Positive chiropractic treatment outcome of migraine
without aura in a 6-year-old presenting with sleep bruxism
and chronic sinus congestion: a case-report
By Eve Laferrière, DC, DICCP
Private Practice, Lachine, QC, Canada
Author’s Email: email@example.com
Migraine is a common disorder affecting up to 10% of children which can interfere with school attendance, academic and sport performance1,2 The proposed pathophysiology has evolved from one purely vascular in origin to perhaps a neuro-inflammatory etiology.3,4 Clinical evaluation is the mainstay of diagnosis and should include family history, sleep habits and environmental triggers.5,6,7 Spinal manipulation of the cervical spine in adults and teenagers has shown similar effectiveness as prophylactic medications.8,9 A Canada-wide survey revealed that 7% of chiropractic pediatric patients presented for headaches.10 Unfortunately, there is no substantial data at this point to support the benefit of spinal manipulation in the pediatric sufferers of migraine.11,12,13 Recent research found a link between sleep parasomnia (bruxism), colic and migraine sufferers.7,14,15,16 To achieve a precise diagnosis, clinicians must refer to the latest diagnostic criteria to differentiate true migraines from tension headaches, sinus headaches or other organic causes.17 This case report discusses the chiropractic treatment outcome of a 6-year-old female patient suffering from migraine without aura, sleep bruxism and chronic sinus congestion. The patient was treated with mechanical assisted and manual manipulation techniques, massage and sinus lymphatic drainage. After 4 visits migraine intensity reduced from a 5/10 to a 2/10 and the frequency of headaches were reduced from 3 times per week to once a week without the use of medication. After 6 weeks of care, patient symptoms were significantly reduced but the treatment plan was not completed because the family relocated and continued travel to the office was prohibitive. After 17 weeks, the patient relapsed and 3 weeks later, they resumed care with progressive improvement of the child’s well-being once we eliminated migraine triggers such as sun exposure, incorporation of resting periods with naps in the afternoon and cardiac coherence training exercises before bedtime.1,5,7,18,19 This case report highlights the need for high quality research on the effect of spinal manipulation in the treatment of pediatric migraine to provide a potential alternative option to the traditional medical treatment of migraine. This case also opens the discussion on the benefits cervical manipulations and cranial work may potentially have on sinus drainage and immune system response in autonomic conditions like sinus congestion.
Keywords: Migraine, children, spinal manipulation, bruxism, sinusitis
Following tension headache, migraine is the second most common cause of chronic recurrent headache in school children with a prevalence ranging from 3.2 to 14.5%.14 Pediatric migraine differs from adult migraine in that they are typically of shorter duration and bilateral in children.3 Diagnostic criteria are based on the international classification of headache disorders 3rd edition (ICHD-3 beta) from the international headache society (Table 1).20
Migraine is divided into six major categories, the two most important of which are migraine without aura and migraine with aura.3 According to the literature, children with migraine have a genetic predisposition in some way activated by an environmental or physiological stimulus such as exposure to drugs, diet, stress or puberty.3,6 The pathophysiology of migraine in children is not perfectly understood due to a dearth of research in the field.11 Recent studies using PET, intracarotid SPECT (single-photon emission computed tomography), MRA (magnetic resonance angiography), functional MRI and TMS (transcranial magnetic stimulation) concluded that the pathogenesis of migraine attacks is explained by a combination of vascular and neurogenic events. It has been proposed that the activation of central cortical and brainstem pathways in parallel with the peripheral trigeminovascular system results in a release of neuropeptides such as CGRP (calcitonin gene-related peptide) and substance P inducing vasodilation and neurogenic inflammation.14,21,22,23 (Figure 1).
*Migraine triggers initiate the neuronal excitation that leads to clinical manifestation in children with a genetic vulnerability to migraine. CSD triggers plasma protein extravasation from cerebral blood vessels, which in turn activates TG afferents within TVS. Gene mutations could reduce the threshold for firing TG neurons. Signals are transduced to the TNC, which receives modulatory inputs from other BN. The TNC projects to rostral brain areas, where the perception of pain is generated.
Cranial autonomic symptoms such as nasal congestion are frequently found in pediatric migraine, often leading to a misdiagnosis of sinus headache, subsequently delaying appropriate migraine treatment.17,24 Recent research found links between sleep parasomnia (bruxism), colic and pediatric migraine sufferers.7,14,15,16 Few older randomized control trials (RCTs) and a more recent one presented by Tuchin suggests that chiropractic spinal manipulative therapy might be equally efficient as propranolol (beta blocker) and topiramate (anticonvulsant) in the prophylactic management of migraine.9,25,26,27 This case-report will discuss the chiropractic care of a 6-year-old female patient suffering from migraine without aura presenting with sleep bruxism and chronic sinus congestion.
An online literature search was conducted using scientific journal databases; PubMed, Elsevier, Index to Chiropractic Literature and Google Scholar. Databases were searched from inception through October 2015 using the keywords: Migraine, children, spinal manipulation, bruxism and sinusitis. Publications utilized included systematic reviews, randomized controlled trials and case studies. Other articles and resources were used to provide background information.
A 6-year-old Caucasian female patient presented with frequent migraines without aura for the past 6 months. The migraines were located in the frontal region bilaterally and occurred 3 times per week graded at a 5/10 on a visual analog pain scale. The patient described the migraine as a diffuse pounding sensation behind her forehead and she felt slightly nauseated. During the episodes the patient could usually continue most of her daily activities at the kindergarten with the exception of some physical activity that involved jumping. On occasion she had to miss school and did not attend her gym class. Parents have reported that the child often ground her teeth at night and although she dealt with chronic sinus congestion year round, it was more intense during the winter time. The patient’s pediatrician recommended the use of ibuprofen when needed which alleviated the patient’s symptoms. The patient was examined by her optometrist 4 months ago who ruled out any visual or ocular problem.
Medical history included mild colic around 2 to 3 months of age followed by chronic otitis media between 3 to 4 years of age. She received 5 rounds of antibiotics for the recurrent otitis media. At age 4, she developed recurrent sinus congestion, most intense during the winter season. Since the age of 5 she often suffered from constipation. The migraines started when she was 5 and a half and progressively became worse. Based on her intake form which includes a detailed description of typical breakfast, lunch and dinner, she has a balanced diet with home cook meals. Her parents denied attempting any food elimination diets and had not identified any specific food triggers. Sun exposure and fatigue were described as common migraine triggers for their daughter. The patient rarely drank water and preferred juices. Both parents suffered from migraines at a younger age. Their home was a smoke-free and pet-free environment. Previous history of injury included a fall from her crib at 6 months of age, a recent fall while tobogganing, and a fall on her head later during the course of care. The patient was an active young female who enjoyed participating in ballet and soccer. Severe migraine episodes interfered with her participation in day camp and athletics. She would watch 1-2 hours of television per day and played on the Leap Pad 2-4 hours per week.
Complete blood count (CBC), Glucose AC, TSH and Epstein-Barr antibodies (VCA IgG IF / EBNA IF) in addition to an eye exam were done 3 months after the beginning of the symptoms. Blood work and eye examination were unremarkable. Parents had been using a “Netty Pot” and administering “Avamys” nasal spray to clear sinus congestion when it was necessary. Ibuprofen was used 1-2 times per week on an as needed basis. On examination cervical passive and active range of motion (ROM) were within normal limits. Muscle tension was noted in the left sub-occipitals, temporalis, masseter and bilateral trapezius muscles. Lymph nodes palpation was sensitive in the posterior cervical chain bilaterally at the initial exam. Segmental dysfunctions palpated at C0-1, T1-2 and L1-2. The temporomandibular joint (TMJ) was palpated superior on the right side with ipsilateral joint restriction. Cranial bones analysis presented an inferior left sphenoid with increased muscle tension at the frontal-temporal junction bilaterally. Postural analysis revealed a mild forward head carriage and bilateral excessive foot pronation. Gait, coordination, blood pressure and neurological testing was within normal limits.
DIAGNOSTIC AND ASSESMENT
The patient’s clinical presentation met the International Headache Society diagnostic criteria for migraine without aura (ICHD-III beta) (Table 2).
The pulsating quality of the headache accompanied with nausea and the avoidance of physical activity led to a probable diagnosis of migraine rather than tension headache. According to Heyer and Papetti, the PedMIDAS is the only instrument validated to assess migraine disability among school-aged children.28,29 This diagnostic tool presents questions to rate the impact of migraine on school performance and level of disability at home. The PedMIDAS score was rated at 4 (little to no disability) at the initial exam and 22 (mild disability) 17 weeks later while she was attending day camp 2 weeks after her 5th visit (Table 3).30
The analog pain scale was rated at a 5/10 at the initial exam to 8/10 as her symptoms relapse 17 weeks after the initiation of chiropractic care. The frontal location of the migraine was less suggestive of organic pathology, which is most commonly located in the occipital region.14 There were no red flags present suggestive of tumor, meningitis or infection. The prognosis for this patient was good given the family’s strong genetic predisposition to migraine, mild disability level, early diagnosis of the condition and healthy lifestyle of the patient.
The patient started chiropractic care 6 months after the initial onset of migraine symptoms. Treatment consisted of spinal manipulation at C0-1, T1-2 and L1-2 using Thompson’s drop, Activator instrument and modified Diversified upper cervical adjusting techniques in addition to massage of the left sub-occipitals, temporalis, masseter and bilateral trapezius muscles. Gentle mobilization of the right TMJ, sinus lymphatic drainage and cranial technique to the sphenoid were also applied. The patient received 5 chiropractic treatments over 3 months. Chiropractic care was re-introduced 6 weeks after following the flare-up of migraine symptoms to a frequency of 1 visit per week for a month and 1 visit every 2 weeks for 2 months. No adverse reaction to chiropractic care was reported by the patient or parents during the course of care. In addition, the patient was recommended to perform daily neck stretching exercises, increase water intake to 4-6 glasses per day and reduce time watching television and playing with her Leap Pad. Parents were also advised to have their daughter go through skin prick testing as well as blood work IgG ELISA testing to identify any possible environmental or food allergies / sensitivity.31 At most recent follow-up this testing had not been performed. After 27 weeks of care (10th visit) the patient was instructed to do cardiac coherence training exercises (deep breathing) before bedtime to promote relaxation and restful sleep.1,19
FOLLOW-UP AND OUTCOMES
During the first month of care the patient didn’t take ibuprofen for migraine. The intensity of migraine dropped to a 2/10 on a visual analog pain scale and frequency reduced to 1 episode a week and no longer interfered with the patient’s daily activity. The patient then had a relapse of her symptom 3 months after the beginning of chiropractic care which brought her to the hospital’s emergency with a migraine rated at an 8/10 on a visual analog scale and accompanied with nausea and constipation. She was kept under observations for few hours and the attending prescribed Elavil, Naproxen and Lax-A-Day. The patient was dismissed from emergency and referred to a neurologist in the following 4 months. Three weeks after the relapse of her symptoms the patient’s complaint was unrelieved by the medication and she resumed chiropractic care. The same treatment protocol was administrated to the patient at a frequency of 1 visit per week for a month then 1 visit every 2 weeks for 2 months. After 2 weeks of re-introducing chiropractic care the patient was still having migraines on a daily basis but they were reduced in intensity to a 4/10 and were alleviated with rest, reduced physical activity and sun exposure. Upon returning to school she reported only mild headache without pounding nature and she was able to fully participate in school and athletics. The parents also indicated that it was the first summer where she wasn’t complaining of mild congestion after going to the pool or playing outside. The parents reported a significant reduction of bruxism at night and the patient reported feeling well rested when she woke up in the morning. The parents continued administering the “Netty Pot” preventatively. Consultation with the neurologist, shortly after the patient’s 11th visit, revealed that the patient no longer needed Elavil and Naproxen on a daily basis and should only use the medication during acute episodes.
This case highlights other health conditions related to migraines and stresses the importance of a thorough intake and clinical examination. In order to achieve a precise diagnosis the clinician must refer to the International Headache Society diagnostic criteria for migraine ICHD-III beta and the PedMIDAS questionnaire.20,28,29 This latest diagnostic tool (PedMIDAS), is questionable in its accuracy when completed during the summer holidays since the first 3 questions are related to school performance.28 Since the brainstem regulates vascular tone and nociceptive function in the body it is logical that upper cervical spinal manipulation could have a positive impact on migraines14,13,32,33 however there is little literature to demonstrate the effectiveness of spinal manipulation on pediatric migraine. Three out-dated RCT’s on spinal manipulation and migraine were found in the literature review.9,26,27 A more recent RCT from Tuchin, Pollard and Bonello discussed the effectiveness of spinal manipulation in migraine patients ranging from 10 to 70 years of age.25 50% of the subjects of this study noticed a reduction in the intensity of the migraine episode. 80% of the participants reported stress as a major contributor of migraine. The research conclusion was that spinal manipulation can have a positive effect on stress related conditions like migraine. Only one case report from 2013 was found by Kuhn where functional neurology and spinal manipulation was applied in the management of a 15 year old boy with migraine and behavioral learning difficulties.33 After 4 months of care the patient was no longer suffering from migraine, his vision improved and tics reduced significantly. This case report suggests that a brain-based model of care may be of value in the chiropractic treatment of migraine and in some non-musculoskeletal conditions. Todd and al. presented a review of literature in 2014 on adverse events due to manual therapies in infants and children.34 There were 31 reported cases of injuries from various healthcare providers (7 chiropractors, 1 medical practitioner, 1 osteopath, 2 physical therapists and 1 unknown practitioner), 12 presented with serious injuries where an underlying pre-existing pathology was identified. Three deaths were reported from a physical therapist, a craniosacral therapist and an unknown practitioner. The current literature outlined no deaths associated to chiropractic care following manual therapy. This review stresses the importance of thorough history, examination and imaging if necessary to rule-out any potential pathology and congenital anomaly before applying manual therapy. Spinal manipulation remains a non-invasive, low risk therapeutic approach with minimal side effect for pediatric migraine.
In order to fully appreciate the long-term benefits of chiropractic care in children presenting with migraine a larger scope of observation should be used ranging from 2 to 5 years instead of 8 months. It is recognized that this a unique case that cannot be generalized to the entire pediatric population affected by migraines. While under 3 months of consistent chiropractic care, the patient experienced improvement in her symptoms. After a 6 week lapse in chiropractic care, symptoms returned and this time the patient was advised to take two types of medication, Elavil and Naproxen. After three weeks of medication without a reduction in symptoms, the patient resumed chiropractic care. Symptoms started to improve again and eventually the patient was able to reduce the medication. The cumulative effect of the medication and chiropractic care in the second scenario may be linked in relieving the symptoms. Whereas initially, chiropractic care was sufficient to reduce the symptoms.
Early identification of possible migraine triggers can greatly influence the course of treatment.6 This case report outlines the need for valid research on the effect of spinal manipulation in the treatment of pediatric migraine to provide an evidence-based treatment alternative to the traditional medical treatment. This case also opens the discussion on the benefits cervical manipulations and cranial work may potentially have on sinus drainage and immune system response in autonomic conditions like sinus congestion.
Special thanks to Sharon Vallone DC, DICCP of KIDSPACE Adaptive Play and Wellness and Rosemary Dos Santos DC from Montreal for their support in the production of this manuscript.
1. Rapoff MA, Connelly M, Bickel JL, Powers SW, et al. Headstrong intervention for pediatric migraine headache: a randomized clinical trial. The Journal of Headache and Pain 2014; 15:12.
2. Treat L, Liesinger J, Ziegenfuss JY, Humeniuk K, et al. Patterns of complementary and alternative medicine use in children with common neurological conditions. Global Advances in Health and Medicine 2014; 3(1):18-24.
3. Shah UH and Kalra V. Pediatric migraine review article. International Journal of Pediatrics 2009; article ID 424192.
4. Tuchin PJ. A case of chronic migraine remission after chiropractic care.
Journal of Chiropractic Medicine 2008; 7:66-70.
5. Chakravarty A, Mukherjee A, Roy D. Trigger factors in childhood migraine: a clinic-based study from Eastern India. Journal Headache Pain 2009;10:375- 380.
6. Pryse-Phillips W, Dodick DW, Edmeads JG, Gawel MJ, et al. Guidelines for the nonpharmacologic management of migraine in clinical practice. Canadian Medical Association Journal 1998; 159:47-54.
7. Dosi C, Riccioni A, Della Corte M, Novelli L, et al. Comorbidities of sleep disorders in childhood and adolescence: focus on migraine. Nature and Science of Sleep 2013; 3(5): 77-85.
8. Chaibi A, Tuchin PJ, Russell MB. Manual therapies for migraines: a systematic review. Journal Headache Pain 2011; 12:127-133.
9. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. Journal of Manipulative Physiological Therapeutic 1998; 21:511-519.
10. Verhoef M. Survey of Canadian chiropractor’s involvement in the treatment s of patients under the age of 18. Journal Canadian Chiropractic Association 1999; 43:50-57.
11. Posadzki P, Ernst E. Spinal manipulations for the treatment of migraine: a systematic review of randomized clinical trials. Cephalalgia 2011; 31(8):964-970.
12. Canadian Paediatric Society. Paediatric Children Health 2002; 7(2):85-89.
13. Cattley P, Tuchin PJ. Chiropractic management of migraine without aura. A case study. Australasian Chiropractic Osteopathy 1999; 8(3):85-90.
14. Spiri D, Rinaldi VE, Titomanlio L. Pediatric migraine and episodic syndromes that may be associated with migraine. Italian Journal of Pediatrics 2014; 40:92.
15. Gelfand AA, Thomas KC, Goadsby PJ. Before the headache: infant colic as an early life expression of migraine. Neurology 2012; 79:1392-1396.
16. Fernandes G et al. Temporomandibular disorders, sleep bruxism and primary headaches are mutually associated. Journal Orofacial Pain 2013; 27:14-20.
17. Senbil N, Gürer Yavuz YK, Üner C, Barut Y. Sinusitis in children and adolescents with chronic or recurrent headache: a case-control study. Journal Headache Pain 2008; 9:33-36.
18. Francis MV. Brief migraine episodes in children and adolescents: a modification to International Headache Society pediatric migraine (without aura) diagnostic criteria. Springer Plus 2013; 2:77.
19. McCraty R, Zayas MA. Cardiac coherence, self-regulation, autonomic stability, and psychosocial well-being. Frontiers in psychology 2014; 5(1090).
20. Headache classification committee of the international headache society. The international classification of headache disorders 3rd edition (beta version). Cephalalgia 2013; 33(9): 629-808.
21. Charles JA, Peterlin BL, Rapoport AM, Linder SL, et al. Favorable outcome of early treatment of new onset child and adolescent migraine implications for disease modification. Journal Headache Pain 2009; 10:227-233.
22. Bernstein C, Burstein R. Sensitization of the trigeminovascular pathway: Perspective and implications to migraine pathophysiology. Journal Clinical Neurology 2012; 8:89-99.
23. Raddant AC, Russo AF. Calcitonin gene-related peptide in migraine: intersection of peripheral inflammation and central modulation. Expert Revolution Molecular Medicine 2012; (6).
24. Gelfand AA, Reider AC, Goadsby PJ. Cranial autonomic symptoms in pediatric migraine are the rule not the exception. Neurology 2013; 81:431-436.
25.Tuchin PJ, Pollard H, Bonello R. A randomized controlled trial of chiropractic manipulative therapy for migraine. Journal of Manipulative Physiological Therapeutic 2000; 23(2):91-95.
26.Parker GB, Tupling H, Pryor DS. A controlled trial of cervical manipulation of migraine. Australian New Zeland Journal Medicine 1978; 8:589-593.
27. Parker GB, Pryor DS, Tupling H. Why does migraine improve during clinical trial? Australian New Zeland Journal Medicine 1980; 10:192-198.
28. Heyer GL, Merison K, Rose SC, Perkins SQ, et al. PedMIDAS-based scoring underestimates migraine disability on non-school days. Headache 2014; 54:1048-1053.
29. Papetti L, Spalice A, Nicita F, Paolino MC, et al. Migraine treatment in developmental age: guidelines update. Journal Headache Pain 2010; 11:267-276.
30. Cincinnati Children Headache Center Online PedMIDAS tool.
31. Mitchell N, Hewitt CE, Jayakody S, Islam M, et al. Randomized controlled trial of food elimination diet based on IgG antibodies for the prevention of migraine like headaches. Nutrition Journal 2011; 10:85.
32. Woodfield HC, York C, Rochester RP, Bales S, et al. Craniocervical chiropractic procedures: a précis of upper cervical chiropractic. Journal Canadian Chiropractic Association 2015; 59(2):173-192.
33. Kuhn KW, Cambron J. Chiropractic management using a brain-based model of care for a 15 year old adolescent boy with migraine headaches and behavioral and learning difficulties: a case report. Journal of Chiropractic Medicine 2013; 12:274-280.
34. Todd AJ, Carroll MT, Robinson A, Mitchell EK. Adverse events due to chiropractic and other manual therapies for infants and children: a review of literature. Journal Manipulative Physiological Therapeutic 2014; 10(30)