Headache Killing You? Your Chiropractor Can Help/ by Dr. Moshe Laub
What kind of headaches do you get? Do you get the ones that start at the top of your head and move downwards? Do you get the ones that feel like some-one has placed an iron band around your temples and is relentlessly tightening it? Do you get the ones that feel like you're being repeatedly hit at the back of your skull with a hammer? Whatever your headaches feel like, your first thought is probably to reach for medication, either prescription or over-the-counter. Calling your chiropractor may be your last thought about how to treat headaches, but research is showing that this may actually be your best option. This is because chiropractors are specialists in the rehabilitation of the nervous system. The pain that we experience in a headache is only the end result of a disease process. Using many different techniques, chiropractors can retrain the body to address the underlying cause of the headache.
Many headaches, including stress headaches, originate in the neck, shoulders or upper back. Muscle tension and skeletal misalignment lead to nervous system irritation, which can cause headaches. These headaches are effectively treated with chiropractic. Research has shown chiropractic to also be useful with vascular headaches, such as migraines. Chiropractors are also well trained to provide lifestyle and dietary counseling toward preventing future headaches.
Chiropractors treat misalignments of bones and other skeletal tissues. When a bone is out of its normal position, it is called a subluxation. Subluxations in the spine can pull on muscles or press on the roots of the nerves that feed into the spinal cord. It may surprise you to find out just how many headaches are potentially related to subluxations. When you think about it, however, it makes a lot of sense: the skull has 22 separate bones and sits on top of the smallest bones in the spinal column. One study showed that people with the most common types of recurring headaches have much less mobility in their neck than a control group . In fact, chiropractic can treat more than 90 percent of the causes of headaches.
Cost of Headaches
Headaches are often disregarded as a minor problem. To the contrary, headaches can be debilitating. People with recurrent headaches miss work more often, use more healthcare resources, and work at lower levels of efficiency while in pain. Headaches are the most common usage of over-the-counter pain medication . All these effects have financial costs. One study estimated that $5.6billion to $17.2billion in worker productivity are lost every year simply to one type of headaches, migraines . Another report estimated 156 million full-time equivalent workdays are lost each year because of headaches.
What Causes Headaches?
No common mechanism causes pain in all headaches, the pain is generated differently in different types of headache . Many people think of a headache as a pain in the brain itself. The brain, however, does not directly feel pain. Even directly stimulating the brain's surface during surgery won't cause pain.
The pain instead largely comes from other places. Many headaches, including stress headaches, originate in the neck, shoulders or upper back. Muscle tension and skeletal misalignment lead to nervous system irritation, which can cause headaches.
Conventional Treatment for Headaches
Conventional treatment options for headaches are almost entirely focused on medications. Non-prescription medications like aspirin and acetaminophen (Tylenol™) are popular options, as are caffeine and herbal preparations. Medication has risks and side effects, of course. Prescriptions have even greater risks and side effects.
Even if medications work, they can cause rebound headaches; this is when after a medication's effects wear off, the headache returns. Rebound headaches occur because they generally don't treat the underlying cause of the headache, they only treat the pain. One study showed that although 85% of those receiving the prescription drug sumatriptan (Imitrex®) experienced relief of their migraine, 45% of those had another migraine within 24 hours.
Of all alternative treatments to medication, chiropractic is the most popular. 15% of people that have tried complementary and alternative medical treatments have used chiropractic, accounting for 18 to 38 million manipulations performed annually . Chiropractic manipulation has demonstrated ability to reduce the frequency and pain of migraine, tension-type, and cervicogenic headaches. Together, these headaches make up 90% of recurring headaches.
Chiropractic is a branch of the healing arts which is based upon the understanding that good health depends, in part, upon a normally functioning nervous system (especially the spine, and the nerves extending from the spine to all parts of the body). "Chiropractic" comes from the Greek word Chiropraktikos, meaning "effective treatment by hand." Chiropractic stresses the idea that the cause of many disease processes begins with the body's inability to adapt to its environment. It looks to address these diseases not by the use of drugs and chemicals, but by locating and adjusting a musculoskeletal area of the body which is functioning improperly.
The conditions which doctors of chiropractic address are as varied and as vast as the nervous system itself. All chiropractors use a standard procedure of examination to diagnose a patient's condition and arrive at a course of treatment. Doctors of chiropractic use the same time-honored methods of consultation, case history, physical examination, laboratory analysis and x-ray examination as any other doctor. In addition, they provide a careful chiropractic structural examination, paying particular attention to the spine.
The examination of the spine to evaluate structure and function is what makes chiropractic different from other health care procedures. Your spinal column is a series of movable bones which begin at the base of your skull and end in the center of your hips. Thirty-one pairs of spinal nerves extend down the spine from the brain and exit through a series of openings. The nerves leave the spine and form a complicated network which influences every living tissue in your body.
Accidents, falls, stress, tension, overexertion, and countless other factors can result in a displacements or derangements of the spinal column, causing irritation to spinal nerve roots. These irritations are often what cause malfunctions in the human body. Chiropractic teaches that reducing or eliminating this irritation to spinal nerves can cause your body to operate more efficiently and more comfortably.
Chiropractic also places an emphasis on nutritional and exercise programs, wellness and lifestyle modifications for promoting physical and mental health. While chiropractors make no use of drugs or surgery, Doctors of chiropractic do refer patients for medical care when those interventions are indicated. In fact, chiropractors, medical doctors, physical therapists and other health care professionals now work as partners in occupational health, sports medicine, and a wide variety of other rehabilitation practices.
Chiropractic Care for Headaches
Chiropractors have a wide variety of tools available to treat pain in general and headaches in particular. These tools include Low Level Laser Therapy (LLLT) or Cold Laser Therapy, Transcutaneous Electrical Nerve Stimulation (TENS), Craniosacral Therapy (CST), Temporomandibular joint (TMJ) gentle adjustments, Spinal Manipulation Therapy (SMT) and Activator Method.
LLLT uses a type of laser that puts out red or near-infrared light. This type of laser does not heat the skin or underlying tissue, so it is also called Cold Laser Therapy. The laser is directed at the skin at the site of and injury to improve wound and soft tissue healing. This can provide relief for both acute and chronic pain. LLLT has shown great promise for chronic pain in areas directly related to the spine, such as the lower back . Even more important, LLLT causes the growth of new blood vessels to supply an injured or diseased tissue. This process, called vascularization, promotes healing by bringing more blood, and therefore more nutrients and healing factors, to the area.
Like LLLT, TENS is used to relieve pain by applying energy to the skin to treat the soft tissues underneath. Unlike LLLT, however, TENS uses electrical currents. This doesn't mean that the chiropractor will be sending electrical shocks through your body, quite the opposite, in fact. The TENS electrodes induce electrical currents, which is what your nervous system also does. There are generally two modes for TENS, one that uses high frequency currents that are weaker than the nervous system signals and one that uses lower frequency currents strong enough to produce muscle contraction, but not pain. TENS has also been shown to reduce chronic musculoskeletal pain by using two different mechanisms. The electric current stimulates a type of nerve fibers that interferes with the perception of pain (called the gate-control mechanism) and it also provides a path for the body's own pain relievers. The brain produces a group of chemicals called endorphins to reduce pain. Usually, when pain or an injury causes these to be released, they travel throughout the body. TENS can help direct the flow of endorphins to the specific spot that needs them, multiplying the effect they have.
Craniosacral Therapy is a treatment therapy that gently works with the patient's skull, spine and the cranial sutures, spinal fascia, and related tissues. This reduces pressure on nerves, helps restore proper flow of the cerebrospinal fluid, and return misaligned bones to their proper positions. Chiropractors physicians have used CST to treat neck and back pain, migraines, TMJ Syndrome, and chronic pain conditions.
The temporomandibular joint is the joint where the lower jaw pivots against the rest of the skull. Misalignments of the structures of this joint cause widespread pain that affects not merely the lower jaw bone, but also nerves, blood vessels, ligaments, menisci, several muscles and more. Correctly aligning this joint through gentle adjustments can reduce or eliminate many cases of long-standing pain in the head that have been resistant to other treatments.
SMT is the type of therapy that most people think of when they think of chiropractors, and was the foundation of modern chiropractic when it was founded in the 1800's. SMT is actually a large collection of techniques that apply force or pressure to an area of the spine, which the chiropractor will combine as needed. Some of these techniques include massage or mobilization of soft tissue, adjustment of spinal subluxations, trigger point therapy, cross-friction massage, active release therapy, mechanical traction or of external resistance on an area of the spine or on an extremity. SMT is also probably the alternative therapy that has the best evidence for efficacy in treating chronic headaches. In one analysis of nine separate studies involving almost 700 patients, SMT was shown to be as effective as drugs in treating the most common chronic headaches.
Activator Method is a low-force chiropractic adjustment technique that uses specially-designed instruments to help the chiropractor restore spinal balance. By providing a controlled force in a specific direction and amount, this method provides faster adjustments that are better than manual adjustments for some patients. Like all direct manipulation methods, Activator Method evaluates, monitors and affects the nervous system and its reflex mechanisms and is not simply a method of moving bones.
The most common recurring headaches are treatable through chiropractic treatments. There are many different causes of headaches, however, and chiropractic can treat most of these cases. Headaches fall into these classifications:
• Cervicogenic-migraine complex
◦ Cervicogenic headaches
◦ Migraine headaches
• Tension headaches
• Disorders of head and neck structures, including temporomandibular joint (TMJ) pain
• Post-concussion headache
• Cluster headaches
• Miscellaneous "benign" headaches, a category that includes ice cream headaches, headaches from exertion, and headaches from external compression (as in a tight-fitting helmet) that are not related to an underlying disorder
• Head trauma, which can either be acute (immediately after the trauma) or chronic (persisting for a long time past the trauma)
• Vascular disorders, one of the most dangerous but also one of the least common causes of headache. They range from acute bleeding into the spaces between the brain and the skull to long-term irritation of the veins and arteries supplying the brain.
• Postural headaches, which are headaches that are related to blood pressure changes from changing position, such as from lying down to standing up.
• Infections like meningitis and encephalitis
• Headaches caused by tumors and other growths
• Drugs and alcohol, including prescription medications like nitrates and nitrites
• Headache from bacterial or viral infections, like the flu
• Metabolic disorders
• Irritation of the nerves that come from the brain stem and supply the head and neck
Cervicogenic-Migraine Complex is a new classification of headaches. Research is emerging that suggests that two formerly separate classifications are part of a continuum of head pain. These two classifications are cervicogenic and migraine headaches. Together, they make the most common source of recurring head pain, and evidence shows that chiropractic care is very useful in treating them.
A very common type of recurring headache is called the cervicogenic headache. In simple terms, "cervicogenic" means "starting at the neck." The anatomy of the joint between the skull and the top of the spine contributes to many headaches. A small muscle which helps tilt the heads backwards runs from the uppermost vertebra in the spine to the back of the skull. There is a small band of tissue that connects this muscle to one of the linings that surround and protect the brain . This means any displacement or misalignment of the top of the neck directly pulls on this lining, causing headaches.
Cervicogenic headaches are a relatively new classification of headaches, so they are frequently undiagnosed. Fortunately, chiropractic can diagnose and treat the subluxations that underlie the headaches. Research has shown that SMT can reduce the use of pain medication by 36%, reduce the length of headaches by 69%, and reduce headache intensity by 36% . Another very recent study found that chiropractic treatment reduced pain by an average of 50% in cervicogenic headaches . Another study found that patients receiving spinal manipulation therapy once a week and those receiving treatment 3 or 4 times a week both experienced pain relief, but those receiving more treatments had greater relief that lasted longer.
Migraines are recurrent headaches that happen at varying periods, and often include visual disturbances. The cause of migraines is still being researched, and subject to some controversy. Most theories indicate that disturbances of messages between brain cells lead to changes in blood flow, eventually causing pain by making the arteries supplying the brain swell. These arteries have pain-sensing nerves in the vessel walls. Besides the pain, this swelling is also theorized to cause the other effects of migraines, like the visual effects and gastrointestinal disturbances.
Treatment by a chiropractor for migraines will address subluxations in the upper neck. The joint tenderness, muscle spasms, and nerve irritations that these subluxations cause are thought to be part of the migraine complex. These subluxations are also the reason why some authorities are considering e migraines and cervicogenic headaches to be related disorders.
In one study, patients receiving spinal manipulation from a chiropractor reported reduction in pain, reduction in the number of migraine attacks per month, and shorter duration of migraines . Another 16-week study reported SMT provided initial relief of pain almost as much as patients taking standard anti-migraine medication, but almost twice as many patients in the spinal manipulation group reported pain relief 4 weeks later.
Tension headaches are recurring headaches that feel like pressing or tightening on the skull. The exact mechanism is not known, but involuntary tightening of the muscles of the head is suspected to contribute. Like cervicogenic headaches, therefore, possible misalignments of the head and neck are likely culprits in the pain.
The standard treatments for tension headaches are either over the counter analgesics (aspirin, Tylenol™, Motrin™ etc.) or prescription antidepressant drugs like amitriptyline. Amitriptyline and other antidepressants have some very serious side effects, however, including a risk of suicidal thoughts in teenagers and young adults. Clearly, alternative treatments for tension headaches are worth investigation.
Fortunately, chiropractors have effective treatments for tension headaches. One study of 150 patients showed that spinal manipulation provided as much pain relief as amitriptyline, but the relief from the drug only lasted as long as treatment did, whereas the relief from spinal manipulation was still significant four weeks later .
Headaches Related to TMJ Dysfunction
As in cervicogenic headaches, disorders or misalignments of other bones and joints of the head and neck can also cause headaches. The most common joint involved is the temporomandibular joint (TMJ). The TMJ is the joint where your lower jaw pivots. Previously, many doctors considered TMJ pain to be basically psychological. The theory was that people with neuroses or high stress would grind their teeth and clench their jaws, causing pain. The recent research is showing almost the opposite is true - that dental problems or dental hardware displaces the lower jaw from proper alignment with the upper skull. Such misalignments irritate nerves, sometimes causing referred pain that is felt as a headache , . Chiropractor can create a TMJ treatment plan using splinting, exercises, massage, ultrasound, manipulation, or other therapies to treat TMJ pain without surgery or medication, often alleviating TMJ-caused headaches.
A concussion is an injury to the brain resulting form a blow or violent shaking. Although the skull and the linings of the brain can usually protect the brain from being directly injured by external forces, such as a blow to the head, the brain is not fixed within the skull. This means violent movements of the head can effectively bounce the brain against the inside of the skull, causing injury. Concussion is the term for this initial injury. There is also a poorly-understood disorder called Post-Concussion Syndrome where symptoms from the concussion such as headaches and dizziness last for weeks to months after the initial injury. Because spinal cord compression is very often a consequence of the same injury that caused the concussion, chiropractors can help form a multi-disciplinary approach to post-concussion syndrome. While the chiropractor will treat the spinal cord, he or she will also refer the patient to other specialists to address other parts of the syndrome.
In addition the above types of headache, there are a number of possible causes of headaches that a chiropractor will consider when making a diagnosis. In making a headache diagnosis, a chiropractor will rule out these other headache causes before starting treatment. If one of these other headache causes is indicated, the chiropractor will refer the patient to another specialist, such as a neurologist.
A chiropractor can benefit many different headache sufferers, without the resorting to medications or other invasive procedures. This is great news for headache sufferers that have multiple health issues, recurring headaches, or just want to avoid invasive medicine. If you have recurring headaches, talk to a chiropractor about them.
Zwart JA. Neck mobility in different headache disorders. Headache;37:6-11
Cypress B. Headaches as the reason for the office visits: National Ambulatory Medical Care Survey, United States, 1977-1978. Adv Data 1981 Jan 7;67:1-6
Osterhaus JT, Gutterman DL, Plachetka JR. Healthcare resource and lost labour costs of migraine headache in the US. Pharmacoeconomics 1992 Jul;2(1):67-76
Sternbach RA. Pain and "hassles" in the United States: findings of the Nuprin pain report. Pain 1986;27(1):69-80
Lance JW, Goadsby PJ Mechanism and Management of Headache sixth edition, 1993, Butterworth-Heinemann, Oxford
Lance JW. A concept of migraine and the search for the ideal headache drug. Headache 1990 Jan;30(1 Suppl):17-23
Von Peter S. Ting w. Scrivani S. et al. Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalagia 2002 Jun;22(5):395-400.
Nelson CF. The tension headache, migraine headache continuum: A hypothesis. J Manipulative Physiol Ther. 1994 Mar-Apr;17(3):156-67
Yousefi-Nooraie R. Schonstein E. Heidari K. et al. Low level laser therapy for nonspecific low-back pain. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005107.
Johnson M. Martinson M. Efficacy of electrical nerve stimulation for chronic musculoskeletal pain: A meta-analysis of randomized controlled trials. Pain. 2007 July ;130(1):157-165
Bronfort G. Assendelft WJ. Evans R. et.al. Efficacy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001 Sep;24(7):457-66.
Alix M. Bates D. A proposed etiology of cervicogenic headache: the neurophysiologic basis and anatomic relationship between the dura mater and the rectus capitis posterior minor muscle. J Manipulative Physiol Ther. 1999 Oct;22(8):534-539
Nilsson N. Christensen H. Hartvigsen J. The effect of spinal manipulation in the treatment of cervicogenic headache. J Manipulative Physiol Ther. 1997 June;20(5):326-330
Haas M. SPegman A> Peterson D. et al. Dose response and efficacy of spinal manipulation for chronic cervicogenic headache: a pilot randomized controlled trial. Spine J. 2009 Oct 15. [Epub ahead of print]
Haas M. Groupp E. Aickin M. et al. Dose response for chiropractic care of chronic cervicogenic headache and associated neck pain: a randomized pilot study. J Manipulative Physiol Ther. 2004 Nov/Dec;27(9)547-553
Tuchin P. Pollard H. Bonello R. A randomized controlled trial of chiropractic manipulatice therapy for migraine. J Manipulative Physiol Ther. 2000 Feb;23(2):91-95
Bronfort g. Assendelft W. Evans R etal. Efficasy of spinal manipulation for chronic headache: a systematic review. J Manipulative Physiol Ther. 2001 Sep;24(7):457-466
Boline P. Kassak K. Bronfort G. et al. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. 1995 Mar;18(3):148-154
Knutson GA, Jacob M. Possible manifestation of temporomandibular joint dysfunction on chiropractic cervical X-ray studies. J Manipulative Physiol Ther. 1999 Jan;22(1):32-7.
Alcantara J, Plaugher G, Klemp DD, Salem C. Chiropractic care of a patient with temporomandibular disorder and atlas subluxation. J Manipulative Physiol Ther. 2002 Jan;25(1):63-70.