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Treating Migraine with osteopathy For her Master of Science thesis in Osteopathy, Ingrid Michal examined how osteopathy can be used to treat migraine: Treatment approaches in osteopathy for the therapy of migraine Master Thesis for obtaining the degree Master of Science in Osteopathy
Submitted at the Donau Universität Krems at the Wiener Schule für Osteopathie By Ingrid Michal Dornbirn, May 2009 Some 6% - 8% of men and 15% - 18% of women in Europe and America suffer from migraine, which Michal defines as: Migraine (from Greek hemicranion, hemicrania – meaning half skull) is a multifaceted disorder, which is characterized by a sudden, pulsatile and unilateral headache that is often accompanied by complaints of the autonomic nervous system and comes along with additional symptoms such as nausea, vomiting, light sensitivity (photophobia) or sensitivity to noise (phonophobia). Migraine headache occurs periodically in the form of attacks. Due to the chronology of the single complaints, a typical migraine attack can be divided into four different phases: prodromal phase (precursors), aura, headache with accompanying symptoms and migraine hangover (Keidel 2007). Migraine is ranked 19th on a WHO scale that ranks disability. Traditional home remedies for migraine include rest, darkened room, cooling the forehead and massaging pressure points on the head and neck. Michal points out that these remedies are not evidenced based. Medication with drugs is effective, but often the patient must take a cocktail of drugs to tackle different symptoms such as nausea. Other remedies include biofeedback, relaxation training, cognitive behavioural therapy, acupuncture and diet. From an osteopathy view according to Michal, migraine has been described thus: Still (1910) classifies migraine among the disease pattern of nervous disorders. According to him migraine means a weakened state of the whole sympathetic system from atlas to coccyx. In the case of migraine he starts treatment at the coccyx and ends at the atlas. He finds overburdened vertebral bodies and displaced ribs which lead to an undersupply of the nervous system. During the treatment he normalizes the position of spine and costal junctions and thus takes away pressure from blood vessels and nerves. Sutherland (1930) thinks that migraine is caused by a traumatic, cranial form of dysfunction. He often detects in such cases a sphenobasilar sidebending/rotation dysfunction. From his point of view, reasons therefore are to be found in childhood traumata (hits, falls). These lead to dysfunctions, which subsequently cause structural malformations of the cranium in later life. Sutherland very often detects in such cases a blocking of the major wings of the sphenoid bone. Due to the malposition of the sphenoid bone, logically the temporal bone is out of position as well. This leads to a restricted mobility of the skull base, which in turn leads to an anomalous tension of the corresponding membrane tissue, which causes the impairment of the vascular channels. He calls this a cranial-membranous articular strain. Sutherland tries to re-establish mobility by means of the sphenobasilar technique and the pars petrosa technique. Liem (2001) calls migraine and headache a multifactorial event. According to him, from a cranial perspective, several different structures may be affected thereby (Liem 2001, p. 567): • SSB-dysfunctions including blocking of different sutures • Tensions of the dura that affect the blood vessels • The vagus nerve can be impaired at the jugular foramen due to dura tension • Upper cervical spine and tension of the neck muscles: the sensitive innervation of one part of the skull and of the dura runs via first three cervical nerves • Tension of hyoidal muscles and masticatory muscles • The blood vessels of the head (of which the arteries are most pain sensitive) are supplied preganglionarily from C8-Th13, via the stellate ganglion (vertebral artery) and via the superior cervical ganglion (internal and external carotid artery) • Visceral structures of the thorax or of the digestive system and their fascial connections.
Liem (2001) lists the following techniques: CV4, atlanto-occipital relaxation, treatment of the SSB, ease the tension of sutures, intercranial dural relaxation techniques, relaxation of neck muscles and hyoidal muscles. According to Milne (1999) that craniosacral techniques are highly recommendable for the treatment of migraine. To him it is important, to settle sphenoid, maxillae, mandible and upper cervical spine. In his point of view, position and mobility of the maxillae seem to decisive factors for triggering migraine and a hint why craniosacral treatment plays such an important role in this respect. According to a lecture held by Ligner (2008) it is of great importance for the treatment of migraine to pay particular attention to the regions of C0-C1, C1-C2, C2-C3, as this is the area of the spine that is responsible for good circulation. Especially C0-C1 is associated with vasomotor disorders and thus has got an influence on migraine. Furthermore it is important to him, to treat clavicle and C6 because of their influence on arterial supply. In addition to that it is crucial to pay attention to the venous drainage of the cranium und to achieve the relaxation of the cranial fascia. Concerning hormonal balance it is important to pay attention to the position of occiput and temporalia and to relax the tentorium, in order to bring the sella turcica into a good position. Also changes of the dura tension, due to previous traumata, can lead to headache and migraine, as they affect the nurturing function of the fascias. In regard of digestion, the osteopath shall give the patient advice concerning nutrition and draw his attention to possible food intolerance, if necessary.
To Gallager (2005) it is particularly important in case of migraine patients to normalize mobility and muscle tone of the spine by means of soft tissue techniques but also by means of manipulation techniques. According to his experience, special attention has to be paid to the muscles in the regions of neck and pericranium. As risk factors and trigger factors differ from patient to patient, Gallager recommends a trial-and error- approach. „Osteopathic physicians with expertise in holistic and muscoloskeletal concepts are particularly well prepared to help“ (Gallagher 2005). From Müller’s (2007) point of view, osteopathic manipulative techniques may have a positive effect on migraine. „Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favourably altering neuromuscular autonomic regulatory mechanism to reduce discomfort from headache“. As many foodstuffs are a trigger factor of migraine, for her this aspect also implies a probable treatment approach. As additional supportive influence on the alleviation of migraine she mentions relaxation exercises, biofeedback and yoga. It is striking that Müller, as an American osteopath, goes into very much detail about the support of medical treatment. For further expert opinion see Michal’s paper. Michal conducted a series of interviews with osteopathic experts with a view to eliciting how they dealt with a patient who presented with migraine. Here are some extracts: M. always makes a very detailed protocol for every patient, in order to grasp all facets of a patient. In case of migraine patients she only asks more precisely when, how, how often and since when migraine attacks occur and whether they are accompanied by an aura or not. Furthermore it is important to her that migraine patients are previously examined by conventional medical practitioners, which is usually the case, as patients with this disease pattern normally have suffered from migraine long before attending therapy. The aspect of posture and stress is of great importance to her as well. In case of migraine patients she pays very much attention to those aspects in anamnesis that deal with nutrition, allergies, eyesight, teeth (occlusion), medication and hormonal problems, in order to be able to draw conclusions concerning posture, organ strain and the like. Furthermore she asks several questions regarding nutrition; whether there are any food intolerances or not. In addition to that, digestion is of great importance to her, again in order to draw conclusions concerning the organs. She mentions the pelvic area as playing an important role as well, however, without going into further detail regarding the reasons. In case of hormonally conditioned migraine she regards osteopathy as not very useful, but leaves it open that other osteopaths probably have better experiences concerning this matter. For the clinical examination M pays attention to the midline (there is a study concerning midline by Monika Dunshirn) and the cranial rhythm and thereby tries to find out where in the body the problem is located. This examination is carried out mainly while the patient is seated. Thereby security tests for the cervical spine and a careful examination of the transitions C0-C1, C7-Th1, Th12-L1 and sacrum-coccyx are important to her, whereby she states that she does not find the coccygeal bone in a malposition too often. In case of migraine patients she does not detect muscular dysbalances and malpositions of cervical spine and upper thoracic spine more often than in other patients. M. states that in her opinion things always run parallel. It is hard to come across with any kind of categorization here, although she suspects that the reason for the disease originates on a mental level, as migraine often implies a hidden depression, too. When it comes to effects, for her, the myofascial aspect is of great importance. M. mainly works with the biodynamic model when it comes to the treatment of migraine patients. • 50% biodynamic techniques • 20% structural techniques • 20% visceral techniques • 10% cranial techniques By means of the biodynamics she particularly aims at a good and well noticeable longitudinal fluctuation, which is a sign of vitality according to the biodynamic model. She applies structural techniques mainly when there is severe impairment, in order to progress faster on the biodynamic level. However, it also depends on the patient, whether she works structurally or biodynamically. But treatment does not differ from the treatment of those patients that do not suffer from migraine. In particular working on the pelvis and to balance out head and pelvis in terms of good symmetry are highly important to her in the case of migraine patients. However, she does not prefer any particular technique, but decides individually for each and every patient. M. treats migraine patients every three to six weeks. After some time, the intervals are lengthened to three to four months. It is important to her that the body has enough time to stabilize after the treatment. For more details of how the experts in the study work, please refer to Michal’s original thesis. But in summary, the treatment regimes for the experts included: Concerning the treatment techniques it is very important for S. to handle migraine patients rather carefully. So she starts working distal to the head. Especially in the first therapy session since the system is already overexcited. Sometimes migraine can be triggered during clinical examination if one touches a cervical vertebra or the head too harshly. This applies to structural as well as cranial techniques. Primarily S. tries to relax the dura via the sacrum. If that is not working well she uses intraoral techniques according to the biodynamic model and works via vomer and base of the skull at the dura. S. learned that this rarely causes reactions. Within the dura there are many blood vessels and so they are also effected by the treatment. This is the vascular element of her work. So to say she tries to loosen the system from within and to achieve a relaxation of the vessels. Regarding structural techiques, S. performs vertebral manipulations. Also here she starts distal to the head and handles especially anxious patients very carefully. The treatment techniques performed split up in the following way: • 40% structural • 40% craniosacral + biodynamic (S. names this together) • 20% visceral Within the visceral model she oftentimes detects the liver as limited regarding its mobility. For the liver she uses biodynamic as well as visceral techniques like for example mobilization of the suspension of ligaments or the liver pump techniques. Depending on what the system shows. There is a certain technique from the biodynamic sector which has a positive effect on migraine patients. While performing this technique she works via the anterior transverse septum according to the biodynamic model. This treatment approach is known from biodynamics. S. recognized that this treatment approach works very well with migraine patients. B. applies the following techniques: • 33% structural • 33% biodynamic and craniosacral • 33% visceral Concerning structural work she frequently applies muscle-energy-techniques and balance-techniques, because, as mentioned above, she encounters strong muscle tensions in the area of C0-C1. Furthermore she often finds muscular trigger points in the sternocleidomastoid and the trapezoid muscle. She tries to mobilize structural blockings of the coccyx and the pelvic ring. B. does not manipulate C0-C1, as for her muscular problems play the central role. However, she manipulates the blockings of the thoracic spine. Concerning the visceral field, she frequently resorts to the liver-pump technique, as there is very often a congestion of the liver. However, if the hormonal aspect is in the foreground, she harmonizes along the hormonal axis. In case of patients, who suffer from food intolerances, she treats the whole intestinal area employing the visceral model. For the treatment of the hormonal axis she likes to resort to the biodynamic and craniosacral model and furthermore those techniques that affect the dural system. She treats the SSB and tendorium by means of craniosacral techniques, if she detects any tensions there. In addition to that she balances the sacrum if it is in a malposition. In case there are problems concerning the venous drainage from the head and she can feel density in the thoracic outlet area, she tries to relax the diaphragm, in order to improve the permeability. Furthermore she aims at opening the jugular foramen, at relaxing the superficial cervical fascia and at treating clavicle, first rib and pectoralis minor. And finally she applies a sinus drainage using cranial techniques according to the craniosacral model. B. starts her therapy of migraine patients away from the head and applies the techniques rather carefully, in order not to trigger anything. She only does what the patient really needs and uses only few techniques; also in order to find out if and how the patient responded to them. B. adjusts the treatment intervals to the techniques she uses during the first treatment. If she works mainly structurally during the first session, she tells the patient to return after two weeks. In case the patient has suffered from migraine for many years already, the intervals are longer. If she is afraid of having stirred up something she tells the patient to return after only one week. On average the intervals are from two to five weeks. After about five treatments the interval can lengthen up to two months. P. uses structural, biodynamic, cranciosacral and visceral techniques to the same extent while working with migraine patients. He does not specify a certain percentage. His personal concept consits in determining the treatment in two to three therapy sessions. In every session he proceeds as follows: 1. Therapy session: During the first therapy session P. works structurally on the pelvis, whereby the sacrum is of great importance to him. He cannot find a specific pattern of lesions for the position of the sacrum in case of migraine patients. P. diagnoses the pattern of lesions of the sacrum via the fascial system with the aid of respiration. For correction he likes to use Mitchell-techniques. Furthermore, in the first session the entire abdominal area and the diaphragm. But he did not observe a certain abdominal organ being affected more frequently. He treats what he finds. At the end the biodynamic model results in a basic adjustment. 2. Therapy session: During this therapy session P. tests the entire spine structurally, starting at the coccyx up to head and loses blockades he finds. On lumbar spine P. works with lumbar-roll- and contract-release-techniques. On the throracic spine P. often manipulates, and losens the blockades of the cervical spine with functional mobilisations, tries to reach the point of release until it reopens. According to P., in case of migraine patients the first ribs are blocked nearly 100%. The patients feel immediate relief when the first rib becomes unblocked (e.g. using Mitchell-techniques and the cervical spine is functionally mobilized. He considers the blocking of the atlas as compensation, due to the malposition of the first rib. At the end of this session he works craniosacrally applying the craniosacral model. 3. Therapy session: In most cases the first two sessions are sufficient. If not, a third therapy session is carried out. During this sesion P. works nearly exclusively according to the craniosacral model. He start with a cranio-structural approach, tests the mobility of each skull bone, loses the sutures, proceeds to the level of fluids and then works mainly on the cerbral membranes. He concludes the therapy session biodynamically, in order to integrate everything. P. does not treat migraine patients more cautiously than other patients. The osteopathic treatment can cause a reaction in the patient and trigger and additional migraine attack. Previously to the treatment he explains to the patient that a reaction might occur, normally the patients agree. For more case studies see Michal's paper. Reference is made to osteopathic models. In summary: Structural model Six of the seven interviewees manipulate or mobilize, respectively, those vertebrae they find blocked in the same way as Still 1930, Ligner 2008 and Gallagher 2005. R., B. and P. additionally apply muscle-energy techniques, contract-release techniques and balance-techniques. C. manipulates those vertebrae of the cervical spine that he finds in lesion, mostly in a compression-rotation-malposition. The cervicothoracic transition is frequently affected, too. Mostly he finds the left occipito-atlanto-axial joint as compensation. Furthermore he manipulates upper thoracic spine and metatarsus or ankle joint if he encounters them blocked during the clinical examination. P. structurally treats the pelvis, and therebyespecially the sacrum, by means of Mitchelltechniques. He treats blockades of the lumbar spine in a lumbar role position by means of contract-release techniques. Furthermore he manipulates the thoracic spine and conducts functional mobilizations of the cervical spine. If necessary he loosens the first rib, again by use of Mitchell-techniques. M. uses structural techniques mainly in case of severe impairment, as this makes it easier to subsequently apply the biodynamic model. B. applies Mittchell-techniques and balance techniques in order to loosen C0-C1. In case of muscular tigger points she uses a contract-release technique. She mobilizes blockades of the coccyx and the pelvic ring and manipulates blockades of the thoracic spine. S. conducts spinal manipulations of the whole spine- depending on what she finds during the previous clinical examination. R. also manipulates those vertebrae she finds in lesion. However, in case of C0-C1 she additionally uses myofascial techniques. Visceral model The visceral model focuses on organs that have shown abnormities in clinical examination. S. assumes that the organ function can be improved by techniques such as mobilization of liver suspension or liver pump (in case of congestion). B., too, applies the liver pump in such cases and treats the intestinal area with its adherences in case of food intolerances. C. tries to untwist twistings of omentum minus with the gall duct, which can lead to liver congestions in order to achieve relaxation within the visceral model. Craniosacral model R., C., S. and P. pay special attention to a good function of the skull base (cf. Sutherland) which is particularly important according to the craniosacral model. P. tries to harmonize the mobility of the individual cranial bones and to release sutures and subsequently works on the level of fluids by use of the craniosacral model. To B. it is important to achieve a relaxation of the tendorium and a harmonization along the hormonal axis, which is both significant in the craniosacral model. In this sense she balances the sacrum. In case there are problems concerning venous drainage, she relaxes the diaphragm, the superficial cervical fascias and carries out a sinus drainage (cf. Ligner 2008). By means of interoral techniques S. tries to work on the skull base whereby she expects, according to the craniosacral model, a relaxation of the dura. All osteopaths agree that in the craniosacral model the relaxation of the dura is of major importance. This corresponds to Ligner (2008), Loza (1998), Liem (2001). According to the interviewees there are several different techniques that can be applied in order to achieve a relaxation of the dura, such as interoral techniques, working on the sacrum, balancing/synchronizing sacrum and occiput. Biodynamic model The biodynamic model aims at a relaxation of the dura as well. With this in mind S.,C., R. and M. apply this model in the treatment of migraine patients. Working on the level of fluids according to this biodynamic model is of great importance for C., M. and R. S. thinks that within this model a relaxation of the anterior transverse septum or of its onsets, respectively can be achieved which can have positive effects on migraine. To M. furthermore working according to the model of midline and working on the pelvis is important. M. considers feeling a strong longitudinal fluctuation important, which is a sign of vitality according to the biodynamic model. P. calls it making a basic adjustment. C. finds even further treatment approaches for the therapy of migraine in the biodynamic model: he loosens the area between dura and arachnoid where he frequently detects adherences and thereby achieves a relaxation of the dura. He pays special attention to sacral plexus and hypogastric plexus if stress is one of the trigger factors of migraine. Applying the biodynamic model, R. aims at harmonizing the hormonal axis (ovaries, pituitary, thalamus) and works on the vascular system of the cranial area. A. examines by means of the biodynamic model each level step by step and layer by layer in order to be able to clearly differentiate, where the problem is located. Thereby he investigates the level of fluid, lymph area and the visceral area. He orients himself by vitality and quality of the system, which is a highly important aspect in the biodynamic model. |