Neck Pain, Headache & Migraine

Our Approach

As with all pain, research clearly shows that head pain should be managed within a biopsychosocial framework and using a multidisciplinary team approach to ensure effective, long term improvements in patient quality of life as well as symptom reduction. Our assessment includes accurate diagnosis and evaluation for medical causes of head pain, hormonal influences, modern pain education, mental health and well-being assessment, sleep quality and thorough assessment for any musculoskeletal triggers.

We employ an ‘attention to detail’ approach to ensure that everything that could possibly be contributing to your headaches is considered and managed. If you suffer from headaches and have not fully addressed all the management options described below, please get in touch with any questions you may have or simply call to book an appointment. We are very likely to have the answers you are seeking.

Diagnosis & Medical Management

Once any serious medical cause of head pain has been ruled out, it is vital that patients receive an accurate diagnosis for ‘primary headache’. This is important as we know that not all headaches are the same and some will respond differently to certain types of medication than others. Matching the correct headache diagnosis with the optimal medication is a really important first step for some patients. For example, migraines can be effectively aborted in many cases by a family of drugs called triptans but migraine is currently under-diagnosed and therefore poorly managed. Although it is also true that many patients will not respond well to triptans, or may simply wish to explore non-medical treatment options first, drug treatments can create a really effective window of symptom relief so that other options, that are perhaps more preferable to some patients in the longer term, can be explored. Chronic migraine, as well as some other types of headache, may also respond well to ‘preventative’ medication but, similarly, many patients do not know that this is an option if they are unaware of their diagnosis. There are often reasons why medication may not have worked initially but with further follow up this can be resolved or other drug options trialled. However, we find that patients often become quickly disillusioned with medical professionals and, rather than persisting with this line of treatment for a little longer, give up and assume that medical help is no use to them.

As with many pain conditions, it is often better to look at what factors may influence or trigger an episode rather than just focusing on pathology. Many Neurologists agree with this approach and are hesitant to scan everyone with headaches, knowing that it is likely that MRI may well unearth benign ‘red herrings’ which, instead of putting a patient’s mind at ease, end up making them more anxious, something that can inadvertently end up increasing headache rather helping it. On the other hand, there are rare cases where head pain does relate to serious medical problems and clearly it is vital that these are not missed. This is why it is so important to take a full and thorough medical history and conduct a proper and considered neurological examination first.

Management of Headache Triggers

As well as understanding the physiological and genetic basis behind different types of primary headache, we also need to understand what ‘triggers’ are involved. This is becoming one of the preferred ways in which headaches are effectively managed. It is often an accumulation of several triggers, building simultaneously to create a ‘perfect storm’, that will start off a headache episode. Many patients prefer to understand their underlying triggers and develop behaviours and lifestyle changes to try and avoid headaches, rather than to persist with less healthy ones and take medicine when an attack happens. Depending on a given patient’s migraine threshold, this is often very effective.

Musculoskeletal Triggers

Lots of patients report having strong musculoskeletal triggers for their headaches and this would certainly concur with our own clinical observations. However, it can often be difficult to establish exact cause and effect relationships and research is not conclusive in this area. For example, does a patient with a stiff neck become more likely to develop tension type headache, or even migraine, or is the neck stiffness often reported by migraineurs around the time of an attack due to muscles in the neck and head area tensing in the presence of head pain that has its origin purely in the brain chemistry? Patients may have a diagnosis of cervicogenic headache (headache that originates from the cervical spine, or neck) which can be established by seeing a Physiotherapist who specialises in the treatment of headache but they often have a mixture of different headache types such as acute migraine and cervicogenic headache together. The features of these headache types are often very similar and hard to separate but even patients with quite obvious migrainous symptoms often improve their overall headache severity and frequency from having their necks treated with manipulative therapies and exercise to maintain optimal tissue health in their upper spine area.

This makes a lot of sense from an anatomical and physiological point of view as we know that the sensory nerves supplying structures in the upper part of the neck share chemical junctions (synapses) in the brain stem with the sensory nerves that supply the head and face (the trigeminal nerves). One of the common features of chronic pain, including head pain, is the impaired ability of the brain to distinguish between sensory inputs from different ‘territories’ or ‘receptive fields’ and so, with chronic headache, signals from the sensory nerves of neck structures are able to create the illusion that the pain is coming from the head, or can amplify signals that are already coming from nerves supplying the head.

Our treatment outcomes using this approach are excellent with the vast majority of patients making significant changes to their headache intensity and frequency as well as being able to reduce or give up taking tablets.

Specialist Physiotherapy

Particularly for those with tension type headache and cervicogenic headache, the British Association for the Study of Headache (BASH) recommends assessment with a Physiotherapist with a specialist interest in headache as one of the first treatment options. These specialist clinicians are able to diagnose and treat any musculoskeletal triggers quickly and effectively. Importantly though, it is a joined up approach, combining lots of different specialists that, in our experience, really makes a difference to this group of pain sufferers.

Pain Education

As with all types of pain, head pain should be explained to each patient so that they fully understand what is causing their symptoms. This is not necessarily an easy task and one which needs to be revisited throughout most patients’ journey to recovery. Pain Education is a huge part of how patients with any type of pain improve their symptoms. Once we understand the real meaning of pain, we tend not to be so anxious or fearful of it and this alone can have significant improvements in patients reported quality of life. Management of stress and anxiety is a big part of how many patients are able to control their headache symptoms.

Mental Well-Being

It is becoming increasingly clear that there are strong links between certain types of headache and mental health problems. For example, if someone has chronic depression, it is more likely that they will go on to develop migraines. Similarly, migraineurs are more likely to develop depression than individuals without migraine headaches. There are also ‘bi-directional’ relationships that we are beginning to understand with other conditions such as anxiety and bipolar disorder. Many patients find it very useful to reflect and ask themselves if there were any stressful life events surrounding the onset of their headaches or if they can see any relationships between their headaches and periods of stress since their onset. Patients are often able to make links between a worsening pattern of head pain and phases of life where levels of anxiety or depression were greater. There are also often links between physical, mental and even sexual abuse and the onset of migraine especially in children and adolescents. It is quite likely that head pain will not respond well to attempts at medical treatment if these underlying causes are not also addressed.

Stress Management

For those with more deep seated psychological issues to explore, seeing a clinical psychologist is certainly recommended. For more simple stress and lifestyle management, someone who has a specific interest in the treatment of pain conditions and works with CBT and stress management techniques such as mindfulness may do just as well.

Sleep Quality

The relationship between sleep and most types of headache is well documented although it is not always clear what the cause and effect relationship is and this needs to be understood well before deciding what the most appropriate treatment options are. However, it is generally accepted that headaches will often respond well to ‘sleep behavioural modification’ where indicated. Sleep behaviour, or ‘sleep hygiene’ refers to a set of optimal conditions that we should observe regarding evening and night time habits such as what we eat and drink in the evening and the timing of food and drink intake, screen use in the evening and the general environment at onset of sleep. Some really good recent research looked at women with chronic migraine (more than 15 headache days a month) and simply by adhering to a set of evening and bed time routines, they were able to transform themselves back to more acute migraine again, in many cases halving the number of headache days and significantly reducing the amount of medication they were taking. Anyone who suffers from migraine will recognise that this is quite life transforming.