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Migraine Changes Everything - Even Back Pain
February 26, 2013 by Dr Matthew D. Long
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Migraine Changes Everything - Even Back Pain
February 26, 2013 by Dr Matthew D. Long
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Migraine Changes Everything - Even Back Pain
February 26, 2013 by Dr Matthew D. Long
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The management of spinal disorders is complex. Not only is the diagnostic process fraught with uncertainty, but there is little consensus as to exactly how we should approach treatment itself. Thankfully we are now beginning to make sense of the dimensions of the problem, with recent research highlighting the significant role that the brain plays in spinal pain. Indeed, the persistence of back pain in some individuals appears to be largely the product of abnormal brain function, rather than the end-result of weak muscles, stiff joints or chronic inflammation. The question is, how does this situation differ in those people who already have compromised neural circuitry - the migraineurs?
In a previous Blog article (here) we looked at the complexity of migraine and the sensitivity that is the hallmark of the disease - a situation that often provokes non-headache symptoms such as irritable bowel syndrome, abdominal migraine, vertigo or even confusional states. But do migraine-sufferers also experience more back pain? It appears that they do. A study just published in the journal PAIN (1) reported that;
"Striking results were found when we analyzed the association between chronic and episodic headache (migraine and tension-type headache) forms with frequent low back pain. We found that the likelihood of having co-morbid frequent low back pain was significantly higher in respondents with chronic headache (OR 13.7-18.3) and episodic headache forms (OR 1.8-2.7) than it was in those without headache."
There are probably a number of factors involved in the predisposition of headache sufferers to lower back pain. Firstly, migraine and tension-type headache are both associated with lower than normal levels of serotonin, an important inhibitory neurotransmitter in all pain pathways, not just those related to head pain. Secondly, advanced imaging known as voxel-based morphometry has shown that migraineurs typically exhibit increased density in the periaqueductal gray and the dorsolateral pons, while also demonstrating diminished gray matter in the anterior cingulate cortex and the insula - signifying structural alterations to important regions devoted to pain processing and regulation (2). The end result of this is a greater tendency to experiencing pain in general.
But it probably goes even deeper than this…
Chronic back pain sufferers are known to have deficits in postural control and spinal stability, a situation that renders them liable to frequent soft-tissue strains and recurrent injury. It appears that migraine sufferers also fail at the basic tasks of regulating posture and balance. Ishizaki and colleagues (3) used computerised static stabilometry to assess equilibrium performance in migraineurs during headache-free periods to gauge their level of postural control. Interestingly, the migraine group (but not the tension-type headache group) showed a significant increase in body sway during testing, and the authors theorised that this might be due to dysfunction in the vestibulospinal system - a system that integrates sensory feedback from the vestibular apparatus, vision and proprioceptive afferents from joints, muscles and tendons.
The relevance of spinal stability becomes even more apparent when we also consider the fact that joint hypermobility syndrome (JHS) is very common in women with migraine. In fact, a study by Bendik and colleagues (4) found that the prevalence of migraine is approximately 75% in female patients with JHS, but not in those suffering from tension-type headache (4). The authors suggested that, "These results suggest that the association between JHS and the prevalence of headache disorders is specific for migraine." They further postulated that joint hypermobility syndrome may be associated with abnormal vascular reactivity and a form of dysautonomia, leading to migraine.
So how does all of this change our treatment approach?
Well, the presence of migraine changes context. That is, if a patient with lower back pain also happens to be a migraineur, then the clinical assessment and treatment decisions surrounding the spinal complaint must make allowance for this fact. Indeed, the migraine context needs careful consideration when deciding upon spinal treatment strategies, particularly when we consider the unstable neurology that defines the disorder. Our approach should seek to address the functional inadequacies and deficiencies prevalent in such patients, in addition to whatever local lumbar issues we might find. The tendency to chronic pain is significantly higher in migraine sufferers, largely as a consequence of their reduced inhibitory capacity. But this can be further exacerbated by other clinical factors common to these individuals, such as vitamin D deficiency (found in 41.8% of chronic migraineurs (5)). As such, it is important that we see migraineurs as fundamentally different when faced with a seemingly simple case of lower back pain.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
In a previous Blog article (here) we looked at the complexity of migraine and the sensitivity that is the hallmark of the disease - a situation that often provokes non-headache symptoms such as irritable bowel syndrome, abdominal migraine, vertigo or even confusional states. But do migraine-sufferers also experience more back pain? It appears that they do. A study just published in the journal PAIN (1) reported that;
"Striking results were found when we analyzed the association between chronic and episodic headache (migraine and tension-type headache) forms with frequent low back pain. We found that the likelihood of having co-morbid frequent low back pain was significantly higher in respondents with chronic headache (OR 13.7-18.3) and episodic headache forms (OR 1.8-2.7) than it was in those without headache."
There are probably a number of factors involved in the predisposition of headache sufferers to lower back pain. Firstly, migraine and tension-type headache are both associated with lower than normal levels of serotonin, an important inhibitory neurotransmitter in all pain pathways, not just those related to head pain. Secondly, advanced imaging known as voxel-based morphometry has shown that migraineurs typically exhibit increased density in the periaqueductal gray and the dorsolateral pons, while also demonstrating diminished gray matter in the anterior cingulate cortex and the insula - signifying structural alterations to important regions devoted to pain processing and regulation (2). The end result of this is a greater tendency to experiencing pain in general.
But it probably goes even deeper than this…
Chronic back pain sufferers are known to have deficits in postural control and spinal stability, a situation that renders them liable to frequent soft-tissue strains and recurrent injury. It appears that migraine sufferers also fail at the basic tasks of regulating posture and balance. Ishizaki and colleagues (3) used computerised static stabilometry to assess equilibrium performance in migraineurs during headache-free periods to gauge their level of postural control. Interestingly, the migraine group (but not the tension-type headache group) showed a significant increase in body sway during testing, and the authors theorised that this might be due to dysfunction in the vestibulospinal system - a system that integrates sensory feedback from the vestibular apparatus, vision and proprioceptive afferents from joints, muscles and tendons.
The relevance of spinal stability becomes even more apparent when we also consider the fact that joint hypermobility syndrome (JHS) is very common in women with migraine. In fact, a study by Bendik and colleagues (4) found that the prevalence of migraine is approximately 75% in female patients with JHS, but not in those suffering from tension-type headache (4). The authors suggested that, "These results suggest that the association between JHS and the prevalence of headache disorders is specific for migraine." They further postulated that joint hypermobility syndrome may be associated with abnormal vascular reactivity and a form of dysautonomia, leading to migraine.
So how does all of this change our treatment approach?
Well, the presence of migraine changes context. That is, if a patient with lower back pain also happens to be a migraineur, then the clinical assessment and treatment decisions surrounding the spinal complaint must make allowance for this fact. Indeed, the migraine context needs careful consideration when deciding upon spinal treatment strategies, particularly when we consider the unstable neurology that defines the disorder. Our approach should seek to address the functional inadequacies and deficiencies prevalent in such patients, in addition to whatever local lumbar issues we might find. The tendency to chronic pain is significantly higher in migraine sufferers, largely as a consequence of their reduced inhibitory capacity. But this can be further exacerbated by other clinical factors common to these individuals, such as vitamin D deficiency (found in 41.8% of chronic migraineurs (5)). As such, it is important that we see migraineurs as fundamentally different when faced with a seemingly simple case of lower back pain.
Something to think about...
Dr Matthew D. Long
BSc (Syd) M.Chiro (Macq)
References:
1. Yoon, M.-S., Manack, A., Schramm, S., Fritsche, G., Obermann, M., Diener, H.-C., et al. (2013). Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: Results of the German Headache Consortium study. Pain, 154(3), 484–492. doi:10.1016/j.pain.2012.12.010
2. Rocca MA, Ceccarelli A, Falini A, Colombo B, Tortorella P, Bernasconi L, Comi G, Scotti G, Filippi M. Brain gray matter changes in migraine patients with T2-visible lesions: a 3-T MRI study. Stroke 2006;37:1765–70.
3. Ishizaki, K., Mori, N., Takeshima, T., Fukuhara, Y., Ijiri, T., Kusumi, M., et al. (2002). Static stabilometry in patients with migraine and tension-type headache during a headache-free period. Psychiatry and Clinical Neurosciences, 56(1), 85–90.
4. Bendik, E. M., Tinkle, B. T., Al-shuik, E., Levin, L., Martin, A., Thaler, R., et al. (2011). Joint hypermobility syndrome: A common clinical disorder associated with migraine in women. Cephalalgia, 31(5), 603–613. doi:10.1177/0333102410392606
5. Wheeler, S. (2008). Vitamin D Deficiency in Chronic Migraine. Headache, 48, 1–2.
1. Yoon, M.-S., Manack, A., Schramm, S., Fritsche, G., Obermann, M., Diener, H.-C., et al. (2013). Chronic migraine and chronic tension-type headache are associated with concomitant low back pain: Results of the German Headache Consortium study. Pain, 154(3), 484–492. doi:10.1016/j.pain.2012.12.010
2. Rocca MA, Ceccarelli A, Falini A, Colombo B, Tortorella P, Bernasconi L, Comi G, Scotti G, Filippi M. Brain gray matter changes in migraine patients with T2-visible lesions: a 3-T MRI study. Stroke 2006;37:1765–70.
3. Ishizaki, K., Mori, N., Takeshima, T., Fukuhara, Y., Ijiri, T., Kusumi, M., et al. (2002). Static stabilometry in patients with migraine and tension-type headache during a headache-free period. Psychiatry and Clinical Neurosciences, 56(1), 85–90.
4. Bendik, E. M., Tinkle, B. T., Al-shuik, E., Levin, L., Martin, A., Thaler, R., et al. (2011). Joint hypermobility syndrome: A common clinical disorder associated with migraine in women. Cephalalgia, 31(5), 603–613. doi:10.1177/0333102410392606
5. Wheeler, S. (2008). Vitamin D Deficiency in Chronic Migraine. Headache, 48, 1–2.