By Danielle Landrum, SPT
I want to give another warm welcome to the readers who decided to venture onto the second part of my blogging series. This article is completely unrelated to the first one which briefly discussed pelvic floor dysfunction in the female athletic population. If any readers did not have the opportunity to consume my first article then I would highly and unbiasedly recommend skimming over the riveting content I managed to conjure up last week. This week I want to dive into the mystery of migraines and discuss how the physical therapy community can utilize different techniques to promote meaningful change for patients who suffer from attacks.
My recent clinical endeavors have led me down the mysterious path of migraines. My compassion and curiosity eagerly want to seek out the best protocols and new treatment regimes for migraine mitigation because of the emotional connection I have to the topic. Witnessing the unpredictable pain rollercoaster my Mom has been on for my entire life helps me deeply empathize for current and future patients.
PT and Migraine Relief
Migraines are equally debilitating as they are stubborn. It is important to note that physical therapy is not included in the international guidelines for migraine due to limited research and high quality randomized control trials. This is definitely not ideal considering I am a student physical therapist writing this for a physical therapy blog but nonetheless the conversation is worth having. Pharmacological treatments are the primary recommendation but the adverse side effects and long term usage of medications can result in systemic complications. Anytime individuals decide to pop a pill there always seems to be some kind of systemic bartering that takes place within the human body. An analysis which assessed over 13,000 individuals with migraines revealed many people who discontinue acute prescription medication have a high level of unmet treatment needs and as many as 37.6% cannot function normally.1 Many individuals seek out physical therapy but it is important to note that physical therapy is not included in the international guidelines for migraine due to limited research and high quality randomized control trials. Common physical therapy treatment usually encapsulates manual therapy techniques for the cervical and thoracic region, soft tissue techniques, stretching, therapeutic exercises for muscular endurance, vestibular exercises, and balance and gait rehabilitation. These foundational treatments are shown to be somewhat effective when the correct combination is tailored to an individual and their subjective health history.
The Vestibular and Sleep Connection
The vestibular system needs to be screened because an estimated 58% of patients with migraines either knowingly or unknowingly have vestibular abnormalities.2 I found this statistic to be relatively interesting because I always thought of balance issues being a symptom rather than a cause. If proper assessment and treatment of the vestibular system is implemented, migraine frequency and severity can be reduced because systemic triggers are being treated through individualized balance interventions. The frequency and duration of migraines negatively impacts vestibular rehabilitation outcomes and delays for success. This can result in individuals feeling a looming sense of hopelessness if they are unable to engage in basic activities of daily living and functional tasks.
Sleep hygiene is also an important part of the subjective history and a crucial area for patient education since irregularities before slumber can be a trigger.3 A pilot study of women with transformed migraines underwent behavioral sleep intervention which showed statistically significant improvements in headache frequency and intensity.4 A recommended 5 component intervention strategy in this article included:
- Scheduling a consistent bedtime that allows 8 hours in bed
- Eliminating watching television, reading, or listening to music in bed
- Using visualization techniques to shorten time to sleep onset
- Consuming supper > 4 hours before bedtime and limiting fluids within 2 hours of bedtime
- Discontinuing naps during the day
Advanced Tools: Biofeedback, Dry Needling and Magnesium
Biofeedback is another tool frequently utilized in the physical therapy setting which has been shown as “grade A evidence” for migraine prevention when paired with relaxation training. More specifically, thermal and electromyographic feedback can help individuals learn to control their body functions.5, 6 Thermal feedback is a technique that involves placing a device around the fingers to allow sensors to provide real time relaxation feedback based on body temperature. As a patient is taken through a downregulation technique, blood flow should increase to distal vasculature showing a rise in temperature. Electromyographic feedback uses electrodes for a patient to witness and adjust the amount of tension or electrical activity that is present in a designated muscle. This can be utilized during therapeutic activities, downregulation techniques or in adjunct with thermal feedback. Biofeedback is a powerful tool that can help a patient reclaim their body and learn to regulate their system which can often feel out of their control.
Dry needling is a tool worth discussing since its popularity is rapidly increasing for the management of musculoskeletal conditions. A systemic review and metanalysis revealed dry needling is not statistically better at decreasing headache pain intensity but is more significantly more effective for improving short term disability. It can also decrease local and referred pain, improve blood flow in head and neck musculature, and muscle activation patterns.7 Dry needling is not recommended as a stand alone treatment but rather another tool in the PT toolbox to be used in conjunction with other modalities. There are numerous limitations with all of the level 1 dry needling studies I found. I can infer that is because it is still relatively new in the physical therapy setting and the PT community needs time to catch up with their EBP.
Supplementation is another piece to the modifiable puzzle. There has been a recent upward trend with the use of magnesium due to its various positive health benefits. Research has found around 600mg/day of oral magnesium significantly reduced migraine frequency by 41.6% and severity by 47%.8 There is other research that rates magnesium as “grade B evidence” suggesting it could be effective for the treatment of migraines. Another study found that increasing dietary magnesium intake can reduce neuro-inflammation and may help promote neurogenesis. 9 Both of those effects show promising biochemical influence due to the nature of migraine attacks consisting of inflammatory substances and spontaneous electrical activity. Some foods high in magnesium include spinach, oats, pumpkin seeds, and almonds. I might be slightly tip-toeing out of the PT scope of practice by making dietary or supplementation recommendations to clientele. However, it is important to provide people with useful information and at the end of the day it is entirely up to the individual on what they choose to do with it.
Tracking Progress and Taking a Whole-Body Approach
A headache journal or diary or calendar can also help for recording the lifestyle logistics and nature of attacks. Oftentimes life can feel hectic or disorganized especially if there are a lot of moving parts and pieces. Keeping record of the frequency, duration, severity, onset, and associated triggers can help clinicians get to the root source of the attack. There is immense power in getting to the root cause of attacks instead of chasing and treating symptoms. This could be a pivotal component for therapists and patients in order to make lasting changes and plan a management strategy.
For the audience members who have managed to make it all the way to my concluding statements, I have some good and bad news to take away from this brief discussion. The best management strategy for migraines does not statistically exist which makes physical therapy treatment more dynamic and less systematic. Migraines are not just a neurologic condition, but a whole-body experience which means they need to be approached and treated as such. By combining different tools and utilizing a multifaceted approach, migraines do not have to be such a pain in the neck for the clinician or the patient.
Citations
- Lipton RB, Hutchinson S, Ailani J, et al. Discontinuation of Acute Prescription Medication for Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study. Headache. 2019;59(10):1762-1772. doi:10.1111/head.13642
- Carvalho GF, Schwarz A, Szikszay TM, Adamczyk WM, Bevilaqua-Grossi D, Luedtke K. Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice. Braz J Phys Ther. 2020;24(4):306-317. doi:10.1016/j.bjpt.2019.11.001
- Carvalho GF, Schwarz A, Szikszay TM, Adamczyk WM, Bevilaqua-Grossi D, Luedtke K. Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice. Braz J Phys Ther. 2020;24(4):306-317. doi:10.1016/j.bjpt.2019.11.001
- Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. 2007;47(8):1178-1183. doi:10.1111/j.1526-4610.2007.00780.x
- Headache Classification Committee of the International Headache Society (IHS) The international classification of headache disorders, 3rd edition. Cephalalgia. 2018;38:1–211. doi: 10.1177/0333102417738202.
- Sremakaew M., Sungkarat S., Treleaven J., Uthaikhup S. Impaired standing balance in individuals with cervicogenic headache and migraine. J Oral Facial Pain Headache. 2018;32:321–328. doi: 10.11607/ofph.2029.
- Fernández-de-Las-Peñas C, Nijs J. Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm. J Pain Res. 2019;12:1899.
- Peikert A, Wilimzig C, Köhne-Volland R. Prophylaxis of migraine with oral magnesium: results from a prospective, multi-center, placebo-controlled and double-blind randomized study. Cephalalgia. 1996;16(4):257-263. doi:10.1046/j.1468-2982.1996.1604257.x
- Alateeq K, Walsh EI, Cherbuin N. Dietary magnesium intake is related to larger brain volumes and lower white matter lesions with notable sex differences. Eur J Nutr. 2023;62(5):2039-2051. doi:10.1007/s00394-023-03123-x
