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Medication Overuse Headaches

Combating Medication Overuse Headaches

Medication Overuse Headaches

Medication overuse headache (MOH) is a very common manifestation of chronic headache patients. It is one of the unique instances where a once effective way of controlling an illness will actually perpetuate the illness further as the body adapts to a chemical intervention. This condition is unique to patients with chronic daily headache disorders and various chronic pain syndromes like fibromyalgia.

The most frustrating part about MOH is that you may do better for a long period of time because of a medication, but as the effectiveness of the medication wanes over time you may actually experience the headache worse than before.

It’s a situation that can cause despair as medications are generally the treatment of choice for all headache conditions. If your body has become resistant to all of the available medications, what can you do next?

Why Is Your Medicine Making Your Head Hurt?

People with chronic headaches will generally have 7-10  headache days per month. For better or for worse, there are a wide variety of medications that can help knock a headache out or prevent them from occurring. It’s not unusual for a chronic headache patient to have  a cocktail of drugs that they have to take on a daily basis.

The problem with a frequent medication regiment in chronic pain conditions is that the cells of your body almost always have an adaptation to to make itself more resistant to the medications’ effects. This can happen even if you’re taking your medications correctly as prescribed by your doctor.

The headache that results from MOH is often called a rebound headache. As the effect of the medication wears off, the headache returns rapidly which can create a need for another dose of medication. In this way it becomes a cycle of struggle as the effects of the medication start to decline faster and the rebound headaches become more persistent. When this occurs, the chronic headache patient can become the chronic daily headache as the headaches will begin to occur greater than 15 days per month. Because of the reliance on these medications, medication overuse headache has become the 3rd most common headache disorder, and the most common cause of migraine-like symptoms.

Research has shown that this can occur regardless of the type of medication you take. It’smost frequently associated with prescription migraine medications, but it has been documented to occur in people taking over-the-counter drugs like ibuprofen. Hard pain meds like oxycontin may be used by headache patients without a doctor’s prescription, and these can tend to accelerate the process to MOH because of the way that opiods sensitize your brain.

You can read more about how pain pills can make your pain worse in this article I wrote last year:

Research: Can Pain Pills Cause More Pain Over Time?

How to Beat Medication Overuse Headaches

The easy answer is to stop taking your medications for a while because….

you can't if you dont

If you don’t understand this meme, then ask someone who is younger than 30. I promise it’s funny.

Unfortunately, biology isn’t that simple, especially if you have chronic pain.  Are there side effects to stopping a daily medication? Will you experience worse pain when you stop taking the drugs? How will you cope with the pain if you can’t take any meds? How long will this take before you can make the meds work again?

Chronic headache patients need effective non-pharmacological methods to deal with the pain of headache physiology.

One specific target for drug-less treatment of headaches is by correcting dysfunctions in the neck.

In many cases, headaches syndromes can be a result of a secondary effect of a shift in at the top of the neck. This is why chronic headache patients are some of my favorite people to see in practice because a gentle correction of the neck  has allowed us to have a very high success rate with chronic headache syndromes.

While addressing the cervical spine may not address the cause of  a medication overuse headache, it may help fix the primary source of a patient’s headache condition so that taking the medication becomes less necessary. The most common comment I get from headache patients is when they tell me that they’re taking less ibuprofen since they started getting their neck better.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

A shift in the atlas can disrupt fluid in the spine and cause neuroinflammation in the brain. In some cases, this may be tied to MS.

Within 2 weeks of neck corrections with the NUCCA procedure, the vast majority of our headache patients experience relief in either the frequency or intensity of their daily headaches.

Not All Neck Adjustments Involve Cracking

A lot of people are scared about having their neck worked on by a chiropractor. The general portrayal of a neck adjustment by viral Youtube videos can make it seem scary.

While chiropractic adjustments have a tremendous track record for safety, the bottom line is that a lot of people just don’t want their neck cracked because the sound and the motion make them really uneasy. This leads to patients tightening up their neck and bracing which can make a neck manipulation hurt in the hands of a chiropractor that is not skilled.

That’s one of the big reasons why I’ve used the NUCCA procedure throughout my career. The NUCCA procedure involves a very light pressure to correct the neck as opposed to a high velocity manipulation. By using the NUCCA procedure, the doctor is able to measure and control how much force goes into the neck, and if we have corrected the underlying dysfunction. All of this happens without the popping, twisting, or cracking of the spine.

Not all patients with headaches are good candidates for the NUCCA procedure. Only patients with a subtle shift in the top vertebra called the Atlas will benefit from the NUCCA correction. A thorough history and examination will help us determine if the Atlas is causing a problem and if it’s something that can be fixed.

 

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head tilt

Is Head Tilt Driving Your Brain Crazy?

Is Head Tilt Driving Your Brain Crazy?

 

A lot of people are starting to recognize the role that posture plays in overall health. Things like text-neck has made it’s way to major publications like the Washington Post, and the perils of slouching have been written about ad nauseum.

I won’t get into that today, because I think there’s a problem that is a lot more important but gets far less attention. Most doctors will ignore this, but chances are it’s a major contributor to headache, balance disorders, vision problems, and overall brain health.

Today we’re going to break down your head tilt.

Cute for Puppies and Sorority Poses, Bad for Patients with Neurological Issues

First we should clarify a couple of things. When we discuss head tilt, we’re not talking about the tilt that comes on when you intentionally tilt your head for a photo. If you are intentionally creating a momentary head tilt, it’s not a big deal. There’s no such thing as a bad posture if you are willfully and intentionally trying to create a specific shape with your body in gravity.

We only classify postures as negative when your body is doing something that it is not intending. If I ask you to stand up as straight as you can and your head tilts to side, it paints a much different picture of your brain than if I asked you to purposefully hold your head to the side. An inability for you to create a straight upright posture suggests that you have a deficiency in your brain’s ability to control your muscular system. You can read about that in greater detail here:

Why Your Posture Isn’t That Important

So what’s the big deal if your head tilts to the side?

It’s a sign that your brain is perceiving the world around it incorrectly.

If your brain is getting wrong information from your senses, then it can’t produce the right response to the world around it.

It doesn’t sound like a big deal when we’re talking about posture, muscles, and bones, but let’s apply the same idea to some of your other senses:

  • If you have a problem with one of your eyes, how will that affect your ability to catch a baseball?
  • If your ears are hearing a high pitched noise all of the time when everything is quiet, how will that make you feel?
  • If your skin is constantly itching, but you have nothing on your skin that is irritating it, will you keep scratching?

All of these are examples of your brain perceiving the environment incorrectly and they all lead to specific conditions from a lack of depth perception, tinnitus, to neuropathic itch. When left for a long time, these conditions can have a significant impact on your enjoyment of life.

So what are the consequences of a chronic head tilt?

The Physiology of Head Tilt

How your brain decides to hold the head up involves a lot more neurology than most people expect. Generally speaking, we think about head tilts being a result of tight muscles pulling the head out of place. When we use this model, treatments become a matter of rubbing one muscle and stretch another and the head will be straight again.

For better or worse, the way the brain moves the head is WAY more complex than that. Your brain decides where to put your head in space based on the interplay of your inner ear organ, your eyes, and the small muscles of your neck.  Here’s how it works:

Normal Head Tilt Reaction

So this is what happens when the system is working okay. When the system works, you can tilt your head when you choose to, but your brain will bring your head back to the normal upright position after it has achieved its purpose.

We see this system break frequently when someone has injuries like whiplash or concussion. The impact of these injuries disrupts normal function of all three systems. It scrambles the inner ear which distorts your eye movements. It also wreaks havoc on the muscles and ligaments of your neck.

What Happens When Your Head Tilt Breaks?

This is why the biggest problems associated with whiplash and concussion injuries are balance and vision issues. You can’t keep your perception of the world straight if your eyes, ears, and spine are giving you inaccurate information about gravity!

When your head and neck get scrambled by a hit and you disrupt these 3 systems, your body takes on an abnormal head posture which can make the other systems work inappropriately. One of the first things I’ll ask someone during a consultation is to sit up as straight as they can, and I’ll look at where they put their head in space. Very often they look like this:


Abnormal Tilt Reaction

 

 

But let’s be honest here; you don’t really care if you have a head tilt, crooked eyes, and tight muscles if it’s not causing you any pain or discomfort right?

Here’s the thing, your body can compensate like this for a little while. But if you’ve ever had to rely on a back up system before, you probably know that backup systems aren’t ideal and they’re more prone to glitches and failure. Your body is the same way with its own back up systems. They will get you out of a pinch for a short time, but they will eventually fail. Or even worse, you may suffer another injury while you are compensating and have even more damage to the brain.

So as your back up systems start to fail and your eyes and neck aren’t working normally you will start to have problems like:

  • Dizziness
  • Feeling off balance
  • Neck and back pain
  • Headache
  • Nausea

Why? Because if your eyes don’t move well, then it leads to difficulty reading or tracking targets in space. If your neck doesn’t move well, it causes pain and headaches. If you have all three systems saying different things, your brain has no idea how to determine it’s sense of balance.

Your Brain Hates Mismatches

Your brain hates it when its sensory organs give it conflicting information causing sensory mismatches. It hates it more than your significant other hates it when you walk out of the door with a brown belt and black shoes.

Your brain hates sensory mismatches even more than your significant other hates this fashion faux pas

Your brain hates sensory mismatches even more than your significant other hates this fashion faux pas. Image Credit to http://www.houseofmarbury.com/can-wear-black-brown/

All kidding aside, these sensory mismatches are the main trigger for the balance issues that can make people miserable. When you combine that with the fact that the balance system shares connections to your autonomic nervous system, then it gives us an understanding for why balance problems can really wreak havoc on our stress response system.

The abnormal movement of the eyes and head are also likely to create persistent headaches and pain in your joints and muscles from abnormal loading patterns.

When your head tilts, all of your spinal system starts to act screwy

When your head tilts, all of your spinal system starts to act screwy

While the symptoms can be bad enough, the biggest concern is the impact that these maladaptive patterns have on the functioning of the brain as a whole. If you can’t orient your world properly, then the parts of your brain that are responsible for normal function start to degrade while the parts of the brain that are producing these abnormal patterns get stronger. This persistent abnormal head pattern can change the way blood flow and oxygen get to various parts of the brain and lead to further problems with thought, focus, and movement.

If we want to make a real impact on the health of your brain, then we have to allow the brain to stop compensating and get your head on straight again.

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Post-Concussion Syndrome

Case Study: 6 months of Post-Concussion Syndrome

Post-Concussion Syndrome

 

Read Time: [3 minutes]

Post-concussion syndrome has become a big deal with more athletes showing concern about the risks of chronic brain injury. Recovery from a concussion usually takes about 7-10 days for most people but many will have symptoms that last 30 days or more.

Our most recent case had post-concussion syndrome that lasted 6 months prior to visiting our office.

Background

A young woman was a passenger in a car that was struck from the side. The shock of the accident caused her head to whip from side to side and she lost consciousness immediately.

Although many concussions are a result of a direct blow to the head, a concussion can occur through rapid acceleration and deceleration of the head causing the brain to move and collide with the inside of the skull.

Following the concussion, the patient began having daily episodes of migraine headaches. During the migraine attacks, she would also have vertigo that led to a persistent feeling of nausea.

After being discharged from the hospital the patient was seen by an orthopedist and chiropractor. While chiropractic adjustments were helpful, she felt her symptoms come back repeatedly within hours of her treatment. The patient had an appointment with her orthopedist to receive neck injections, but was referred to our office before that to see if correcting her atlas would help.

Assessing the Neck in Concussion

The patient was put through a full examination to evaluate the  neck. In many cases of post-concussion syndrome, the neck has numerous pain-generating tissue that can be responsible for these neurological symptoms. This includes precise x-rays of the top of the neck, evaluation of neck muscle tone, structural positioning, and evaluation of head and neck control.

You can see some images of our head control laser testing below.

img_4266

Laser head positioning system

Testing head control using a maze

Testing head control using a maze

When people suffer a concussion or whiplash injury, it can cause damage to the muscles and allow us to control our head and neck movement. These injuries can lead to headaches, but they also cause problems with our sense of balance.

Once we have some baseline information on their current abilities, we can monitor how they respond and heal from the damage to their neck.

Results:

After her 2nd visit, the patient said that her headaches and nausea were almost completely non-existent.

Imagine that. Going from daily migraines, to no headaches for an entire week. All from a getting the head and neck into a better structural position.

Now that isn’t to say that life is perfect after that. There were certainly some ups and downs along the way. Overall, the patient’s headaches have improved about 80% in frequency and intensity. She has elected to skip getting injections, and is working hard everyday to get stronger.

Here’s the most important element and really the part that matters:

After the head injury, the patient was unable to do the things that made her life fun. She had trouble working out and getting motivated to exercise. Staying focused at work meant having to rely on pain killers. Taking care of a young daughter meant gritting her teeth through pain and nausea instead of being present in the moment.

That’s what all of this is about. It’s not about the pain reduction, it’s about the restoration of normal life!

For more information, you can read this patient’s testimonial below:

I’m a very active mommy that carries around the weight of a 6 year old and owning a salon full time. Work and mommy duties call for my body to be at all times ready and with it. There isn’t time for rest, much less any fatigue or achy-ness. Between playing sports when I was young, actively working out and having the burden of standing on my feet the majority of my work days, my simple adjustments just got me through. I didn’t realize that there could be a cure for my migraines, constant neck stiffness and what seemed to be a much older body that I was trapped in.

I was a back seat passenger in a car crash on New Years, where the car was deemed totaled. There were no major signs of trauma, besides the concussion and black eye I received, however, I knew something was wrong when my pain was continuing to get worse months after the accident. My routine visits to the chiropractor, became tedious weekly visits that just got me through; my pain kept coming back if I didn’t get adjusted that day. I refused to succumb to cortisone shots previously, but felt desperate. Instead of my Chiropractor sending me off the receive the possible relief from an invasive procedure, he referred me to his dear friend Dr. Chung that specializes in post concussion, migraines, fatigue and achy-ness.

Dr Chung was very thorough and did a series of X-rays and tests to see how my whole body was aligned and reviewed my MRI. He explained the symptoms and showed me what was happening to my brain and surrounding inflamed tissues. After one precise adjustment and many months of not being able to be active or myself, I felt 150%. I was scared and apprehensive as to when my pain would return. To my surprise, months later and just a few maintenance NUCCA adjustments, my pain has not returned and I was immediately able to carry on with my workouts, mommy life and my physically involved career. I was even able to hike, travel and do Cross-fit within weeks of being adjusted. My energy and range of motion has returned. I couldn’t be happier for the referral to such a dedicated, intelligent, passionate Doctor of Chiropractic. Thank you so much for your passion to treat your patients and wish you much success.
Jessica S.

Anatomy

The Anatomy of a Headache

Anatomy

 

Outline: [5-10 minute read time]

  • Headaches come in different shapes and sizes and may have different anatomical triggers
  • The brain cannot generate pain. Head pain must come from a source outside the brain
  • Common sources of head pain
  • How head and neck positioning can help

Not all headaches are created equal. Part of being a doctor that sees patients of all shapes and sizes, we have to become familiar with the different types. Here’s a short list of the most common types:

  • Tension headache
  • Migraine headache
  • Sinus headache
  • Hypertensive headache
  • Cluster headache
  • Post-traumatic headache
  • Cervicogenic headache

It can be a challenge for a doctor to identify the type of headache you have because while these headaches have distinct characteristics, most of them overlap and make the clinical picture very gray. In some part, the type of headache you are having is determined by the anatomy that is generating the pain signal.

Although the pain of a headache can make it feel like your brain is going to explode,  there are actually zero pain generating tissues within the brain itself. That means that something outside of the brain is transmitting a signal to the brain that something has gone wrong. I won’t go into some some of the more serious secondary causes of headache like tumors, strokes, etc, this will be more focused on primary headache.

Headache Anatomy

1. Arteries in the brain -

For decades, scientists have studied arteries in the brain and their role in headaches. While we don’t know everything about migraines, we do know that migraine attacks tend to happen when the arteries of the brain swell and lead to inflammation of the nerves that are connected to the artery. These nerve endings are transmitted to the trigeminal ganglion causing the pain portion of the headache.

It’s for this reason that many of the drugs used to treat migraine are those that reduce the swelling of brain arteries. In fact, the target of new drug therapies are using antibodies to target the molecules that cause the arteries to open, and hopefully prevent the attacks from occurring to begin with.

2. C1, C2, C3 Nerve Roots

The top 3 nerves in your spine are highly linked to headaches following a head and neck injury. When someone suffers a whiplash injury or concussion, these upper cervical nerves can become irritated and generate pain across the back and top of the head. In some cases, this leads to a condition called occipital neuralgia where the nerves are chronically disturbed leading to unrelenting pain or numbness in the skull.

c1 c2 c3 nerves

The nerves coming from the top of the neck

 

3. The Meninges

The meninges is a layer of tissue that wraps around the brain, spinal cord, and nerves. When you hear people talking about meningitis, we are referring to this outer covering becoming enflamed. One of the symptoms of meningitis can be a bad headache, and the meninges can be a cause of headache pain even without a meningitis infection.

Some anatomical studies show that small muscles in the neck can connect into the meninges which may be the problem with certain types of headaches.

Brain Meninges

A cross-section of the skull showing the brain and the meninges

4. Head and Neck Muscles

Muscles of the head and neck have been long associated with tension type headaches. While the influence of these muscles in headache were exaggerated over the years, certain muscles do play a role in head pain. Neck pain generated by muscles like the  splenius capitus can generate pain that refers into the head.

With TMJ patients, the jaw muscles like the masseter, pterygoids, and temporalis muscles can become highly contracted and become potent pain generators which is one of the reasons why jaw problems are highly associated with headache.

Neck Muscles

Muscles commonly associated with headache

5. Dysfunctional Neck Joints

The joints of the neck play a large role in postural feedback to the brain. These joints are also sensitive to irritation through injury and chronic malpositioning. Headaches resulting from dysfunctional neck joints are known as cervicogenic headache. These types of headaches are hard to diagnose because they are generally classified by whether a neck treatment helps, but we do know that this is more commonly seen with whiplash and head injuries.

What Do They All Have In Common?

So here’s the fun part. What is it about all of these different pieces of anatomy have in common besides the fact that they all cause headaches? Neurologically it comes down to a bundle of nerves that make up the trigeminal complex.

The Trigeminal Complex

The Trigeminal Complex

This particular piece of anatomy is important because it is the hub for almost all pain signals in the head and neck. Everything from the C1-C3 spinal nerves, meninges, jaw muscles, and skin of the face gets transmitted and processed by these nerves. In some cases, a chronic headache problem might possibly be a less severe form of trigeminal neuralgia.

That means if we can can change the way the trigeminal complex is working, then we can have a meaningful effect on the status of someone’s headache disorder.

How Structural Correction of the Neck Can Help

In our Wellington office, we work heavily on correcting the positioning of the top part of the neck. We talked about how C1, C2, and C3 nerves can transmit pain in regards to a headache, but they also transmit valuable information about your posture and positioning in space.

When the head and neck are in a normal position, then this information gets to the brain without a problem and all seems well. However, a structural shift like Atlas Displacement Complex creates a scrambled signal into the brain and allows pain to be the dominant message. That’s why those nerves at the top of your neck are so important. They can dampen pain signals going into the trigeminal complex and stop the headache process from starting!

 

Image credit to Dan Murphy, DC thechiropracticimpactreport.com

Diagram showing how the nerves from the neck meet with the trigeminal nerves Image credit to Dan Murphy, DC thechiropracticimpactreport.com

 

Our success rate with headaches is so high, not because we’re treating each headache we see differently, but we are finding the neurological element that seems to tie them all together. In many cases, it can be as simple as the Atlas Displacement Complex.

 

 

Could your problems be the result of ADC?

Could your problems be the result of ADC?

Case Study

Case Study – What Happens When A Current Patient Has a Head Injury – Chiropractor in Wellington

Case Study

 

Last week I had a really unique situation that I wanted to share. It really helps to clarify what my approach to patient care is when a case is not going the way that I expect.

Case Presentation:

A year ago, a woman came into the office to see me for daily headaches. The headaches had been a problem for over 40 years. They had been using over the counter medications and meditation techniques to keep the headaches under control. The worst times for the patient were the days that it rained. On rainy days, their dull headache would start to become more of a pounding type pain. In West Palm Beach where it rains most days in the summer, it’s a pretty miserable way to live.

After 2 weeks of gentle Atlas Corrections, the patient’s headache frequency dropped to 1x/week and the rain no longer had an impact on their headaches.

Within 2 months, almost all headache symptoms had resolved completely.

Enter the Concussion

The case above is a pretty standard and regular occurance in the office. Headache cases are probably the fastest responding and most successful Secondary Conditions that resolve when the Atlas is corrected. What made this case interesting is what happened about a year after she first saw me.

The patient ended up having a concussion, and as a result started showing new symptoms. There was neck pain that was never present, a new headache pattern, and a persistent abnormal tingling that wouldn’t go away.

The patient came in about a week after the concussion happened. After evaluating the patient to make sure it was safe to take care of them, I attempted to use a similar adjustment that had worked on her in the past.

While some of the post-concussion symptoms got better, the headache and the abnormal sensations didn’t budge. The patient was concerned that they might have to seek out more aggressive medical options to address the new symptoms.

Many times, an Atlas Correction is like a key to a unique lock. It rarely changes over time, but a head trauma can force that lock to break, which means you need a new key. A new and different correction becomes necessary.

I decided that I needed to re-evaluate the situation based on the NUCCA protocol for Structural Correction.

Some people think it’s uncalled for, and others think it’s excessive, but I decided to take a new set of X-rays on the patient. The radiation dosage on craniocervical X-rays are about the same as a cross-country flight, and the patient thought it was worth it.

I never want to irradiate a patient more than they need and I look to avoid X-rays if I don’t need them. I decided that the chance to help this patient recover from their post-concussion symptoms warrented a new series.

Concussion Created a New Lock, NUCCA Provides a New Key

As it turns out, the new imaging revealed a completely different angle that I needed to use for the correction. The head injury disrupted the structure of the neck so much, that it rendered the previous correction useless.

Within minutes of using the information from the new X-ray, the patient’s headache and abnormal head sensations vanished.

It’s one of the reasons I embrace the NUCCA procedure because it provides a very elegant way of troubleshooting a difficult case, especially one that had achieved such success in the past.

Some people go through and have an extremely successful run with chiropractic care, but out of nowhere it stops working.

In these moments, I encourage people not to dismiss chiropractic as a whole, but to reevaluate the APPLICATION of chiropractic to find what went wrong.