Migraine is a severe headache type and can have a considerable impact on the daily life of sufferers and affects between 17 per cent of women and 6 per cent of men, although estimates vary. Accurate diagnosis of the different presentations of migraine is the foundation of effective prescribing, management and treatment. 

Diagnostic pointers for migraine:

1. Attacks last from 4 to 72 hours
2. Patients are usually symptom-free between attacks
3. Headache is at least two of the following
   1. Unilateral (on one side)
   2. Pulsating
   3. Moderate to severe
   4. Aggravated by routine activities
4. Accompanying symptoms may include
   1. Photophobia (more sensitive to light)
   2. Phonophobia (more sensitive to noise)
   3. Nausea and Vomiting

In any medical condition it is of paramount importance for the diagnosis to be accurate and this can only be made by your health professional or neurologist who knows your private medical history in detail. Only after this has been achieved can an appropriate management plan be established. In the late 1980s, the International Headache Society (IHS) formulated a classification for migraine, which has helped us to determine the correct patient groupings for migraine clinical trials. If five headache attacks meet the criteria, the patient is given the diagnostic label of “migraineur”. It is important to realise that not all four main symptoms have to be present. It is quite possible for the patient to have a mild headache which is bilateral, but still have migraine.

Recently clinicians have realised that it is helpful to ask questions of patients with acute or intermittent headaches. Information about their quality of life and ability, or otherwise, to perform normal activities is very important. High impact, acute headache would, therefore, tend to have a default diagnosis of migraine and the IHS classification is used to confirm this.

The main part of the classification is concerned with the headache phase of the attack. However, approximately 10 per cent of patients will have reversible sensory symptoms in the hour preceding the headache. These symptoms are known as aura and will often include visual changes, such as zigzag lines or scotoma (holes in the vision), but a variety of other symptoms may also occur.

Other symptoms include, dizziness, numbness and “word salading” (words being mixed up). About 40 per cent of patients describe more vague symptoms of aura that can last substantially longer. In the day or two before an attack, prodromal symptoms, such as cravings and lethargy, can be observed. From within these two groups of symptoms, useful warnings can be identified and patients taking simple treatments during such a warning may have success in heading off a migraine before it has started.

Often ignored is the postdrome phase of migraine. Once the headache has subsided the postdrome usually involves the patient feeling quite washed out or hung-over. A few patients may feel entirely the opposite, almost as if they are super-human. Relatively little can be done to alleviate these prodromal symptoms, the cost in terms of disruption to work, relationships, and social activities, which can result from this phase of the attack can be considerable.

Trigger Factors For Migraine

Environmental factors: Build up of tiredness over the working week, emotion and stress (eg, anger), missed meals (hypoglycaemia), smoke, strong odours (eg, perfume, paint), too much/little sleep, weather changes, bright/flashing lights.

Hormonal changes: Hormone replacement therapy (HRT), menstruation, oral contraceptives, pregnancy.

Exercise or exertion: Eye strain, head injury, irregular/no exercise.

Food/ingredients: Alcohol, artificial sweeteners, caffeine, chocolate, cultured dairy products fermented/pickled foods, fruits, mature cheese, monosodium glutamate, nitrates (eg, in cured meats), sugar, sulphites, vegetables, yeast.

Cervicogenic headache is pain referred from the cervical spine. Early studies also highlighted the sub occipital and posterior cervical muscles, although it has been shown that anterior structures in the cervical spine elicit referred pain in the occipital, frontal and orbital regions. By contrast, stimulation of more posterior structures lead to pain in the neck, which could be referred to the occipital regions, although not to distant regions of the head. Studies indicate that the C2–3 joints are the most common source of cervicogenic headache, accounting for about 70% of cases.
Estimates of the prevalence of cervicogenic headache vary from 1% to 4% in the general population and as high as 17•5% among patients with severe headaches. The prevalence is thought to be as high as 53% in patients with headache after whiplash. The most reliable features for diagnosis are considered to be pain that starts in the neck and radiates to the fronto-temporal region, the ipsilateral shoulder and arm and pain that is made worse by neck movement. Pain is of varying duration or a fluctuating continuous pain, moderate, non-throbbing pain, and associated with a history of neck trauma.

Cluster headaches is an excruciating condition that is fortunately rare. It affects 1 in 1000 men and 1 in 6000 women; most are in their twenties or older and many are smokers. It is characterised by frequently recurrent, short lasting headache and autonomic symptoms. Cluster Headache Type is highly recognisable. The episodic form occurs in bouts (clusters), typically of 6-12 weeks’ duration once a year or every two years and at the same time of year. Strictly unilateral intense pain around the eye develops once or more daily, commonly at night. This headache type is sudden in onset and lasts between 15 -180 minutes and can occur between once a day to eight times a day. The eye is red and waters, the nose runs or is blocked on that side, and ptosis (droopy eyelid) may occur. Atypical presentations are more common in women. In the chronic form, which is less common, no remissions occur between clusters, and a continuous milder background headache may additionally develop. The episodic form can become chronic, and the chronic form episodic, but once present, cluster headache can persist for 30 years or more.

Tension Headache Type or Muscle Contraction Headache occurs in about 50% of the population on a monthly basis but is usually low impact which is why it is not seen a lot in primary care. Typically this headache type is mild to moderate only, non-pulsating and bilateral. Sensory sensitivity to noise or light is more likely to be associated with migraine. Difficulties arise when patients who are suffering from migraine are misdiagnosed as having a tension headache type. They then do not receive appropriate management. Patients often describe the pain as a “feeling of tightness or squeezing’. The causes of tension headache type are not known. It is possible but rare to get a tension headache type without exacerbations – causing daily or near daily background symptoms. This is part of the Chronic Daily Headache Syndrome and needs managing as such.

Getting you pain free and functioning properly is a process, not an event. With this in mind, most people do require a course of treatment but the length varies greatly depending on the severity of your condition and previous injuries etc.  As your condition improves visits become less frequent. At Hub we emphasise the importance of thorough rehabilitation to prevent injuries from recurring and on some occasions we do recommend that patients return from time to time in the long term to maintain the improvements and to check that there are no further issues building up.

When deaing with headaches & migraines, we use a very thorough process of:

ASSESSMENT

We will carry out a full case history and physical assessment to take in all the possible contributing factors to your current symptoms. Our movement assessment is very thorough as we hope to be able to identify any areas of weakness, tightness and imbalance, even in areas of the body away from your symptoms as these can commonly be significant. We will also carry out a full assessment of your diet and lifestyle in order to identify any habitual postures/toxins that may be contributing to your issue.

DIAGNOSIS

Following the assessment, we will be able to identify what structure is causing your pain and symptoms as well as the underlying cause of why it has happened. This information will guide the nature of the treatment and rehabilitation plan going forwards. At this stage we may be able to give a prognosis of how long your recovery will take.

TREATMENT

Treatment plans will vary greatly depending on the cause of your issue but will definitely include work to alleviate your symptoms, such as soft tissue work and spinal manipulation as well as techniques to address any mechanical issues which may be causing the strain to the tissues which are in pain. In addition, at this stage any nutritional and lifestyle factors will be addressed.

MANAGEMENT

Following the treatment and rehabilitation of your injury, you will be given a management plan that may consist of continued rehabilitation exercises, lifestyle/postural changes and possibly future check ups to ensure the problem does not recur.

Once you are fully recuperated, our team are perfectly placed to help you remain injury-free through:

• ongoing treatments to maintain physical health
• exercise programmes to improve fitness / weight levels
• nutritional plans to optimise health levels