Background and purpose of the study

Migraine headache is a common and potentially debilitating disorder often treated by family physicians. Before diagnosing migraine, serious intracranial pathology must be ruled out. Treating acute migraine is challenging because of substantial rates of nonresponse to medications and difficulty in predicting individual response to a specific agent or dose. Data comparing different drug classes are relatively scarce. Abortive therapy should be used as early as possible after the onset of symptoms. Effective first-line therapies for mild to moderate migraine are nonprescription nonsteroidal anti-inflammatory drugs and combination analgesics containing acetaminophen, aspirin, and caffeine. Triptans are first-line therapies for moderate to severe migraine, or mild to moderate migraine that has not responded to adequate doses of simple analgesics. Triptans should be avoided in patients with vascular disease, uncontrolled hypertension, or hemiplegic migraine. Intravenous antiemetics, with or without intravenous dihydroergotamine, are effective therapies in an emergency department setting. Dexamethasone may be a useful adjunct to standard therapy in preventing short-term headache recurrence. Intranasal lidocaine may also have a role in relief of acute migraine. Isometheptene-containing compounds and intranasal dihydroergotamine are also reasonable therapeutic options. Medications containing opiates or barbiturates should be avoided for acute migraine. During pregnancy, migraine may be treated with acetaminophen or nonsteroidal anti-inflammatory drugs (prior to third trimester), or opiates in refractory cases. Acetaminophen, ibuprofen, intranasal sumatriptan, and intranasal zolmitriptan seem to be effective in children and adolescents, although data in these age groups are limited. (Am Fam Physician. 2011;83(3):271-280. Copyright © 2011 American Academy of Family Physicians)

Triptans are migraine-specific drugs that bind to serotonergic receptors. They are considered first-line therapy for moderate to severe migraine, or mild to moderate attacks unresponsive to nonspecific analgesics. Seven triptans are currently available, but data guiding which to select for an individual patient are limited. A Cochrane review found that all triptans are similar in effectiveness and tolerability. A meta-analysis of 53 trials using oral triptans found that the three most effective agents for pain relief were 10 mg of rizatriptan (Maxalt), 80 mg of eletriptan (Relpax), and 12.5 mg of almotriptan (Ferrari MD, Roon KI, Lipton RB, Goadsby PJ. Oral triptans (serotonin 5-HT(1B/1D) agonists) in acute migraine treatment: a meta-analysis of 53 trials. Lancet. 2001;358(9294):1668-1675). A Cochrane review found a dose of 100 mg of sumatriptan to be more effective than lower doses (McCrory DC, Gray RN. Oral sumatriptan for acute migraine. Cochrane Database Syst Rev. 2003;(3):CD002915). It is sometimes necessary to increase the dose of an individual agent before judging response. Trials suggest that nonresponders to one triptan may respond to another; therefore, switching triptans is also reasonable. Triptans differ from one another in pharmacokinetics. Rizatriptan has a quicker onset of action than sumatriptan; frovatriptan (Frova), naratriptan (Amerge), and eletriptan have longer half-lives than sumatriptan. In practice, route of administration or pharmacokinetics often guide choice. Some triptans are available as nasal sprays, rapidly dissolving tablets (absorbed despite vomiting), or subcutaneous injections. Some physicians choose a triptan by matching pharmacokinetics to the temporal pattern of their patient’s migraine (e.g., rapidonset medication for short course of migraine versus longer-acting medication with slower onset for longer lasting symptoms); however, there is no definitive evidence to support this approach. The vasoconstrictive properties of triptans preclude their use in patients with ischemic heart disease, stroke, uncontrolled hypertension, or hemiplegic or basilar migraine. However, the chest pain occurring in 3 to 5 percent of oral triptan users has not been associated with electrocardiographic changes and is rarely ischemic. A post-marketing study of subcutaneous sumatriptan in 12,339 patients without ischemic heart disease revealed 36 cardiac events, only two of which occurred within 24 hours of sumatriptan use (O’Quinn S, Davis RL, Gutterman DL, Pait GD, Fox AW. Prospective largescale study of the tolerability of subcutaneous sumatriptan injection for acute treatment of migraine. Cephalalgia. 1999;19(4):223-231). Nonetheless, if patients taking triptans develop suspected cardiac symptoms, triptans should be discontinued pending further evaluation. Cardiac evaluation is reasonable before triptan initiation in patients with multiple vascular risk factors.28 Triptans are contraindicated in patients taking monoamine oxidase inhibitors. Combining triptans with selective serotonin reuptake inhibitors can lead to serotonin syndrome, a potentially life-threatening condition characterized by altered mentation, autonomic instability, diarrhea, neuromuscular hyperactivity, and fever. The true incidence of serotonin syndrome in this setting is unknown. A 2006 U.S. Food and Drug Administration (FDA) alert cited 29 case reports over five years, although almost 700,000 patients per year are prescribed both selective serotonin reuptake inhibitors and triptans (Sclar DA, Robison LM, Skaer TL. Concomitant triptan and SSRI or SNRI use: a risk for serotonin syndrome. Headache. 2008;48(1):126-129). Physicians treating patients who are taking triptans and selective serotonin reuptake inhibitors should be vigilant for serotonin syndrome, and should minimize drug dosages.

NSAIDs are a convenient first-line therapy for mild to moderate migraine or historically responsive severe attacks. A 2007 meta-analysis of ibuprofen for moderate to severe migraine showed that 200-mg and 400-mg doses were effective for short-term pain relief, but had 24-hour pain-free rates similar to placebo. The 400-mg dose also helped relieve photophobia and phonophobia. A study comparing ketoprofen with zolmitriptan showed zolmitriptan to be modestly more effective (two-hour relief in 61.6% versus 66.8% of participants, respectively), but it was associated with more adverse events, such as tight throat and flushing (Dib M, Massiou H, Weber M, Henry P, Garcia-Acosta S, Bousser MG; Bi-Profenid Migraine Study Group. Efficacy of oral ketoprofen in acute migraine: a double-blind randomized clinical trial. Neurology. 2002; 58(11):1660-1665). Ketorolac, a parenteral NSAID commonly used in emergency departments, was found to be effective in reducing selfreported headache symptoms one hour after injection, including one study showing more effectiveness than intranasal sumatriptan.

Description of cases

Case 1: LR is a 57 manager in a multinational company and his job includes many trip, both by car and plane, to visit customer all over Italy and to visit the Headquarters in Northern Europe. He initially presented the first symptoms of a left sided migraine in September 2013. It appeared suddenly without previous symptoms or neck stiffness. It was initially treated by his GP with Ibuprofen (200 to 800 mg orally every 6 to 8 hours, not to exceed 2.4 g per day) and, later, with Naproxen (250 to 500 mg orally every 12 hours, not to exceed 1 g per day) but the therapy did not work out and the patient started suffering heartburn, gastric rebound headache, and his renal function degenerated (Creatinine was 0.95 in Sept 2013; 1.3 in Mar 2014 and 1.9 in Oct 2014) so he decided to ask a neurologist who suspended the therapy with NSADIs and introduced Sumatriptan (oral: 25 to 100 mg, can be repeated in 2 hours, not to exceed 200 mg per day) which only controlled the symptoms. He arrived at our observation on request of the neurologist in Feb 2015 to evaluate any possible psychiatric and psychosomatic involvement.

Case 2: AR is an unemployed 35-year-old guy. He came into observation in Nov 2014 for a right-sided headache with aura resistant to classical NSADIs and cortisone. He was initially treated with Zolmitriptan (oral disintegrating tablets: 2.5 mg, can be repeated in 2 hours, not to exceed 10 mg per day) with weak results.

Treatment: both cases were initially treated with osteopathic manipulation and with re-educational posture exercises. During the treatment drugs were systematically reassessed and decreased. After 24 weeks of treatment (in Aug 2015), LR had been symptoms-free for 10 days and drugs were definitely suspended. During the December’s follow up he reported he had no more symptoms since then. After 16 weeks of treatment (in Mar 2015), AR stopped taking any drug and kept only the posture treatment for 3 more weeks. After this period he had no more symptoms.

Discussion

The most important factor in a true migraine syndrome is the position of the C1 and C2 vertebrae, the top two vertebrae in the neck. These two structures are completely unique in comparison to the rest of the vertebrae. The ellipsoidal joints between the occipital bone (the base of the cranium) and C1 and the similar joint between C1 and C2, allow for a great deal of mobility at this level of the spine. This high degree of mobility here opens up the possibility for some negative effects on the vertebral artery and veins, as well as the brainstem itself, when these structures move into a distorted position. Where blood flow to and from the cranium is provided by the vertebral arteries and veins is concerned, opposing rotations of the C1 and C2 seem to have the biggest influence on migraine headache. When one of these structures is rotated to the right while the other is rotated to the left a great deal of compression of these vascular structures occurs. Since veins are much easier to compress than arteries, blood flows more easily into the intracranial space, the area around your brain, than out of it. Blood then becomes trapped inside the cranium increasing the pressure there, triggering migraine headache pain. Medical theories relating to the vasodilation causes by certain neuropeptides is a cause of migraine headache. One explanation for the presence of these neuropeptides could be that the body is trying to deal with increased blood pressure in the head that occurs as described above. In examining the cadavers of migraine sufferers, this opposing rotation of C1 and C2 has been observed by our staff in conjunction with patterns of the cranial vascular system that have been imprinted on the internal bony surface of the cranium due to the high degree of pressure in those structures. Eliminating these distortions of C1 and C2 is been vital in eliminating migraine headache in our patients.

There are other implications for the nervous system when C1 and C2 are distorted. At this level the brainstem is extending down into the spinal canal before transitioning to the spinal cord at about C3. A cranial nerve emanating from the brainstem, the trigeminal nerve has been implicated as a source of migraine headache. The trigeminal nerve is an extremely sensitive nerve that is responsible for sensation and function in the jaw, teeth, face, tongue, lips, eyes, sinuses and the brain itself. When C1 and C2 become distorted, a reduction in the space that the brainstem occupies occurs. This intrusion into the brainstem can especially be seen when the C1 projects or shears forward on the C2. In this case part of the C2, called the odontoid process, can begin to migrate backwards, compressing the brainstem and cranial nerves, including the trigeminal nerve. When this process begins, disruption of many neurological functions can occur contributing to migraine pain that stems from these structures. Once again, we see postural distortion jeopardizing a critical area of the body.

Conclusions

The role of postural distortion in conditions such as hip or back pain is obvious. When we recognize that these distortions have a profound effect on vital structures in the cervical spine and cranium, we have a tremendous opportunity to create healing. It might seem strange that, in order to eliminate migraines, we might have to treat muscles in your thighs. However, along with very specific structures in the neck and head, it is, so, important to look at all facets of postural distortion in order to alleviate pain. As with our approach to relieving pain in any situation, creating balance and symmetry is the key.