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Tanya should have seen it coming; these headaches rarely hit without warning. The coincidence of an unusually stressful day at work, that sleepy feeling she tried to counter with caffeine, and haywire hormones constituted ideal conditions for the perfect storm of headaches: a migraine. Tanya is one of approximately eight million — or 11 out of 100 — people in the U.S. afflicted by migraine, a phenotypical, chronic neurological disorder that manifests in episodic attacks that can include severe head pain, nausea, and sensory sensitivity.

Often resistant to over-the-counter medications, migraines are frequently disabling, to the extent that the condition accounts for some 113 million lost workdays every year, according to the Migraine Research Foundation. Women are three times more likely to get migraines than men, and children of migraine sufferers are two to three times more likely to be afflicted than children of nonsufferers.

Unstable Structure

“Migraine is a chronic disorder with episodic attacks,” says Richard Lipton, MD, director of the Montefiore Headache Unit in New York, professor and vice chair of neurology and professor of epidemiology and population health at the Albert Einstein College of Medicine, where he is a Lotti and Bernard Benson Faculty Scholar. “However, even between attacks, sufferers have an enduring predisposition to headache on a genetic basis.”

Migraine pain has two key components: a brain and blood vessel component, and an inflammatory component. The more dated vascular theory assumed that the primary events of migraine occurred in the blood vessels, but there is growing evidence that migraine is caused by primary events in the brain in which certain triggers activate the trigeminal nerve, producing dilation and inflammation in the blood vessels of the head and sending pain information back along that nerve.

“This neurovascular theory recognizes that the brain is the perpetrator and the blood vessels the victims,” Lipton says, who explains that these primary brain events are triggered when a specific combination of external and/or internal factors transcends the brain’s limit to cope with them.

Almost any dramatic internal or external change can trigger a migraine reaction in a susceptible person.

“Migraine susceptibility is determined by thousands of genetic combinations,” says Mark Green, MD, director of Headache Medicine at Columbia University and clinical professor of neurology at the College of Physicians and Surgeons, College of Dental Medicine, in New York. “Maybe years from now, we’ll be able to identify the DNA sequence, dial it in, and mix a custom drug.”

While custom cures remain the realm of science fiction, migraine management involving a combination of medication and trigger reduction can be tremendously effective.

“At the headache center, we’re more interested in identifying remedial triggers than in establishing a long list of things to avoid,” Green says. “And by identifying the symptoms of a pending episode, we can use medication to circumvent the attack.”

Digging In

Migraine treatment is typically divided into three categories: acute treatment at the time of attack, daily prevention, and preemptive treatment taken at high-risk times to head off an attack before the pain hits. Preemptive intervention is possible for the 60 percent of sufferers whose migraines are heralded by a premonitory phase or prodrome — a single symptom or set of identifiable symptoms such as cold hands and feet, yawning, frequent urination, or craving for chocolate — about a day before an attack.

“Current practice favors treating a migraine attack as soon as possible after pain begins, but there is tremendous interest in developing treatments that preempt the headache,” Lipton notes. “Taking a triptan such as frovatriptan prior to menstrual migraine is the best developed example of preemptive treatment with good evidence from double blind studies.”

While daily prophylactic treatment is reserved for the one-third of patients who suffer at least three days of disabling headache per month, just 12 percent actually take advantage of it. “If you’re losing 10 percent of your life to headache, it’s worth taking prevention medication,” Lipton observes. “There are already four FDA-approved preventive medications for migraine on the market, and a combination product called Treximet [that’s] designed to target both the neurovascular and the inflammatory components is on its way.” Treximet has been shown to help not just with head pain but with the neck pain that frequently leads to PT consultation.

Patching Holes

Because neck and postural conditions can trigger or exacerbate migraines, physical therapy plays an important role in circumventing or relieving the intensity of pain associated with the condition.

“A classic migraine is not a musculoskeletal event, so there is no indication for a biomechanical approach to treatment,” says Julie Mills Roth, MPT, the PT coordinator at the Michigan Headache and Neurological Institute in Ann Arbor. “However, a cervical neuromusculoskeletal problem can act as a migraine trigger; we can’t cure the entire disease, but we can eliminate that one trigger.”

Roth examines patients for the presence of biomechanical contribution to headache and makes recommendations based on how PT may apply to their treatment plan.

“It’s important to evaluate patients for the presence of neural tension systemically [i.e., slump sit test] and perform a thorough evaluation of the cervical and thoracic spine, paying attention to any maneuvers or techniques that reproduce or alleviate the head pain,” she says. “We can then incorporate them into the treatment plan.”

Lipton is an avid proponent of PT for the subpopulation of patients who experience migraine due to temporomandibular joint disorders and neck conditions. “PTs are crucial in a multidisciplinary environment because they can resolve some of the triggers that make migraine hard to treat,” he says. “The interesting thing is that by including PTs in the early stages, I now consider issues of the neck and jaw immediately rather than only when patients aren’t getting better, and I have a lot more success with migraine treatment because of it.”

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Ceri Usmar is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to pteditor@gannetthg.com.

© Copyright 2009 Gannett Healthcare Group