- Your headache is new and severe. Any new presentation of severe head pain should be examined for an underlying medical cause.
- You have a sudden change in your headache presentation. For people with a long standing history of headaches this could involve s change in the usual area, intensity, frequency or duration of your symptoms.
- You have an unusual headache after suffering trauma to the neck.
- Your headache changes significantly when you lay down or stand up.
- In benign headache or migraine the symptoms first appear between the age of 15 and 50 years old. Any new headache or migraine appearing earlier or later than this should be assessed.
- You develop a stiff neck, thoracic (mid back) or lumbar (low back) ache and sciatica (pain down the back of one leg) within a few days of a severe headache
- Headache accompanied by neurological signs such as numbness, pins and needles, confusion, loss of coordination or cognitive ability.
We have all had the experience of going for a massage, or treatment from a manual therapist, who pushes on a part of our body that, prior to them pushing we weren't aware was actually sore. Our brain is very good at ignoring areas in our body that are constantly painful even with moderate to high pain levels. It works the same way as when you put on a woollen jumper. Initially it feels itchy against your skin, but after 30 seconds or so the itchiness goes, and you don't notice it anymore unless you move the jumper against your skin. Low level irritating signals get turned down and ignored.
The research informs us that between 60-70% of all headache sufferers have some symptoms in the neck. We also know from research that upwards of 80% of headache sufferers have the neck as a source of their symptoms. Doing the math that leaves 10-20% of sufferers who can have their symptoms relieved with diagnostic blockades to the neck, who don't have neck symptoms. These figures match very closely the data from this clinic.
I often treat people who don't suffer neck pain as part of their headache/migraine, but as we assess the neck it becomes apparent very quickly that the top part of the neck is very stiff and tender, and being affected by constant, low level dysfunction, which has to overstimulate the trigeminal nucleus. The only thing left to test is whether this dysfunction actually relates directly to the pain in the head.
This can be assessed clearly in the first session. We don't go into a treatment cycle unless we can clearly demonstrate a connection between the neck and the usual headpain.
For information on the research supporting this response read the cervicogenic headache page here.
The short answer is no if the real question relates to being able to diagnose a migraine by imaging, and this goes for all types of investigation (CT, MRI, X-ray, blood tests).
Naturally the next question is should you have imaging done. The main reason your doctor will recommend imaging is to exclude other serious causes of similar symptoms – for example an aneurysm or brain tumour. This is especially the case for new an acute presentations of pain. So people that have never had an episode before who suddenly start having migraines should see their doctor. So should people who may have had a long history of migraines but they change suddenly in terms of location, intensity, frequency or duration.
It is quite typical of migraines to behave like a river - gradually over time just shift course a little becoming more intense, more frequent, or presenting in different areas. Again, if the changes occur suddenly, the chances are it is nothing serious, but don’t leave it to chance – see your doctor and be sure.
The long answer is a little more complicated. Functional MRI’s are designed to look at changes in blood flow in real time.
Whilst these types of scans put an end to the vascular theory of migraine – initially thought to be vasoconstriction or decreased blood flow, triggering an ‘overcompensating’ vasodilation – hence the throbbing pain.
These huge changes do not occur, but there are areas that can be observed to change, and most notably in the brainstem region corresponding with the trigeminocervical nucleus (the area housing nerves for the head/face and upper neck).
Interestingly, white matter lesions are often noted in sufferers, particularly in migraine with aura. The cause is believed to relate to the decreased blood flow (and resultant wave of spreading depression of nerve activity) that occurs during migraine aura.
While this sounds serious, there doesn’t appear to be any cause for alarm as to date, research is indicating that the lesions are not causing symptoms or contributing to other brain problems such as stroke. However a higher number of lesions is often associated with more significant aura.
Whilst it might seem that identifying these lesions could be diagnostic for migraine, it is not the only condition in which they are observed as a natural part of aging, but also in other conditions such as Alzheimer’s disease and multiple sclerosis.
"I have a 7 year old daughter who has been vomiting about once a month since May 2013. But most recently she has been vomiting every 2 weeks almost exactly to the day. When this first started happening I was most concerned about the vomiting and didn't worry that it usually started with an intense headache first.
I have been keeping a record, and I have noticed that every time she vomits it starts with the headache, she looks hot(not a fever), is lethargic and crying. I cool her down with a cold cloth on her head and she will sleep for at least 3 hours. She will then get up and start vomiting, sometimes 3-4 hours and sometimes it will go all night and day, I have been to my general practitioner who says there is nothing she can do and I have to just try and find the triggers for her headache and avoid them.
I have been to a naturopath who has done food sensitivity tests and we are keeping away from those foods. She is very weak now that it is happening more often. What else can I do?"
as a parent there is nothing harder than feeling helpless when it comes to the health of your child.
The good news is there are more things you can look at beyond chasing triggers that may get closer to the heart of the problem.
Firstly the symptoms you are describing are quite typical of migraine in younger people. We usually associate migraine in teens and older with the severe headpain. In children the nerves related to the stomach are much more sensitive and as such usually present with “abdominal migraine” or “cyclical vomiting syndrome” both of which related closely to traditional migraine.
While you can keep looking for triggers, the timing cycle with these episodes would indicate that you are unlikely to find much joy there. Migraines that relate strongly to controllable triggers tend to be a bit more sporadic (i.e. related to trigger exposure) rather than working to an internal clock as these appear to.
Greg is right to suggest looking at the neck. Far from being a “long shot” the scientific evidence is becoming much clearer. The neck is becoming front and centre in the search for answers in migraine.
We know that with all headache types an area in the top of the neck called the brainstem has become overactive. This area houses all the nerves for the head and face and must be “switched on” for you to have a headache. Sitting immediately behind this area is a control centre for nausea and vomiting, which is why many migraineurs will report nausea and/or vomiting as a predominant symptom. Again, in children this area tends to “light up” quicker and vomiting is usually a much stronger feature.
The position of the brainstem is the problem. Sitting in the top of the neck, it receives direct input from the 3 nerves in the top of the neck. What this means is the nerves in the top of the neck have direct access to the headache centre, and as such can drive this overactivity.
There is now very good evidence that using specific techniques, known as the “Watson Headache Approach” we can assess the neck and determine if it is playing a role, and if it is, treat successfully and normalise the activity in the brainstem - decreasing the likelihood of headaches and the accompanying nausea/vomiting that often goes with them.
Rather than go to a generalist, I would see someone who deals with this type of problem all day every day. There are dedicated headache clinics using these techniques in Melbourne (my clinic), Sydney, Brisbane and Adelaide. Let me know where you are and I can put you in touch with the appropriate contact.
Unless you have been treated using the techniques taught by the Watson Headache Institute then we can assure you this treatment is different.
Having used the "traditional" physiotherapy mobilisation techniques for many years, and having treated many people reporting on the outcome of their usual care I know the type of results that normally occur. Typically after treatment with your physiotherapist, osteopath, chiropractor, acupuncturist, the muscles and joints in the upper neck will be stretched, and generally provide at best, some short term relief. The root of the problem has not been treated. What causes the muscle to spasm and put stress on the joints in the first place? Without a precise knowledge of the underlying problem it is also quite easy in the right client, to upset the upper cervical spine and provoke a migraine or headache episode.
We identify the problematic segment of the spine AND the underlying problem that is causing the muscle and joint to be painful. We treat the underlying problem and teach you how to manage it by yourself.
Due to our treatments targeting the underlying problem we set high expectations for ourselves.
We expect significant improvement after the 5th treatment over a 2 week period. If we don't see significant change we stop. No ongoing therapy that isn't effective month after month. This occurs in 10% of cases. In the other 90% who have had significant improvement there may be some need for further treatment, however, there is a strong emphasis from the outset for self management, and we expect to discharge 80% of people within 4 weeks of starting treatment.
The short answer is that it doesn't seem to provide any significant benefit. Read more about the current research here.
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