Migraine and chronic headache alleviated by manual manipulations and mindfulness
Migraine is a common and often disabling disorder with a high impact on work, household and social life[i]. The 1-year prevalence of migraine is estimated at 15%, The 2016 Global Burden of Disease study estimated that migraine accounts for 5.6% of years lived with disability (YLDs) across all age groups[ii]. And Migraine is ranked as the seventh-highest cause of disability in the Global Burden of Disease study[iii].
Migraine is usually managed by medication, but the currently available oral pharmacological migraine treatments may be poorly tolerated by some patients. Unpleasant side effects and lower than hoped for efficacy.[iv]
The use of non-pharmacological treatments for migraine represents an expanding clinical practice and interesting area of research, these may include invasive or non invasive stimulation of various cranial nerves which have been found to be effective.[v] At the same time Various Randomized Clinical Trials suggest that non technological methods such massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine, while others suggest that they have no significant effect[vi]. In parallel behavioral interventions for migraine such as relaxation training, stress management, cognitive-behavioral therapy, ACT and biofeedback have been shown to be effective in diminishing migraine frequency.[vii],[viii]
The current paper intends to present case studies demonstrating the effectiveness of a technique of Manual Neuro Modulation Migraine & Headache relief, colloquially known as the MHRMprtotocl (The ‘Migraine & Headache Relief Method’).
The MHRMprotocol is a self applied Manual Neuromodulation technique. Which involves the following application of the following elements:
- Mindful non reactive awareness
- Manual manipulations, that take the form of massage to various pressure points in areas innervated by branches of the Trigeminal nerve
- Deep abdominal breathing
- And progressive muscular relaxation
During an MHRM protocol session the patient is asked to perform one of approx 30 physical manipulations, involving pressure points, neck stretches, and massage, to various areas, mainly in the head and back. At the same time the practitioners are instructed to perform deep abdominal breathings, facial gestures, and relax muscular tension in the face and body. Patients are also advised to remain in a non-reactive mindful state of mind as they perform these techniques. The techniques are laid out in specific sequences which are propounded to connect to specific migraine symptoms including the pain location, quality of pain, and symptoms like nausea, irritation and cognitive dysfunctions.
Patient 1, Female, aged 42 had been suffering from migraine with aura for 20 years. Prior to treatment with the MHRM protocol she had suffered from an average of 10 migraine days per month, each migraine lasting 1-2 days, with an average pain index of 9 during the peak of the attacks. During her 20 years of dealing with the condition she was unsuccessfully treated with a variety of medications, including: Topamax, Relpax, Valerian, botulinum injections, and even the new CGRP inhibitor Emgality. These treatment modalities were reportedly ineffective, and the patient complained of multiple side effects including: Depression, Weight loss, and insomnia. The patient has also attempted alternative methodologies such as Chiropractic manipulations and massage. She was prescribed a 45 minute sequence that included 2 types of abdominal massage, a diaphragmatic manipulation, a spinal manipulation to the level of T5 vertebrae, a manipulation of the neck, a suboccipital massage, massage to the zygoma, and a manipulation of the nasal bone. Within 1 week she was able to successfully apply the method. At a 6 month follow up Patient 1 reported that she now suffers from less than 5 migraine days per month, with a maximal pain index of 3, and a recovery time of 1 hour per migraine attack.
This patient, Male, aged 65 was referred to me after suffering for 6 months from daily persistent headache. Manifesting as a stabbing pain located on the right side of the head, the nose and around and behind the orbit of the eye. This condition prevented him from attending his workplace during its 6 months manifestation. Blood work and Imaging did not reveal any significant findings, and treatment consisted of high doses of ibuprofen and cortisol shots which had some limited effect in the early manifestation of the condition, but which became ineffective within weeks. Patient 2 tried the application of alternative methods such as acupuncture & massage to no effect. Upon beginning his treatment with the MHRM protocol he was prescribed to perform a sequence consisting of a massage to the temporomandibular joint, the supraorbital foramen, and the suboccipital region. And to apply all the elements of the MHRMprotocol outlined in the introduction to this paper. Within 2 days of beginning to perform the techniques in a single 15 minute session performed upon awakening, the pain remitted completely. The patient was advised to continue with the same 15 minute sequence on a daily manner as a preventive therapy. The patient was still completely pain free in a checkup performed 2 years later.
Patient 3, Male, aged 22 is a professional athlete, was referred after suffering from recurring Migraine with aura attacks following training sessions. He was treated with Imigran Radis 100mg. When presented to us he was suffering from a MIDAS score of 9, and a HIT-6 score of 69. He suffered from 2 migraine attacks per month, lasting 2 days each with a maximal pain index of 9. This patient was treated with a single technique from the MHRM protocol – forced left nostril breathing, that was applied at the end of each training session for a duration of 30-120 minutes based on the discretion of the patient. A one year follow-up revealed that he had not suffered a single migraine attack during the entire year. His MIDAS score was 0, and his HIT-6 was the minimum of 36.
The MHRM protocol is believed to utilize a three level approach to downregulate pain.
It is hypothesized that during the application of the manual manipulations, first order nociceptive nerve endings of A𝛿 fibers, and C fibers of the trigeminal ganglion, innervating extracranial structures are stimulated.[ix]
A first level of analgesic effect may occur by a pain gating mechanism in the spinal trigeminal nucleus caudalis.[x]
A second level of analgesic effect may involve the relaxation response[xi] the analgesic effects of which are attributed to the hypothalamic pituitary adrenal axis (HPA) and the sympathoadrenal medullary (SAM) system. And may also be effected by Vagal modulation achieved by deep rhythmic breathing. These two pathways converge on second order trigeminovascular neurons located in the principal sensory nucleus of trigeminal nerve in the medullary dorsal horn, producing a down regulatory response.
Finally a third level of analgesic effect, which may have repercussions towards other migraine symptoms as well, involves the use of mindful non reactive awareness. Mindfulness is believed to activate brain regions that mediate the cognitive control of pain, including the ACC and a significant deactivation of brain regions that facilitate low-level sensory and nociceptive processing including the thalamus and periaqueductal gray matter (PAG), from where the bodies of third order neurons along the trigeminothalamic axis project into the primary sensory cortex[xii]
As the cases reported above demonstrate, the MHRM protocol can be an effective method for both acute migraine pain reduction, as well as migraine prevention. While these cases are demonstrative, a randomized clinical trial comparing the MHRM to a placebo group will be required in order to determine the true efficacy of the method. And further imaging studies will be required to determine the mechanism of action behind these effects.
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[ii] Steiner, T. J., Stovner, L. J., Vos, T., Jensen, R., & Katsarava, Z. (2018). Migraine is first cause of disability in under 50s: will health politicians now take notice?.
[iii] Stovner, L. J., Nichols, E., Steiner, T. J., Abd-Allah, F., Abdelalim, A., Al-Raddadi, R. M., … & Edessa, D. (2018). Global, regional, and national burden of migraine and tension-type headache, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 17(11), 954-976.
[iv] Goadsby, P. J., & Sprenger, T. (2010). Current practice and future directions in the prevention and acute management of migraine. The Lancet Neurology, 9(3), 285-298.
[v] Puledda, F., & Shields, K. (2018). Non-pharmacological approaches for migraine. Neurotherapeutics, 15(2), 336-345.
[vi] Chaibi, A., Tuchin, P. J., & Russell, M. B. (2011). Manual therapies for migraine: a systematic review. The journal of headache and pain, 12(2), 127-133.
[vii] Smitherman, T. A., Wells, R. E., & Ford, S. G. (2015). Emerging behavioral treatments for migraine. Current pain and headache reports, 19(4), 13.
[viii] Kropp, P., Meyer, B., Meyer, W., & Dresler, T. (2017). An update on behavioral treatments in migraine–current knowledge and future options. Expert Review of Neurotherapeutics, 17(11), 1059-1068.
[ix] Kendroud S, Fitzgerald LA, Murray I, Hanna A. Physiology, nociceptive pathways. StatPearls [Internet]. 2020 Sep 25.
[x] Mense, S., 2008. Anatomy of nociceptors.
[xi] Benson H, Beary JF, Carol MP. The relaxation response. Psychiatry. 1974 Feb 1;37(1):37-46.
[xii] Zeidan F, Emerson NM, Farris SR, Ray JN, Jung Y, McHaffie JG, Coghill RC. Mindfulness meditation-based pain relief employs different neural mechanisms than placebo and sham mindfulness meditation-induced analgesia. Journal of Neuroscience. 2015 Nov 18;35(46):15307-25.