When I was 5 I started suffering from debilitating migraines.  I remember having pain from my waist to my head, wrapping around the side of my face and settling behind one of my eyes. 

Usually I woke up in the middle of the night in severe pain, close to vomiting before I even realized what was going on.  By the time I was 6 I had an EEG to rule out epilepsy, a CT scan to check for an aneurysm and a variety of other tests to find out the source of my pain.  All the tests came back negative and I was told I would “grow out of them.”

Spoiler alert: I didn’t.

In fact I spent about 20 years having some level of pain 24 hours a day.  However, my parents instilled a sense of agency in me very early on.  I understood I was going to have pain, but I wasn’t in danger, and that I had a choice to make.  I quickly learned how to keep living while managing the headaches and pain to be minimally impactful on my life.  I completed a Master’s in Physical Therapy, held a stressful job, and lived an active life.  

The fact is not all headaches are created equal. 

I was eventually diagnosed with chronic daily headache (headache pain more than 15 days a month), migraine without aura and tension-type migraine headaches.  There are too many types of headaches to review in this setting, and the patient should always have serious conditions such as epilepsy or aneurysm ruled out. 

However, the National Headache Foundation is a good informational resource for both you and your patient www.headaches.org

Decreased Headache, Increased Sleep Quality With Massage

For most patients with severe migraines, prophylactic medication will be the first line of treatment.  Anti-seizure medication such as Topomax or anti-depressant such as Amitriptyline are the most common.  Some patients will have full resolution of their migraines, but most will have a decrease in frequency or intensity only. 

This was the case with me.  I still had close to 15 days a month with migraines, but minimal intensity and only about 4 migraines a month that required additional pain medication.  For me that was a win, but still meant I was in pain a lot of my life!  This led me to find massage therapy as a treatment.  Massage allowed me to have some days without any pain and decreased intensity on the days I did.  

An interesting thing happens when you have a chronic condition for 37 years.  Medicine tends to shift regarding the “why.”  Migraines used to be contributed to a rapid vasodilation followed by vasoconstriction and treatment was based on blood pressure (prophylactic propranolol) and making sure we avoided this change as much as possible.  Now childhood migraines are attributed to a version of sensory overload and sensory integration issues. 

I had a neurologist tell me I had a “special brain.”  My brain wants to process everything around me, and get a picture of how everything relates to each other and not just what is immediately in front of me.  This causes an overload in environments that are noisy, with lots of lights and smells.  Some kids have behavioral issues; I had migraines.  This idea of equating migraines to a “sensitive” nervous system made me start looking into massage therapy as a management technique to decrease my underlying pain and continue to try to decrease my overall headache days.

The Journal of Headache and Pain published a systematic review of manual therapy and randomized controlled trials in 2014.  The most RCTs were performed on patients with tension type migraines.  The systematic review found manual therapy including massage to be an effective treatment for tension migraines, reducing the headache frequency and intensity better than usual care by the general practitioner.  In a 2011 study, massage therapy was found to reduce pain intensity by 71% compared to the control group.  Massage therapy also improved sleep quality for migraine sufferers.  

So how does massage help with migraines?  Well just like with any massage, it works on the nervous system.  If my migraine is being triggered by upregulation, massage is an excellent intervention to modulate my parasympathetic nervous system.  The benefits of massage range from the actual touch factor, to the patient resting for those moments on the treatment table, to neuromodulation, to improved sleep hygiene, all of which translate into less pain and migraine days.  It’s important for the patient to feel empowered to give feedback regarding depth, strokes and intensity of massage to continue a beneficial and collaborative environment.  If a massage is painful or perceived as damaging, it could increase the patient’s pain.  And please avoid nocebo language! 

It’s important your patient reflect on possible triggers for their migraines and address those as well.  With that being said, life involves unavoidable stimulus and stress.  Massage therapy can help and is a viable and a researched treatment option for patients with chronic migraines. 

References:

Chaibi and Russell: Manual therapies for primary chronic headaches: a systematic review of randomized controlled trials. The Journal of Headache and Pain 2014 15:67

Chaibi A  Tuchin P  Russel M: Manual Therapies for Migraine: a systematic review.  The Journal of Headache and Pain 2011: 12: 127-133

Lenssinck ML, Damen L, Verhagen AP, Berger MY, Passchier J, Koes BW (2004) The effectiveness of physiotherapy and manipulation in patients with tension-type headache: a systematic review. Pain 112(3):381–388

Yancy J  Sheridan R  Koren  K  Chronic Daily Headache: Diagnosis and Management.  American Family Physician  April 2014: 642-648.

In the January 2019, Pain Journal published an article comparing pain to the Bayes rule in math.

PAIN Symptom Perception, placebo effects, and the Bayesian brain. It suggests the brain can follow a theory of probability in math known as the Bayes rule.  In statistics/math, the rule looks at the likelihood of a given hypothesis.  It takes into account prior evidence, current evidence, likelihood probability of other related hypotheses and makes a prediction.  The brain generates a top-down, out of our awareness, neurally encoded hypothesis about the state of us and the world. So cool!

This top-down hypothesis is met by its bottom-up sensory input.  Any mismatch between the two results in a “coding error” or “prediction error” and the brain revises it’s hypotheses and prediction rules for next time.  These hypotheses include those built in from evolution and the person’s personal experiences.  Throughout our lifespan, they are constantly changing and updating to help predict the next set up sensory inputs.  The implication of this theory is that we perceive not how the world actually is, but the brain’s best guess of it. This definitely makes sense when we think about visual perception.

In the case of chronic pain, the brain puts a high emphasis on the hypotheses generated by the brain and less precision on the sensory experience.  Slight and otherwise harmless stimulus (or bottom-up experiences) cause the brain to misinterpret these as contributing to the pain and continue to modify the hypothesis to include these.  Individuals without chronic pain would tend to ignore these inputs as “noise.”  Conditions such as anxiety, threat, and catastrophizing have a tendency to worsen symptoms by maintaining vigilance to these predictor hypotheses.  

So how does the Placebo Effect fit into this theory? The Bayesian perspective states relief of symptoms is not necessarily due to restoring bodily function but more about the lack of interference from the bottom into the hypotheses.  As sensory input diminishes the hypothesis again changes.  This change, however, seems to be slower if the patient does not have external cues that the change is happening.  It’s almost like the brain ignores the improvement as “noise” unless there are other cues to say it’s time to revise the hypothesis.  This may be why avoiding nociceptive language AND encouraging our patients that they are RESILIENT and CAN DO their important activities is so important.  Your body is getting better so go ahead and revise your hypothesis!  This may also be why the placebo effect works.  Experiments where the patient was given analgesics in a manner that did not let them know the medications were supposed to help reported significantly less pain relief than those who were told what they were receiving.

I don’t think the article was saying anything we haven’t already approached with pain science.  However, I appreciate this statistical analysis way of looking at it. Maybe it’s because I live in Seattle and there are tons of tech-driven people here, but I feel like I have one more analogy to help my patients.  AND I don’t actually have to calculate any statistics!