Migraine headache

Kidd RF, Nelson R 1993 Musculoskeletal dysfunction of the neck in migraine and tension headache. Headache 33: 566569 Lewit K 1999 Manipulative Therapy in the Rehabilitation of the Motor System, 3rd ed. Butterworths, London Lipton RB, Stewart WF 1993 Migraine in the United States: a review of epidemiology and health care use. Neurology 43 (Suppl 3): S6S10 Long II C 1956 Myofascial pain syndromes: Part IIFsyndromes of the head, neck, and shoulder girdle. Henry Ford Hospital Medical Bulletin 4: 2228 Lu J, Ebraheim NA 1998 Anatomic considerations of the C2 nerve root ganglion. Spine 23: 649652

MacGregor EA, Chia H, Vohrah RC, et al. 1990 Migraine and menstruation: a pilot study. Cephalalgia 10: 305310 Marcus DA, Schar L, Turk D, Gourley LM 1997 A double-blind provocative study of chocolate as a trigger of headache. Cephalalgia 17: 855862 Radanov BP, Di Stefano G, Schnidrig A, Strurzenegger M 1994 Common whiplash: psychosomatic or somatopsychic. Journal of Neurology, Neurosurgery, and Psychiatry 57: 486490 Raskin, NH 1998 Headache, 2nd ed. Churchhill Livingstone Inc., New York Simons D, Travell J 1999 Myofascial Pain and Dysfunction, Vol 1, 2nd ed. Baltimore, MD, 316pp

Stewart WF, Lipton RB, Celentano DD, Reed ML 1992 Prevalence of migraine headache in the United States. Journal of the American Medical Association 267: 6469 Teasell RW, McCain GA 1992 Clinical spectrum and management of whiplash injuries. In: Tollison CD, Sutterthwaite JR ed. Painful cervical trauma, Williams and Wilkens, Baltimore, MD, 292318 Upledger J 1983 Craniosacral Therapy. Eastland Press, Seattle pp 8687 Weiselsh S 1994 Manual Therapy. ANA Publishing, West Hartford 25pp

Migraines the Applied Kinesiology and Chiropractic perspective

Terry M. Hambrick

Introduction
This case is notable in that it contains most of the classical multifactorial elements typically found in instances of migraine headaches. Purely from a structurally based Chiropractic perspective, correction of the cervical and thoracic subluxations resulting from the postural distortion is imperative. Further, a comprehensive evaluation of the patient with the standard techniques of Applied Kinesiology provides additional data that informs the clinical decision-making process and directs therapy.

History
As with any patient, attention to familial patterns and the circumstances surrounding onset is revealing. In this instance, there is a family history of migraines which follows the statistical predilection for gender, occurring only in females in the maternal lineage (Merck 1992). The onset of Shellys headaches during high school indicates the possibility of hormonal inuence at or near menarche. It is often very informative in the history-taking process to inquire of the patient what else was happening in your life when your symptoms began? This question provides insight into emotional factors, circumstances of life and habit patterns, which cause or contribute to symptoms, though they may appear unrelated in the mind of the patient.

Terry M. Hambrick DC, DIBAK 110 W. Harvard Street, Fort Collins, CO 80524, USA Tel.: +1-970-282-1173; Fax: +1-970-282-1175; E-mail: hambrick@peakpeak.com
........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 37^41 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00065-7 S1360-8592/03/$ - see front matter

Examination
While the history and symptom picture guide the examination, care
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should be taken to search for causes. Particularly in the natural healthcare community, the most commonly accepted causes or contributors to migraine are: food allergies (Sinclair 1999), vascular (Merck 1992), endocrine imbalances (Sinclair 1999) nutritional deciencies (Murray 1996), structural/biomechanical (Nelson et al. 1998), stress (Sinclair 1999), acupuncture imbalance (Walther 1988; Sprott 1998). Often, patients present with complaints of migraines although they have not been classically or carefully diagnosed with true migraines. Severe headaches do not necessarily t in the accepted denition of migraines. Clinicians and practitioners are cautioned to avoid conclusions about causation, based exclusively on the patients report that they suer from migraines. As a result, the suggestion to x what you nd is well taken in this instance. As a result, the examination should proceed based on clinical observation rather than presumption.

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As with any patient, after gathering the pertinent data in the patients history, a thorough examination is directed by the history, the current presentation and known etiologies. Standard vital signs should always be monitored as these simple examination procedures provide valuable information that further directs the evaluation. Blood pressure taken in the supine, seated and standing positions oers indications of impaired kidney function and adrenal function as well as conrming frank hypotension or hypertension as possible inuences on the vascular portion of migraine headaches. Pulse rate above 80 or below 60 indicates the need for considering autonomic nervous system imbalance such as parasympatheticotonia or sympatheticotonia. The Nutri-Spec system suggests an even narrower range of pulse rate (6777) indicative of autonomic imbalance (Schenker 1995). The above-stated range of 6080 is presented as a simple set of round numbers for the examiner to keep in mind when reviewing vital signs on a migraine patient. Axillary temperature below 98.2 leads to a consideration of hypothyroidism which is known to correlate with migraines (Murray 1996, p. 472). Accelerated respiratory rate may indicate metabolic acidosis which requires additional evaluation and may point to deeper causes for the migraine such as food allergy/intolerance. Conversely, it also suggests the possibility of frank hyperventilation which occurs with respiratory alkalosis and can result from anxiety, among other more serious pathological causes (Merck 1992). Blood sugar imbalances are also worthy of consideration in both directing the exam and ruling out underlying causes. There are many simple questionnaires available that

provide insight into this potential in patients presenting with any type of headache. These are found as symptom survey forms provided by various nutrition companies such as Nutri-West and Standard Process Labs. Hypoglycemia, such a simple entity to identify, can often be overlooked inadvertently in the search for more complex causative factors. Also, a simple glucometer is useful in monitoring symptomatic patients for more graphic swings in blood glucose levels. A more indepth clinical and diagnostic evaluation would involve the administration of a 6-glucose tolerance test, well described in Dr David Walthers textbook on Applied Kinesiology (Walther 1988). When spinal subluxation is either the cause or a contributing factor, both static and motion palpation will reveal reduced motion in the vertebral segments, rotational malposition of involved segments and the presence of trigger points in the cervical and sub-occipital musculature (Travell & Simons 1983). These osseous ndings can be conrmed by X-ray analysis, as stated below. Commonly, a series of AP and lateral cervical lms plus an AP-open mouth view are indicated as the preliminary screening for the spinal component in the case presented. In light of the postural presentation of rounded shoulders and the diaphragmatic restrictions, an AP and lateral thoracic lm is also indicated. Typically, the views ordered in the Chiropractic oce are dependent, not only on the case presentation, but also on the practitioners orientation and technique. Thus, a full-spine series is often performed, providing insight into the structural inuence of pelvis and lumbar balance on the thoracic and cervical alignment. Suce it to say that, at minimum, the AP, lateral and APOM cervical series are indicated when structural correction
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by spinal adjusting is based on radiographic ndings. Care should be taken to avoid overexposure to radiation, both by virtue of proper radiographic technique, collimation and shielding as well as by taking only those views that are absolutely necessary to diagnose and direct treatment. The overutilization of X-ray as a practice-building tool has no legitimate place in patient management. Applied Kinesiology practitioners most commonly base their adjustive thrusts on therapy localization (TL) and challenge of the suspected segments. These diagnostic procedures are well described, as below, in Dr David S. Walthers Applied Kinesiology Synopsis (see Boxes 1 and 2). Range of motion evaluation points to both soft and hard tissue restrictions that respond well to manual therapies. A simple test with a Thera-bite or some other dental device for identifying range of opening and lateralization of the jaw serves well to inform the clinician of possible temporomandibular joint involvement (see Box 3).

Treatment
Since migraines are considered to have a vascular component (Merck 1992), it is logical to consider the impact of cervical subluxation on the cerebro-vascular tree primarily through the eect of subluxations on the vertebral artery. The ecacy of spinal manipulation as therapy for migraine headaches is documented (Nelson et al. 1998) and known to be clinically appropriate when the presence of cervical subluxation is demonstrable. This case, as described, portends a nding of hypolordosis or kyphosis in the cervical spine. While one may be led to suspect this as a constant presentation in forward head posture, in some cases, this postural pattern is accompanied by hyperlordosis of the lower cervical

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Box 1 Therapy localization Therapy localization is dened as a procedure of placing the patients hand over areas of suspected involvement, then using muscle-testing procedures to determine any change in strength. Placing the patients hand on dierent locations stimulates nerve endings in the area being touched and produces a momentary alteration in the input to the central nervous system. It is a diagnostic tool to be combined with other information gathered from examination in order to indicate where treatment is needed. An example of proper utilization of therapy localization is to test an individual muscle to use as an indicator. For example, the examiner can isolate the pectoralis major, clavicular division on the patient and determine the level of resistance the patient is able to produce. Next, the examiner has the patient use their free hand to touch the cervical vertebrae, one at a time, while the examiner re-tests the previously intact pectoralis muscle to ascertain whether touching any of the vertebrae causes a change in muscle facilitation. If the muscle becomes neurologically inhibited (weakens) as a result of the patients therapy localization to C2, for example, this is an indication that there is some problem in the area of C2. In order to interpret the results of this form of diagnosis, it is important to understand the characteristics and meanings of therapy localization. It does not tell what the problem is, only where the problem is located. Using the example of C2 above, touching the second cervical and observing a weakening of the pectoralis clavicular means only one thing: something is dysfunctioning in the area of C2. Perhaps it is a subluxation or, it might be an active acupuncture point on the bladder, gall bladder or governing vessel meridians which course along the surface of the posterior cervical region. It could also be an active neurolymphatic reex or a scar that is causing interference with normal nerve transmission in the area. As a result, therapy localization is utilized only to determine where a problem is located and additional techniques are required to identify what the problem is and what needs to be done to relieve the problem.

Box 2 Vertebral challenge Challenge is also performed based on neurologic feedback loops. It is dened as a mechanism used as a testing procedure to determine the bodys ability to cope with external stimuli. In the case of using challenge to identify which spinal segment to adjust in which direction, the articulation is pushed in a direction that is suspected to be the proper direction for correction and a previously intact muscle is re-tested immediately after the articulation is challenged. Dierent directions or vectors are challenged until the one vector that causes the previously intact muscle to weaken is identied. This is considered the proper direction for an adjustive thrust to be made. Using the example from the therapy localization discussion above, if pressing the second cervical vertebra from posterior to anterior on the left and immediately releasing the pressure causes the pectoralis major to weaken, the correct adjustment would be a P to A thrust on the left side of C2. The premise is that the second cervical is subluxated posteriorly on the left side and that the intrinsic spinal muscles are hypertonic, holding it in that position. When the vertebra is challenged out of subluxation, the hypertonic spinal muscles respond in a rebound fashion, pulling the vertebra back into an exaggeration of the subluxation, thereby inputting noxious stimulation to the central nervous system. This noxious input results in a temporary conditional inhibition of the previously intact muscle. Thus, challenge can identify what is wrong with C2 that was implied by the where of therapy localization in the example above.

segments and kyphosis in the segments above. The radiographic images oer clarity on the true orientation of the cervical spine and should be referenced to determine treatment. In the Applied Kinesiology based Chiropractic practice, correction of the cervical subluxation and xation patterns is

made based on palpation, radiographic analysis and the aforementioned therapy localization and challenge. This patients report of food cravings especially chocolate around menstruation guides the Applied Kinesiologist to use the standard techniques of muscle testing to
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evaluate for food sensitivities. It is a common observation in clinical practice that patients tend to crave foods to which they have some allergic sensitivity or intolerance. Another possible reason for food cravings is in an unconscious attempt to raise blood sugar in the presence of a hypoglycemic event. Schmitt and Leisman (1998) report a 90.5% correlation between manual muscle testing for food sensitivities and laboratory results for IgG and IgE reactions to the same food substances. When performed in accordance with the standard procedures outlined in the Status Statement of the International College of Applied Kinesiology, manual muscle testing provides an eective and ecient method of screening for foods that an individual patient should avoid due to systemic insult. This testing is administered by rst identifying a muscle or group of muscles that exhibit normal neuromuscular facilitation, labeled as a strong indicator muscle. The patient is then asked to insalivate, but not swallow, a substance commonly considered to be allergenic to some percentage of the population. The most prevalent allergenic foods are chocolate, soy, corn, wheat gluten, peanuts, dairy, eggs and potato or other nightshades. Another substance frequently ingested by humans unaware of its negative impact on health is Aspartames. While some hypersensitive individuals may be reactive to many more food substances than those mentioned above, elimination of the most common allergens often minimizes or eliminates the reactivity to the other less reactive foods. One shortcoming of muscle testing as a diagnostic indicator of food reactions is that it does not oer a graded response scale to dierentiate the more severe from the less severe sensitivities.

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Box 3 Thera-bite range of motion scale The Thera-bite is an instrument which is used to identify the range of opening and lateralization of the jaw joint. It is simply a sheet of card-stock which has a curved edge marked with millimeters on the edge for measuring the opening. A notch at the bottom edge of the curve is placed on the lower central incisors and the patient is instructed to open their mouth as wide as they can while the examiner moves the curved edge to follow the upper teeth to their limit of opening. The number of millimeters of opening is read from the markings on the curved edge. Lateralization is tested with the at side of the card which is also marked with a central point and millimeter measurements to each side. The central point is placed in line with the lower frenulum or center point of the central incisors. The patient is instructed to move their jaw as far to one side as possible while the examiner reads the number of millimeters that the patient is able to laterally displace their jaw. Normal opening is at least 38 mm and lateralization should be equal from side to side and a minimum of 10 mm each side. Thera-bite Range of Motion Scales can be purchased in the US by calling 610-356-9500 or 800-322-2650.

Box 4 Food sensitivities 1. Be sure that the subjects mouth is free of any other substances such as gum, breath mints, etc. 2. Identify at least one intact strong indicator muscle to be used on each subsequent test. Following the generally accepted protocols for testing individual muscles requires, during the test, the patient to not be touching any part of their body with their hands, keep their legs uncrossed, pay attention to the testing, be tested with equal force, same vector, same contact point, and same stabilization on each successive test. Additional parameters for accurate, valid and artful muscle testing are outlined in Dr David S. Walthers book, Applied Kinesiology Synopsis 3. Sprinkle a small amount of the substance to be tested on the patients tongue and have them hold it on their tongue without swallowing. 4. Re-test the previously intact muscle for change in strength (inhibition). 5. If the muscle test remains normally facilitated, this indicates that there is no sensitivity to the food being tested. 6. If the muscle becomes neurologically inhibited, this indicates sensitivity to the substance. 7. After each test, have the patient rinse their mouth with water and, if necessary, wipe their tongue o with gauze or tissue before the next test. 8. Re-test the indicator muscle to be sure it is strong before introducing the next substance.

Powdered sources of all the above food items are relatively easy to procure for testing. It is important for the patient to thoroughly rinse the oral cavity between each substance introduction in order to avoid false positives or combinations that create reactivity and confuse the results. Additionally, the accuracy of testing is improved by re-testing for strength (normal facilitation) before each new material is tested. The procedure for testing for food sensitivities is as in Box 4.

Once the foods and substances that are oensive to the patient have been identied, it is imperative to have them removed entirely from their diet. Patients have a tendency to say that they will cut down on the oending foods, not understanding that it is an all-or-none proposition if they are to gain symptomatic relief. Clinical experience also indicates that patients are both unaware of what foods might contain their allergenic substances and unwilling to change their diet. To quote, Dr Doug Hayes, people will change their
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religion before theyll change their lunch. As a result, patient education in food constituents is required in order to eect complete elimination of the oending agents from the dietary. For example, many breads and pastries contain milk or other dairy products and sugar is the rst ingredient listed on most processed food items. Since people do tend to crave the foods to which they are allergic, this course of treatment for migraines is much more eective if the clinician can minimize or eliminate the cravings. To this end, there are some amino acids that have proven to be very helpful in reducing the desire for substances such as sugar, chocolate and caeine. The L form of phenylalanine, included in DLPA supplements, reduces cravings for Nutrasweets and caeine while L-glutamine is very eective at eliminating sugar, alcohol and starch cravings when used in high enough doses. Tyrosine is benecial in cases of caeine cravings, as well (Chaitow 1985; Ross 1999). Supplementation with individual nutrients and botanicals can also provide some relief for those suering from migraines. Riboavin (vitamin B2) is often used in dosages of 400 mg daily to reduce frequency and intensity of migraines (Murray 1996). Magnesium has been suggested to alter the threshold for migraine when taken in the 600 mg/ day dosage and botanical extracts of Tanacetum parthenium (feverfew) are often used to mediate the pain associated with migraines (Sinclair 1999).

Conclusion
Migraines, having multiple causative and contributory factors, require a multi-factorial approach to both diagnosis and treatment. Utilization of techniques and procedures which take into account the unique

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individuality of each patient and their complicating circumstances is more likely to provide a satisfactory solution than any singular approach in the majority of cases. Treatment must be directed toward the specic imbalances presented in each case while also educating the patient in methods and behaviors that remove the elements which trigger their troubling symptoms. Management of the migraine patient is very rewarding when the diagnosis, treatment and patient compliance are eectively matched. Applied Kinesiology and Chiropractic procedures are valuable tools in the diagnosis and treatment of migraine headaches.

REFERENCES
Chaitow L 1985 Amino Acids in Therapy. Thorsons, Wellingborough, North Qnts, UK, 95pp. Merck 1992 The Merck Manual of Diagnosis and Therapy, Sixteenth Edition. Merck Research Laboratories, Rahway, 1425pp Murray M 1996 Encyclopedia of Nutritional Supplements. Prima Publishing, Rocklin Nelson CF, Bronfort G, Evans R et al. 1998 The ecacy of spinal manipulations, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative and Physiologic Therapeutics 21: 511519 Ross J 1999 The Diet Cure. The Penguin Group, New York, 127pp Schenker G 1995 An Analytical System of Clinical Nutrition. Privately Published, Miintown, 280pp

Schmitt W, Leisman G 1998 Correlation of applied kinesiology muscle testing ndings with serum immunologlobulin levels for food allergies. International Journal of Neuroscience 96: 237244 Sinclair S 1999 Migraine headaches: nutritional, botanical and other alternative approaches. Alternative Medicine Review 4: 8695 Sprott H, Franke S, Kluge H, Hein G 1998 Pain treatment of bromyalgia by acupuncture. Rheumatology International 18: 3536 Travell JG, Simons DG 1983 Myofascial Pain and Dysfunction The Trigger Point Manual. Williams and Wilkins, New York Walther D 1988 Applied Kinesiology. Synopsis Systems DC, Pueblo, 214pp

Endocrine inuences on migraine headache

Gina Makris

Introduction
The aim of this article is to discuss some of the hormonal factors that inuence female migraine headaches. When someone presents with a history of chronic migraine, knowing what the hormonal triggers are can dictate treatment design, inuence treatment success and direct client lifestyle and education programs.

Premise The therapist can have a profound inuence on chronic migraines. Latey (2001) points out that a nal end to migraines is best found in the discussions between the practitioner and the patient. This author would like to add that information gathering comes from many sources and takes a variety of forms. Whether from evaluating tissue tonus, breathing patterns, watching gait mechanics, spinal changes, taking the history or graphing the patterns, being a witness to the therapeutic moment is best served by providing or creating a space for the client to listen to themselves (Rongo 2002). The symptoms of chronic headache when properly documented are great markers for diagnosis, treatment design and measuring success in therapy. They are easy to quantify: onset time,
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duration, intensity, and frequency. The therapist is in a unique position to assist the person in becoming more aware of and charting this information, e.g. what triggers the onset, increases or decreases frequency, intensity and duration. Patterns are an informative and quantiable way to document success in treatment and make the appropriate changes. Having knowledge of hormonal inuences can also help in the choice of which treatment option or therapeutic tools to employ. Case With Shelly, her headaches rst presented in adolescence, a time when headaches are chronicled as primarily hormonal (Silberstein 2001a). Throughout her subsequent 40 years there have been other hormonal, structural and mechanical insults and injuries that

Gina Makris DC, CCN Optimum Health Management, 127N. 4th Street, Geneva, IL 60134, USA Correspondence to: Gina Makris Tel.: +1-630-208-5929 E-mail: drmakris@earthlink.net
........................................... Journal of Bodywork and Movement Therapies (2003) 7(1), 41^45 r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S1360-8592(02)00066-9 S1360-8592/03/$ - see front matter

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