eight, six of the eleven subjects had a reduction of >30% in headache days per month. Over 24 weeks, subject 01 reported essentially no change in headache days while subject 02 had a reduction of one headache day a month from study baseline of seven to end of study reports of six days.
Figure 6: Headache days and headache pain intensity from diary (n = 11). (a) Number of headache days per month. (b) Average headache intensity (on headache days). Circle indicates the mean and the bar indicates the 95% CI. Circles are individual subject scores. A significant decrease in headache days per month was noticed at four weeks, almost doubling at eight weeks. Four subjects (#4, 5, 7, and 8) exhibited a greater than 20% decrease in headache intensity. Concurrent medication use may explain the small decrease in headache intensity.
At baseline, mean headache intensity on days with headache, on a scale of zero to ten, was 2.8 (SD = 0.96). Mean headache intensity showed no statistically significant change at four (p = 0.604) and eight (p = 0.158) weeks. Four subjects (#4, 5, 7, and 8) exhibited a greater than 20% decrease in headache intensity.
Quality of life and headache disability measures are seen in Table 4. The mean HIT-6 score at baseline was 64.2 (SD = 3.8). At week four after NUCCA correction, mean decrease in scores was 8.9, 95% CI (4.7, 13.1), p = 0.001. Week-eight scores, compared to baseline, revealed mean decrease by 10.4, 95% CI (6.8, 13.9), p = 0.001. In the 24-week group, subject 01 showed a decrease of 10 points from 58 at week 8 to 48 at week 24 while subject 02 decreased 7 points from 55 at week 8 to 48 at week 24 (see Figure 9).
Figure 9: 24-week HIT-6 scores in long-term follow-up subjects. Monthly scores continued to decrease after week 8, end of first study. Based on Smelt et al. criteria, it can be interpreted that a within-person minimally important change occurred between week 8 and week 24. HIT-6: Headache Impact Test-6.
MSQL mean baseline score was 38.4 (SD = 17.4). At week four after correction, mean scores for all eleven subjects increased (improved) by 30.7, 95% CI (22.1, 39.2), p < 0.001. By week eight, end of study, mean MSQL scores had increased from baseline by 35.1, 95% CI (23.1, 50.0), p < 0.001, to 73.5. The follow-up subjects continued to show some improvement with increasing scores; however, many scores plateaued remaining the same since week 8 (see Figures 10(a)–10(c)).
Figure 10: ((a)–(c)) 24-week MSQL scores in long-term follow-up subjects. (a) Subject 01 has essentially plateaued after week 8 throughout to end of the second study. Subject 02 shows scores increasing over time demonstrating minimally important differences based on Cole et al. criteria by week 24. (b) Subject scores seem to peak by week 8 with both subjects showing similar scores reported at week 24. (c) Subject 2 scores remain consistent throughout the study while subject 01 shows steady improvement from baseline to the end of week 24. MSQL: Migraine-Specific Quality of Life Measure.
Mean MIDAS score at baseline was 46.7 (SD = 27.7). At two months after NUCCA correction (three months following baseline), the mean decrease in subject’s MIDAS scores was 32.1, 95% CI (13.2, 51.0), p = 0.004. The follow-up subjects continued to show improvement with decreasing scores with intensity showing minimal improvement (see Figures 11(a)–11(c)).
Figure 11: 24-week MIDAS scores in long-term follow-up subjects. (a) Total MIDAS scores continued a decreasing trend over the 24-week study period. (b) Intensity scores continued improvement. (c) While 24-week frequency was higher than at week 8, improvement is observed when compared to baseline. MIDAS: Migraine Disability Assessment Scale.
Assessment of current headache pain from VAS scale data is seen in Figure 7. The multilevel linear regression model showed evidence of a random effect for the intercept (p < 0.001) but not for the slope (p = 0.916). Thus, the adopted random intercept model estimated a different intercept for each patient but a common slope. The estimated slope of this line was −0.044, 95% CI (−0.055, −0.0326), p < 0.001, indicating that there was a significant decrease in the VAS score of 0.44 per 10 days after baseline (p < 0.001). The mean baseline score was 5.34, 95% CI (4.47, 6.22). The random effects analysis showed substantial variation in the baseline score (SD = 1.09). As the random intercepts are normally distributed, this indicates that 95% of such intercepts lie between 3.16 and 7.52 providing evidence of substantial variation in the baseline values across patients. VAS scores continued showing improvement in the 24-week two-subject follow-up group (see Figure 12).
Figure 7: Subject global assessment of headache (VAS) (n = 11). There was substantial variation in baseline scores across these patients. The lines show individual linear fit for each of eleven patients. The thick dotted black line represents the average linear fit across all eleven patients. VAS: Visual Analog Scale.
Figure 12: 24-week follow-up group global assessment of headache (VAS). When subjects were queried, “please rate your headache pain on average over the past week” VAS scores continued showing improvement in the 24-week two-subject follow-up group.
The most obvious reaction to the NUCCA intervention and care reported by ten subjects was mild neck discomfort, rated an average of three out of ten on pain assessment. In six subjects, pain began more than twenty-four hours after the atlas correction, lasting more than twenty-four hours. No subject reported any significant effect on their daily activities. All subjects reported satisfaction with NUCCA care after one week, median score, ten, on a zero to ten rating scale.
Dr. Alex Jimenez’s Insight
“I’ve been experiencing migraine headaches for several years now. Is there a reason for my head pain? What can I do to decrease or get rid of my symptoms?” Migraine headaches are believed to be a complex form of head pain, however, the reason for them is much the same as any other type of headache. A traumatic injury to the cervical spine, such as that of whiplash from an automobile accident or a sports injury, can cause a misalignment in the neck and upper back, which may lead to migraine. An improper posture can also cause neck issues which could lead to head and neck pain. A healthcare professional who specializes in spinal health issues can diagnose the source of your migraine headaches. Furthermore, a qualified and experienced specialist can perform spinal adjustments as well as manual manipulations to help correct any misalignments of the spine which could be causing the symptoms. The following article summarizes a case study based on the improvement of symptoms after atlas vertebrae realignment in participants with migraine.
In this limited cohort of eleven migraine subjects, there was no statistically significant change in ICCI (primary outcome) after the NUCCA intervention. However, a significant change in HRQoL secondary outcomes did occur as summarized in Table 5. The consistency in the magnitude and direction of improvement across these HRQoL measures indicates confidence in enhancement of headache health over the two-month study following the 28-day baseline period.
Table 5: Summary Comparison of Measured Outcomes
Based on the case study results, this investigation hypothesized a significant increase in ICCI after the atlas intervention which was not observed. Use of PC-MRI allows quantification of the dynamic relationship between arterial inflow, venous outflow, and CSF flow between the cranium and the spinal canal . Intracranial compliance index (ICCI) measures the brain’s ability to respond to incoming arterial blood during systole. Interpretation of this dynamic flow is represented by a monoexponential relationship existing between CSF volume and CSF pressure. With increased or higher intracranial compliance, also defined as good compensatory reserve, the incoming arterial blood can be accommodated by the intracranial contents with a smaller change in intracranial pressure. While a change in intracranial volume or pressure could occur, based on the exponential nature of the volume-pressure relationship, a change in after-intervention ICCI may not be realized. An advanced analysis of the MRI data and further study are required for pinpointing practical quantifiable parameters to use as an objective outcome sensitive for documenting a physiologic change following atlas correction.
Koerte et al. reports of chronic migraine patients demonstrate a significantly higher relative secondary venous drainage (paraspinal plexus) in the supine position when compared to age- and gender-matched controls . Four study subjects exhibited a secondary venous drainage with three of those subjects demonstrating notable increase in compliance after intervention. The significance is unknown without further study. Similarly, Pomschar et al. reported that subjects with mild traumatic brain injury (mTBI) demonstrate an increased drainage through the secondary venous paraspinal route . The mean intracranial compliance index appears significantly lower in the mTBI cohort when compared to controls.
Some perspective may be gained in comparison of this study’s ICCI data to previously reported normal subjects and those with mTBI seen in Figure 8 [5, 35]. Limited by the small number of subjects studied, the significance these study’s findings may have in relation to Pomschar et al. remains unknown, offering only speculation of possibilities for future exploration. This is further complicated by the inconsistent ICCI change observed in the two subjects followed for 24 weeks. Subject two with a secondary drainage pattern exhibited a decrease in ICCI following intervention. A larger placebo controlled trial with a statistically significant subject sample size could possibly demonstrate a definitive objectively measured physiologic change after application of the NUCCA correction procedure.
HRQoL measures are used clinically to assess the effectiveness of a treatment strategy to decrease pain and disability related to migraine headache. It is expected that an effective treatment improves patient perceived pain and disability measured by these instruments. All HRQoL measures in this study demonstrated significant and substantial improvement by week four following the NUCCA intervention. From week four to week eight only small improvements were noted. Again, only small improvements were noted in the two subjects followed for 24 weeks. While this study was not intended to demonstrate causation from the NUCCA intervention, the HRQoL results create compelling interest for further study.
From the headache diary, a significant decrease in headache days per month was noticed at four weeks, almost doubling at eight weeks. However, significant differences in headache intensity over time were not discernable from this diary data (see Figure 5). While the number of headaches decreased, subjects still used medication to maintain headache intensity at tolerable levels; hence, it is supposed that a statistically significant difference in headache intensity could not be determined. Consistency in the headache day numbers occurring in week 8 in the follow-up subjects could guide future study focus in determining when maximum improvement occurs to help in establishing a NUCCA standard of migraine care.
Clinically relevant change in the HIT-6 is important for completely understanding observed outcomes. A clinically meaningful change for an individual patient has been defined by the HIT-6 user guide as ≥5 . Coeytaux et al., using four different analysis methods, suggest that a between-group difference in HIT-6 scores of 2.3 units over time may be considered clinically significant . Smelt et al. studied primary care migraine patient populations in developing suggested recommendations using HIT-6 score changes for clinical care and research . Dependent on consequences resulting from false positives or negatives, within-person minimally important change (MIC) using a “mean change approach” was estimated to be 2.5 points. When using the “receiver operating characteristic (ROC) curve analysis” a 6-point change is needed. Recommended between-group minimally important difference (MID) is 1.5 .
Using the “mean change approach,” all subjects but one reported a change (decrease) greater than −2.5. The “ROC analyses” also demonstrated improvement by all subjects but one. This “one subject” was a different person in each comparison analysis. Based on Smelt et al. criteria, the follow-up subjects continued to demonstrate within-person minimally important improvement as seen in Figure 10.
All subjects but two showed improvement on the MIDAS score between baseline and three-month results. The magnitude of the change was proportional to the baseline MIDAS score, with all subjects but three reporting an overall fifty percent or greater change. The follow-up subjects continued to show improvement as seen in continued decrease in scores by week 24; see Figures 11(a)–11(c).
Use of the HIT-6 and MIDAS together as a clinical outcome may provide a more complete assessment of headache-related disability factors . The differences between the two scales can predict disability from headache pain intensity and headache frequency, by providing more information on factors related to the reported changes than either outcome used alone. While the MIDAS appears to change more by headache frequency, headache intensity seems to affect HIT-6 score more than the MIDAS .
How migraine headache affects and limits patient perceived daily functioning is reported by the MSQL v. 2.1, across three 3 domains: role restrictive (MSQL-R), role preventive (MSQL-P), and emotional functioning (MSQL-E). An increase in scores indicates improvement in these areas with values ranging from 0 (poor) to 100 (best).
MSQL scales reliability evaluation by Bagley et al. report results to be moderately to highly correlated with HIT-6 (r = −0.60 to −0.71) . Study by Cole et al. reports minimally important differences (MID) clinical change for each domain: MSQL-R = 3.2, MSQL-P = 4.6, and MSQL-E = 7.5 . Results from the topiramate study report individual minimally important clinical (MIC) change: MSQL-R = 10.9, MSQL-P = 8.3, and MSQL-E = 12.2 .
All subjects except one experienced an individual minimally important clinical change for MSQL-R of greater than 10.9 by the week-eight follow-up in MSQL-R. All but two subjects reported changes of more than 12.2 points in MSQL-E. Improvement in MSQL-P scores increased by ten points or more in all subjects.
Regression analysis of VAS ratings over time showed a significant linear improvement over the 3-month period. There was substantial variation in baseline scores across these patients. Little to no variation was observed in the rate of improvement. This trend appears to be the same in the subjects studied for 24 weeks as seen in Figure 12.
Many studies using pharmaceutical intervention have shown a substantial placebo effect in patients from migrainous populations . Determining possible migraine improvement over six months, using another intervention as well as no intervention, is important for any comparison of results. The investigation into placebo effects generally accepts that placebo interventions do provide symptomatic relief but do not modify pathophysiologic processes underlying the condition . Objective MRI measures may help in revealing such a placebo effect by demonstrating a change in physiologic measurements of flow parameters occurring after a placebo intervention.
Use of a three-tesla magnet for MRI data collection would increase the reliability of the measurements by increasing the amount of data used to make the flow and ICCI calculations. This is one of the first investigations using change in ICCI as an outcome in evaluating an intervention. This creates challenges in interpretation of MRI acquired data to base conclusions or further hypothesis development. Variability in relationships between blood flow to and from the brain, CSF flow, and heart rate of these subject-specific parameters has been reported . Variations observed in a small three-subject repeated measures study have led to conclusions that information gathered from individual cases be interpreted with caution .
The literature further reports in larger studies significant reliability in collecting these MRI acquired volumetric flow data. Wentland et al. reported that measurements of CSF velocities in human volunteers and of sinusoidally fluctuating phantom velocities did not differ significantly between two MRI techniques used . Koerte et al. studied two cohorts of subjects imaged in two separate facilities with different equipment. They reported that intraclass correlation coefficients (ICC) demonstrated a high intra- and interrater reliability of PC-MRI volumetric flow rate measurements remaining independent of equipment used and skill-level of the operator . While anatomic variation exists between subjects, it has not prevented studies of larger patient populations in describing possible “normal” outflow parameters [49, 50].
Being based solely on patient subjective perceptions, there are limitations in using patient reported outcomes . Any aspect affecting a subject’s perception in their quality of life is likely to influence the outcome of any assessment used. Lack of outcome specificity in reporting symptoms, emotions, and disability also limits interpretation of results .
Imaging and MRI data analysis costs precluded use of a control group, limiting any generalizability of these results. A larger sample size would allow for conclusions based on statistical power and reduced Type I error. Interpretation of any significance in these results, while revealing possible trends, remains speculation at best. The big unknown persists in the likelihood that these changes are related to the intervention or to some other effect unknown to the investigators. These results do add to the body of knowledge of previously unreported possible hemodynamic and hydrodynamic changes after a NUCCA intervention, as well as changes in migraine HRQoL patient reported outcomes as observed in this cohort.
The values of collected data and analyses are providing information required for estimation of statistically significant subject sample sizes in further study. Resolved procedural challenges from conducting the pilot allow for a highly refined protocol to successfully accomplish this task.
In this study, the lack of robust increase in compliance may be understood by the logarithmic and dynamic nature of intracranial hemodynamic and hydrodynamic flow, allowing individual components comprising compliance to change while overall it did not. An effective intervention should improve subject perceived pain and disability related to migraine headache as measured by these HRQoL instruments used. These study results suggest that the atlas realignment intervention may be associated with reduction in migraine frequency, marked improvement in quality of life yielding significant reduction in headache-related disability as observed in this cohort. The improvement in HRQoL outcomes creates compelling interest for further study, to confirm these findings, especially with a larger subject pool and a placebo group.
The authors acknowledge Dr. Noam Alperin, Alperin Diagnostics, Inc., Miami, FL; Kathy Waters, Study Coordinator, and Dr. Jordan Ausmus, Radiography Coordinator, Britannia Clinic, Calgary, AB; Sue Curtis, MRI Technologist, Elliot Fong Wallace Radiology, Calgary, AB; and Brenda Kelly-Besler, RN, Research Coordinator, Calgary Headache Assessment and Management Program (CHAMP), Calgary, AB. Financial support is provided by (1) Hecht Foundation, Vancouver, BC; (2) Tao Foundation, Calgary, AB; (3) Ralph R. Gregory Memorial Foundation (Canada), Calgary, AB; and (4) Upper Cervical Research Foundation (UCRF), Minneapolis, MN.
ASC: Atlas subluxation complex
CHAMP: Calgary Headache Assessment and Management Program
CSF: Cerebrospinal Fluid
GSA: Gravity Stress Analyzer
HIT-6: Headache Impact Test-6
HRQoL: Health Related Quality of Life
ICCI: Intracranial compliance index
ICVC: Intracranial volume change
IQR: Interquartile range
MIDAS: Migraine Disability Assessment Scale
MSQL: Migraine-Specific Quality of Life Measure
MSQL-E: Migraine-Specific Quality of Life Measure-Emotional
MSQL-P: Migraine-Specific Quality of Life Measure-Physical
MSQL-R: Migraine-Specific Quality of Life Measure-Restrictive
NUCCA: National Upper Cervical Chiropractic Association
PC-MRI: Phase Contrast Magnetic Resonance Imaging
SLC: Supine Leg Check
VAS: Visual Analog Scale.
Conflict of Interests
The authors declare that there are no financial or any other competing interests regarding the publication of this paper.
H. Charles Woodfield III conceived the study, was instrumental in its design, helped in coordination, and helped to draft the paper: introduction, study methods, results, discussion, and conclusion. D. Gordon Hasick screened subjects for study inclusion/exclusion, provided NUCCA interventions, and monitored all subjects on follow-up. He participated in study design and subject coordination, helping to draft the Introduction, NUCCA Methods, and Discussion of the paper. Werner J. Becker screened subjects for study inclusion/exclusion, participated in study design and coordination, and helped to draft the paper: study methods, results and discussion, and conclusion. Marianne S. Rose performed statistical analysis on study data and helped to draft the paper: statistical methods, results, and discussion. James N. Scott participated in study design, served as the imaging consultant reviewing scans for pathology, and helped to draft the paper: PC-MRI methods, results, and discussion. All authors read and approved the final paper.
In conclusion, the case study regarding the improvement of migraine headache symptoms following atlas vertebrae realignment demonstrated an increase in the primary outcome, however, the average results of the research study also demonstrated no statistical significance. Altogether, the case study concluded that patients who received atlas vertebrae realignment treatment experienced considerable improvement in symptoms with decreased headache days. Information referenced from the National Center for Biotechnology Information (NCBI). The scope of our information is limited to chiropractic as well as to spinal injuries and conditions. To discuss the subject matter, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
Curated by Dr. Alex Jimenez
Additional Topics: Neck Pain
Neck pain is a common complaint which can result due to a variety of injuries and/or conditions. According to statistics, automobile accident injuries and whiplash injuries are some of the most prevalent causes for neck pain among the general population. During an auto accident, the sudden impact from the incident can cause the head and neck to jolt abruptly back-and-forth in any direction, damaging the complex structures surrounding the cervical spine. Trauma to the tendons and ligaments, as well as that of other tissues in the neck, can cause neck pain and radiating symptoms throughout the human body.
1. Magoun H. W. Caudal and cephalic influences of the brain stem reticular formation. Physiological Reviews. 1950;30(4):459–474. [PubMed]
2. Gregory R. Manual of Upper Cervical Analysis. Monroe, Mich, USA: National Upper Cervical Chiropractic Association; 1971.
3. Thomas M., editor. NUCCA Protocols and Perspectives. 1st. Monroe, Mich, USA: National Upper Cervical Chiropractic Association; 2002.
4. Grostic J. D. Dentate ligament-cord distortion hypothesis. Chiropractic Research Journal. 1988;1(1):47–55.
5. Alperin N., Sivaramakrishnan A., Lichtor T. Magnetic resonance imaging-based measurements of cerebrospinal fluid and blood flow as indicators of intracranial compliance in patients with Chiari malformation. Journal of Neurosurgery. 2005;103(1):46–52. doi: 10.3171/jns.2005.103.1.0046. [PubMed][Cross Ref]
6. Czosnyka M., Pickard J. D. Monitoring and interpretation of intracranial pressure. Journal of Neurology, Neurosurgery and Psychiatry. 2004;75(6):813–821. doi: 10.1136/jnnp.2003.033126. [PMC free article][PubMed][Cross Ref]
7. Tobinick E., Vega C. P. The cerebrospinal venous system: anatomy, physiology, and clinical implications. MedGenMed: Medscape General Medicine. 2006;8(1, article 153) [PubMed]
8. Eckenhoff J. E. The physiologic significance of the vertebral venous plexus. Surgery Gynecology and Obstetrics. 1970;131(1):72–78. [PubMed]
9. Beggs C. B. Venous hemodynamics in neurological disorders: an analytical review with hydrodynamic analysis. BMC Medicine. 2013;11, article 142 doi: 10.1186/1741-7015-11-142. [PMC free article][PubMed][Cross Ref]
10. Beggs C. B. Cerebral venous outflow and cerebrospinal fluid dynamics. Veins and Lymphatics. 2014;3(3):81–88. doi: 10.4081/vl.2014.1867. [Cross Ref]
11. Cassar-Pullicino V. N., Colhoun E., McLelland M., McCall I. W., El Masry W. Hemodynamic alterations in the paravertebral venous plexus after spinal injury. Radiology. 1995;197(3):659–663. doi: 10.1148/radiology.197.3.7480735. [PubMed][Cross Ref]
12. Damadian R. V., Chu D. The possible role of cranio-cervical trauma and abnormal CSF hydrodynamics in the genesis of multiple sclerosis. Physiological Chemistry and Physics and Medical NMR. 2011;41(1):1–17. [PubMed]
13. Bakris G., Dickholtz M., Meyer P. M., et al. Atlas vertebra realignment and achievement of arterial pressure goal in hypertensive patients: a pilot study. Journal of Human Hypertension. 2007;21(5):347–352. doi: 10.1038/sj.jhh.1002133. [PubMed][Cross Ref]
14. Kumada M., Dampney R. A. L., Reis D. J. The trigeminal depressor response: a cardiovascular reflex originating from the trigeminal system. Brain Research. 1975;92(3):485–489. doi: 10.1016/0006-8993(75)90335-2. [PubMed][Cross Ref]
15. Kumada M., Dampney R. A. L., Whitnall M. H., Reis D. J. Hemodynamic similarities between the trigeminal and aortic vasodepressor responses. The American Journal of Physiology—Heart and Circulatory Physiology. 1978;234(1):H67–H73. [PubMed]
16. Goadsby P. J., Edvinsson L. The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats. Annals of Neurology. 1993;33(1):48–56. doi: 10.1002/ana.410330109. [PubMed][Cross Ref]
17. Goadsby P. J., Fields H. L. On the functional anatomy of migraine. Annals of Neurology. 1998;43(2, article 272) doi: 10.1002/ana.410430221. [PubMed][Cross Ref]
18. May A., Goadsby P. J. The trigeminovascular system in humans: pathophysiologic implications for primary headache syndromes of the neural influences on the cerebral circulation. Journal of Cerebral Blood Flow and Metabolism. 1999;19(2):115–127. [PubMed]
19. Goadsby P. J., Hargreaves R. Refractory migraine and chronic migraine: pathophysiological mechanisms. Headache. 2008;48(6):799–804. doi: 10.1111/j.1526-4610.2008.01157.x. [PubMed][Cross Ref]
20. Olesen J., Bousser M.-G., Diener H.-C., et al. The international classification of headache disorders, 2nd edition (ICHD-II)—revision of criteria for 8.2 medication-overuse headache. Cephalalgia. 2005;25(6):460–465. doi: 10.1111/j.1468-2982.2005.00878.x. [PubMed][Cross Ref]
21. Stewart W. F., Lipton R. B., Whyte J., et al. An international study to assess reliability of the Migraine Disability Assessment (MIDAS) score. Neurology. 1999;53(5):988–994. doi: 10.1212/wnl.53.5.988. [PubMed][Cross Ref]
22. Wagner T. H., Patrick D. L., Galer B. S., Berzon R. A. A new instrument to assess the long-term quality of life effects from migraine: development and psychometric testing of the MSQOL. Headache. 1996;36(8):484–492. doi: 10.1046/j.1526-4610.1996.3608484.x. [PubMed][Cross Ref]
23. Kosinski M., Bayliss M. S., Bjorner J. B., et al. A six-item short-form survey for measuring headache impact: the HIT-6. Quality of Life Research. 2003;12(8):963–974. doi: 10.1023/a:1026119331193. [PubMed][Cross Ref]
24. Eriksen K., Rochester R. P., Hurwitz E. L. Symptomatic reactions, clinical outcomes and patient satisfaction associated with upper cervical chiropractic care: a prospective, multicenter, cohort study. BMC Musculoskeletal Disorders. 2011;12, article 219 doi: 10.1186/1471-2474-12-219. [PMC free article][PubMed][Cross Ref]
25. National Upper Cervical Chiropractic Association. NUCCA Standards of Practice and Patient Care. 1st. Monroe, Mich, USA: National Upper Cervical Chiropractic Association; 1994.
26. Gregory R. A model for the supine leg check. Upper Cervical Monograph. 1979;2(6):1–5.
27. Woodfield H. C., Gerstman B. B., Olaisen R. H., Johnson D. F. Interexaminer reliability of supine leg checks for discriminating leg-length inequality. Journal of Manipulative and Physiological Therapeutics. 2011;34(4):239–246. doi: 10.1016/j.jmpt.2011.04.009. [PubMed][Cross Ref]
28. Andersen R. T., Winkler M. The gravity stress analyzer for measuring spinal posture. Journal of the Canadian Chiropractic Association. 1983;2(27):55–58.
29. Eriksen K. Subluxation X-ray analysis. In: Eriksen K., editor. Upper Cervical Subluxation Complex—A Review of the Chiropractic and Medical Literature. 1st. Philadelphia, Pa, USA: Lippincott Williams & Wilkins; 2004. pp. 163–203.
30. Zabelin M. X-ray analysis. In: Thomas M., editor. NUCCA: Protocols and Perspectives. 1st. Monroe: National Upper Cervical Chiropractic Association; 2002. p. p. 10-1-48.
31. Miyati T., Mase M., Kasai H., et al. Noninvasive MRI assessment of intracranial compliance in idiopathic normal pressure hydrocephalus. Journal of Magnetic Resonance Imaging. 2007;26(2):274–278. doi: 10.1002/jmri.20999. [PubMed][Cross Ref]
32. Alperin N., Lee S. H., Loth F., Raksin P. B., Lichtor T. MR-intracranial pressure (ICP). A method to measure intracranial elastance and pressure noninvasively by means of MR imaging: baboon and human study. Radiology. 2000;217(3):877–885. doi: 10.1148/radiology.217.3.r00dc42877. [PubMed][Cross Ref]
33. Raksin P. B., Alperin N., Sivaramakrishnan A., Surapaneni S., Lichtor T. Noninvasive intracranial compliance and pressure based on dynamic magnetic resonance imaging of blood flow and cerebrospinal fluid flow: review of principles, implementation, and other noninvasive approaches. Neurosurgical Focus. 2003;14(4, article E4) [PubMed]
34. Koerte I. K., Schankin C. J., Immler S., et al. Altered cerebrovenous drainage in patients with migraine as assessed by phase-contrast magnetic resonance imaging. Investigative Radiology. 2011;46(7):434–440. doi: 10.1097/rli.0b013e318210ecf5. [PubMed][Cross Ref]
35. Pomschar A., Koerte I., Lee S., et al. MRI evidence for altered venous drainage and intracranial compliance in mild traumatic brain injury. PLoS ONE. 2013;8(2) doi: 10.1371/journal.pone.0055447.e55447 [PMC free article][PubMed][Cross Ref]
36. Bayliss M. S., Batenhorst A. S. The HIT-6 A User’s guide. Lincoln, RI, USA: QualityMetric Incorporated; 2002.
37. Coeytaux R. R., Kaufman J. S., Chao R., Mann J. D., DeVellis R. F. Four methods of estimating the minimal important difference scores were compared to establish a clinically significant change in Headache Impact Test. Journal of Clinical Epidemiology. 2006;59(4):374–380. doi: 10.1016/j.jclinepi.2005.05.010. [PubMed][Cross Ref]
38. Smelt A. F. H., Assendelft W. J. J., Terwee C. B., Ferrari M. D., Blom J. W. What is a clinically relevant change on the HIT-6 questionnaire? An estimation in a primary-care population of migraine patients. Cephalalgia. 2014;34(1):29–36. doi: 10.1177/0333102413497599. [PubMed][Cross Ref]
39. Sauro K. M., Rose M. S., Becker W. J., et al. HIT-6 and MIDAS as measures of headache disability in a headache referral population. Headache. 2010;50(3):383–395. doi: 10.1111/j.1526-4610.2009.01544.x. [PubMed][Cross Ref]
40. Bagley C. L., Rendas-Baum R., Maglinte G. A., et al. Validating migraine-specific quality of life questionnaire v2.1 in episodic and chronic migraine. Headache. 2012;52(3):409–421. doi: 10.1111/j.1526-4610.2011.01997.x. [PubMed][Cross Ref]
41. Cole J. C., Lin P., Rupnow M. F. T. Minimal important differences in the Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1. Cephalalgia. 2009;29(11):1180–1187. doi: 10.1111/j.1468-2982.2009.01852.x. [PubMed][Cross Ref]
42. Dodick D. W., Silberstein S., Saper J., et al. The impact of topiramate on health-related quality of life indicators in chronic migraine. Headache. 2007;47(10):1398–1408. doi: 10.1111/j.1526-4610.2007.00950.x. [PubMed][Cross Ref]
43. Hróbjartsson A., Gøtzsche P. C. Placebo interventions for all clinical conditions. Cochrane Database of Systematic Reviews. 2010;(1)CD003974 [PubMed]
44. Meissner K. The placebo effect and the autonomic nervous system: evidence for an intimate relationship. Philosophical Transactions of the Royal Society B: Biological Sciences. 2011;366(1572):1808–1817. doi: 10.1098/rstb.2010.0403. [PMC free article][PubMed][Cross Ref]
45. Marshall I., MacCormick I., Sellar R., Whittle I. Assessment of factors affecting MRI measurement of intracranial volume changes and elastance index. British Journal of Neurosurgery. 2008;22(3):389–397. doi: 10.1080/02688690801911598. [PubMed][Cross Ref]
46. Raboel P. H., Bartek J., Andresen M., Bellander B. M., Romner B. Intracranial pressure monitoring: invasive versus non-invasive methods-A review. Critical Care Research and Practice. 2012;2012:14. doi: 10.1155/2012/950393.950393 [PMC free article][PubMed][Cross Ref]
47. Wentland A. L., Wieben O., Korosec F. R., Haughton V. M. Accuracy and reproducibility of phase-contrast MR imaging measurements for CSF flow. American Journal of Neuroradiology. 2010;31(7):1331–1336. doi: 10.3174/ajnr.A2039. [PMC free article][PubMed][Cross Ref]
48. Koerte I., Haberl C., Schmidt M., et al. Inter- and intra-rater reliability of blood and cerebrospinal fluid flow quantification by phase-contrast MRI. Journal of Magnetic Resonance Imaging. 2013;38(3):655–662. doi: 10.1002/jmri.24013. [PMC free article][PubMed][Cross Ref]
49. Stoquart-Elsankari S., Lehmann P., Villette A., et al. A phase-contrast MRI study of physiologic cerebral venous flow. Journal of Cerebral Blood Flow and Metabolism. 2009;29(6):1208–1215. doi: 10.1038/jcbfm.2009.29. [PubMed][Cross Ref]
50. Atsumi H., Matsumae M., Hirayama A., Kuroda K. Measurements of intracranial pressure and compliance index using 1.5-T clinical MRI machine. Tokai Journal of Experimental and Clinical Medicine. 2014;39(1):34–43. [PubMed]
51. Becker W. J. Assessing health-related quality of life in patients with migraine. Canadian Journal of Neurological Sciences. 2002;29(supplement 2):S16–S22. doi: 10.1017/s031716710000189x. [PubMed][Cross Ref]