Treating Migraines
Migraines are in the top 5 in most lists of the most disabling pain conditions, especially in any case where occasional migraines have escalated into chronic migraine or even status migrainosis. The current consensus is that true migraines (I say to distinguish not in intensity, but between migraines and some other varieties of headaches which can be even more severe, but may have a different mechanism) occur due to a genetic condition for migraines, but the triggers that initiate them and the context that can lead to increase in severity and frequency are widely variable and are things we can act on therapeutically.
I myself have had two migraines in my lifetime, so have the specific genes/gene expressions, but may have much higher thresholds to hit adequate triggers to experience a migraine, while some people may have 20+ events a month, sometimes with little to no sense of their trigger. This is a high priority condition for us to treat, as largely pain centered therapists, and luckily we do have therapeutic options to help many of our patients with migraines.
Triggers themselves vary widely, with some being especially reactive to changes in hormones, or foods, among others that may offer some therapeutic treatment options or obstacles which are more appropriate for other provider types, but as with many things in our purview; it is not always about attempting to cure the condition by approaching it head on, but at times treating secondary mechanisms or consequences in the causal chain that we CAN approach.
As such, this is more of what we’ll be addressing today: what we can treat that can have a profound impact on migraines even when the patient's most common triggers are not what we’re approaching. Anything that takes us further from a migraine threshold is going to be useful for that patient, even if some cases are more significantly improved by our work than others, we can have some impact on them all.
To wrap up this preamble, I will not be approaching an in-depth discussion of the mechanisms of migraine, its apparent genetic basis, or other treatments that are not really within our scope or specialty, though I can offer some resources towards those for the curious. I am also not here to teach the techniques themselves, but to talk about the treatment road map I use.
With that, there are two main avenues to migraine treatment I focus on (as well as some others that are very case by case and I will not cover here today), with one fairly simple in implementation, and the other much more complicated.
Infrared Therapies
Infrared therapies are very simple in implementation, but one of our most profound options for migraine. Infrared is listed in the first sentence of our OBMT scope of practice statement, but is very under used by our profession. We’re not just using it to heat some part of the patient's body, but to help improve blood flow, metabolic rate, and lower chronic inflammation (luckily acute inflammatory processes are not negatively affected by infrared, which we need for healing and fighting infections), with a staggering list of additional mechanisms and benefits, as long as we are within the appropriate dosing window for the given type of tissue, its depth, and our intent.
As an example, this group of scientists carried out a study with their test groups suffering an average of 20 migraine headache incidents a month, which they split into control, botox, and infrared test groups. In just one month of treatment (deploying the infrared on the same spots as are selected for botox for migraines) incidents dropped by 50%. At the end of the second month, an incredible 90% reduction of incidents was achieved, with only two treatments a week. We seldom see such results in all of medicine, especially when lacking a curative element.
The full study can be viewed here: https://www.scielo.br/j/anp/a/KcDcMJgRGBMZ48FvFz3PYqN/?lang=en#:~:text=This%20was%20a%20preliminary%20pilot,improved%20in%20the%20LLLT%20group
In our office we have both a handheld laser as well as an LED device that is flexible and allows us to treat a broader area more efficiently (there have been no studies showing any efficacy loss in switching from laser to LED, though laser may have some greater penetrating depth capacity), including one we keep in our waiting room for patients to come in and use once instructed correctly so that they do not have the burden of having to actually book two provider appointments a week for adequate infrared treatment.
In practice, the treatment with our particular devices is 2-3 location applications for about 13 minutes each.
Trigeminal / Nerve Focused Work
We’re going to talk about a range of anatomy first, and then I promise we’ll get to the therapeutic side more directly (though it will still be more of an in depth summary, than any manner of technique guide).
The Trigeminal Nerve:
This category is much more complicated due to the wide range of related structures and relationships therein that we will want to address, and the fact that these are not always simple relationships. That said, let’s start with the core of it: the trigeminal nerve.
This is one of the most migraine associated structures we’re aware of, most likely due to its role in intracranial vascular innervation and supplying nociceptive (pain, more or less) sensation to some of the few structures in the skull that can feel pain. As it is believed that vascular changes are a core mechanism of migraines, this is not a surprise. On top of that, it is a very…very busy nerve, and honestly should be getting similar amounts of attention that we give the vagus nerve, even bridging into general health topics above and beyond its role in physical medicine and migraines.
It is responsible for innervating much of the face and head, including the motor functions of chewing, some of the muscles of the eustachian tubes, some of the hyoid muscles, and even the tensor tympani in the ear (a vital part of the tympanic reflex that I’m sure we’ll get around to talking about at some point in another article). Just on the mastication side and the connection that makes with the deep front line (using Anatomy Trains terms) integrates it deeply into full body myofascial/musculoskeletal tension relationships.
The sensory side is just as expansive and potentially more important, supplying sensation to much of the face, scalp, jaw and some of the tongue, the sinuses, and an ongoing list but also, crucially, innervating the falx and tentorium. These membranes are important for the brain itself as structural supports, but also is part of the spring system that allows our spinal cord to be brought back up into place after being stretched from things like bending forward. The falx and tentorium are thick membranous portions of the dura itself, and the trigeminal nerve is going to be gathering a constant stream of rich sensory data from this, informing the brain about the connective tissue at the very hub of the CNS.
To boot, it also has an informing role on the portion of the brain the vagus nerve is coming out of and is a major part of our autonomic nervous system and sense of safety, interacting with several direct reflexes (such as some around breathing and eating, and the tympanic reflex as mentioned).
So just on the basis of the above, the trigeminal nerve is far more involved and important than many of our cranial nerves, and is a functional and anatomical bridge between the CNS itself, the deep core, our eating and breathing apparatus, a range of our CNS, and even some of the intracranial blood supply.
Also given that we’ve mentioned them several times in this section as is, the falx cerebri and tentorium cerebeli are major direct therapeutic targets, and the entirety of the dura (including around the venous sinuses).
The Occipital Nerves
A highly therapeutically relevant connection for the trigeminal nerve is its anastomosis with the occipital nerves, connecting the two over the scalp. The occipital nerves come out of the upper three cervical vertebrae, and are significantly affected by the functional (and structural articular) stability of the upper vertebrae. Of particular consequence is the myofascial-dural bridge between the suboccipital muscles and the dura, giving us another mechanical connection to the trigeminal nerve, on top of its major role in muscle tension triggers for migraines. As it is, the occipital nerves and upper cervical functional stability are my primary targets for non-migraine tension headaches.
Side Note: As it is, migraines can be a potential consequence of CCI (cranial cervical instability) and chiari malformations (where the tonsils of the cerebellum are slipping into the spinal canal and compressing the brain stim), neither of which are especially common outside of hypermobile populations, however…if you’re seeing migraine patients, hypermobility and these conditions become less rare. As such, this should be considered, especially if the migraines are positional (better with lying down for chiari) or with certain movements (such as certain active or passive Cx positions may trigger a migraine due to CCI).
Other Structures of Importance
The spinal accessory nerve and because of this, the jugular foramen as the exit of this nerve from the skull, and its other contents, especially the jugular veins to minimize their contribution to inappropriate intracranial blood pressure, and while we’re at it, any C1 mechanical impact on the internal jugular vein. The spinal accessory nerve is a target due to its role in innervating the upper traps and their common impact on traditional tension headache triggers for migraines. There is also some mechanical connection between these nerves and the occipital nerves, which is in an almost tiered relationship with the vagus, glossopharyngeal and auricular nerves.
The maxilla and palatine bones in particular have a very strong impact on trigeminal irritation, and as they are not linked through sutures, they can be found several millimeters out of place! The temporal bone with its petrous portion as a major attachment of the tentorium is something we always treat alongside the tentorium. The occiput and parietals are other strong attachments for these structures, but I do find them a bit less impactful on migraines in particular than the maxilla and temporal bone. That said, we always treat the skull as a cohesive and integrated organ.
The sinuses are common and significant targets, as sinus dysfunctions are common for many people as it is, but sinus pressure is a frequent migraine trigger. With our largest sinus being in the maxilla, and all of them being innervated by trigeminal nerve branches.
The brain itself. Inappropriate increases or decreases in brain function are very much on the table here. This is unsurprisingly a potentially complicated topic, that I won't discuss in much detail here at all, and is very contextual to the patients situation.
The stellate ganglia / sympathetic nerves. These are not direct mechanistic targets, but are well worth a mention and check because of their significant impact on sympathetic autonomic function, which can impact pain levels and vascular changes. Approaching the stellate ganglia is also quite quick, but we may check through the thoracic and lumbar sympathetic chain as well, contextual need depending.
We do have some other targets, but it more quickly moves into things which are more contextual to the person and their medical history, most commonly being relevant through their impact on some of the above structures. Sacral dysfunctions are a direct connection to cranial issues, while visceral traumas are usually slightly less direct, but significant changes to core function will impact spinal stability and jaw tension, easily contributing to migraines.
The bladder and kidneys are common visceral contributors to neck/head pain, and while they are not generally directly migraine contributors, they have significant overlap. Sensory dysfunctions should also be mentioned as they place real strain/load on the nervous system in some very complex ways.
From here it gets increasingly contextual for each patient and their medical history.
Treating Migraines
A lot of techniques are involved in treating the above structures, and an article certainly isn’t going to be adequate medium to teach them. But we can certainly speak about our approach.
First of all, we are going to try to maintain ongoing twice a week infrared treatment. Some of my patients have their own infrared devices, otherwise we’ll make sure this is being carried out around our appointments or in the waiting room.
Beyond that, our order of operations will be in substantial part dictated by what we find to be the most irritated for that given patient, so will be adjusted as needed. But these are our main components.
A full, in depth treatment of the trigeminal and then occipital nerves. This is most often my very first post-assessment step as it will do the most to calm down our core mechanisms and make subsequent steps easier. We start work on the trigeminal nerve with the external ganglia, treating any nerve buds, and our main three branches (in order of irritation found via a ‘local listening,’ or based on the tension bias if no ‘local listening’ is present. Luckily, after a fashion, this is the main structure we look to treat for jaw dysfunctions as well (though we certainly like to address jaw articular tissues in addition). We may need to track down further smaller branches for their contribution, with the supraorbital (especially as it passes the notch) always being addressed.
We then turn to the occipital nerves, and with the close connection between the occipital and auricular, we’ll always check through the full range while we’re in the area. I most often find the largest irritations between the levels of the C2 spinous process and the external occipital protuberance, but the entire length over the scalp is on the table. If anything is being slow to improve, going to our c1-0 dural connection or to c1/2 articular concerns would be a next step.
Important to note: I will check out these nerves (at least main trigeminal and occipital, and whatever else was severe and grabbed our attention) at the start of each appointment as long as they remain relevant.
We then check the skull at the vertex for what the biggest irritation is, with it being quite likely that a given falx or tentorium will grab our attention quite quickly. If something else pops up as a bigger irritation while working with a migraine patient, we do not want to ignore it. We will always follow these interventions with a check of general cranial motility, touching up anything needed. Lateral decompression of the temporal bone is often needed after tentorium work to help ‘jump start’ the motility after changes in the tentorium tension.
This will be something we check for each session for a while, and address what the day's biggest needs are. I will do stim based work on the tension of the tentorium/falx once even if it does not show up in our assessment as a needed point of treatment, as it is relevant and contributing, even if it is not part of the body's loudest complaints.
If we have not done so already, I would often now work on a full length dural treatment, working primarily at our C1-0 and L5-S1 myofascial-dural bridges (with L5-S1 SP articular inductions to follow), and then working sacrum to T8/9, occiput to T8/9, and occiput to sacrum, and any other necessary detail work in-between.
At this point we have likely handled the main direct topics I would get to in the first appointment for time (I do long 2 hour sessions most of the time). If I had enough time I would address the jugular foramen, vagus and spinal accessory nerves and the stellate ganglia.
From there if somehow things were progressing quickly enough to allow more time, we’d look into any substantial head, spine, or abdominal scars, and perhaps impacts (approached in a stim-based functional neurology skillset, which we would apply to the rest of this as well), and would consider any other major exacerbating factors, largely being injury focused in deep core affecting tension lines, but also potentially including bladder/uterus or kidney issues if big enough issues grab our attention. Most likely these would be targets for session 2-3+ due to time requirements for higher priority targets.
A major powerhouse target we may have looked to in the first session, but I often leave until our second session so we can get some things calmed down, is any maxillary misalignment in the hard palate. This is a significant adjustment, and I expect to approach it 2-3 times to gently get the full adjustment I’d like (especially as it often requires some back and forth rubik’s cube like work with the rest of the skull to get it all to where we want it together).
I prefer approaching this earlier in the session so that we have plenty of time to do any follow up cranial work. Ideally we’ll see any height disparity minimized and some overall improvement in the vertical positioning in the first session. While I am doing intra-oral work, I will check out the tensor veli palatini for its impact on the maxilla/palatine bones, the eustachian tubes, some cranial nerves, and so on. Note that the left maxillary/palatine is usually the higher one and when the right one is instead it is more likely to be a bigger problem.
I will want to judge based on overall dysfunction severity and levels of reported irritation/sensitivity to sensory input to decide when to start sensory work and how much I want to include each session. Within that, I will focus on what they find most irritating (most frequently this being light exposure and then sound, but sometimes olfactory stimulation as well) plus common migraine contributors including smooth pursuits, overall oculomotor function, and convergence/divergence (which has surprising impacts on neck function when dysfunctional).
From here we will continue checking trigeminal, occipital and skull targets as long as they appear necessary, and diving further into contextual issues for the given patient. If head impacts or whiplash are in their history, the whiplash will be approached in the first few appointments, while the head impact work takes time to peel back layers to calm things down enough to successfully treat that without significant irritation, but is often a necessary hurdle to try to take this patients case to any form of conclusion. We will continue to address any contextual elements, whatever they may be.
So what should we be expecting in and from this process? I expect to be able to help every single migraine sufferer to some extent. Some will get more mild relief in frequency and intensity, others will have them functionally disappear entirely. Their genetic predisposition for migraines remains, but we’ve shifted the context enough that they just aren’t hitting a threshold to trigger a migraine. I cannot say in advance where a given patient will fall in that range, we just get to say that we know we can help some, but we’ll have to find out together how much, though if they have substantial head/sensory trauma history, it’s far more likely the improvements we offer will be profound. If they are able to keep up the infrared treatment, in combination with direct care, their prospects are very good. How long it will take is also uncertain; it largely depends on how much relevant trauma they have as far as how long it will take for our direct work to have its impact.
My favorite case example was a young woman who had ~2-3 migraines a week for about 8 years since early high school, and head pain every single day, in addition to significant neck, shoulder and TMJ pain. Looking at her jaw opening, it had to dramatically laterally translate after only a few millimeters of opening to create enough room to fully open. It looked like a typewriter hitting the end of its line and having to return. Her maxillary/palatine was also several millimeters off but not even just one side low, one side high; the front of one and back of another were diagonally severely off. This was near a decade ago and I haven’t seen such profound jaw dysfunction since.
On top of some other significant health conditions, it was and still is amazing to me that she could work through this. But luckily (in a fashion) she had a lot of physical traumas, including 5 known concussions, one MVA whiplash, a collapsed lung from an infection, and likely Marfan’s Syndrome. This is good(ish) because our chances of helping her are much higher.
So we approached the profound jaw dysfunctions quite early on, and with the maxillary adjustment…migraines were simply gone from that session on. She had one minor migraine start a number of weeks later while we were approaching all the concussions (which is a fairly provocative process as far as causing significant fluctuations in the skull so can be weird or temporarily unpleasant) but it never hit full force. After that…none, and I’ve kept in touch ever since. She had a moment of realization when she was leaving the house one day and realized her Motrin was left inside and her fiance asked if he should go get it…she thought for a second and said…no, I don’t think I need to keep it on hand anymore.
Not every case we will be able to help so completely, but it is at times within our abilities, and can be among the most life changing work we offer our patients.