Thursday, June 14, 2012

Migraine and Colic

The following article comes courtesy of Matthew Long and Anthony Nicholson at CDI and

Approximately 20 to 40% of patients who consult a chiropractor do so for the chief complaint of 'headache' and it may seem surprising but many respond favourably following physically based treatments of the spine.  It has even been controversially reported that chiropractors can treat Colic in infants but what on earth has this got to do with headache?

Can chiropractors 'cure' these ailments or are we looking at a far more complex condition which responds to many different types of stimuli?  What do we know?

The highlights are mine.

Migraine, Colic and Complexity

The results of a recent study to be presented next month at the American Academy of Neurology (AAN) 64th Annual Meeting has focused attention yet again upon the complexity of migraine. Dr Amy Gelfand will discuss the findings of an investigation into the relationship between mothers with migraine and the tendency for their children to suffer infantile colic. In summary, maternal migraine is associated with a greater-than two-fold increase in the chance of having a colicky baby. But what underlies this relationship?

Migraine is a genetic neurological disease that is frequently misunderstood. While the condition certainly
can cause headache, it should not be defined by headache symptoms nor restricted to a category of headache pain. In essence, migraine represents a fundamentally flawed brain that struggles to regulate neuronal activity and maintain equilibrium. One could describe the migrainous brain as a genetically predisposed, serotonin depleted, nor-adrenaline deficient, dopamine sensitive, calcium channel deformed, ATP constrained, magnesium compromised, bundle of hyper-excitable circuitry in a state of precarious membrane stability. The end result - a highly reactive brain that is unduly sensitive to both internal and external stimuli. Furthermore, the way in which this instability manifests is not limited to 'bad headaches' or even the more complex aura symptoms.

Many migraineurs go through life experiencing signs and symptoms of their disease that are never attributed as such. It now appears that these symptoms may well manifest in infants as colicky behaviour. The concept of 'abdominal migraine' in children has gained greater acceptance in recent years (2), with Carson
et al suggesting that it accounts for 4-15% of recurrent idiopathic abdominal pain. Furthermore, as childhood progresses even more complex 'migraine equivalents' start to appear and challenge our notions of what exactly constitutes a migraine. Such migraine equivalents include abdominal migraine and cyclical vomiting syndrome, acephalgic migraine (visual), acute confusional migraine, migrainous vertigo and torticollis (3). The trouble is, these episodes are often unrecognised as an expression of the underlying disease that lies at its core.

To return to the subject of colic, we must ask ourselves what this new insight might do for colic management? Chiropractors have long claimed efficacy for treating infantile colic, but the evidence is definitely patchy (4,5). However, we must also understand that the diagnosis of colic is subjective and there is no firm agreement on an underlying pathophysiology. With so much confusion and uncertainty it is of no surprise that controversy reigns. But what if we included migraine as a possible aetiology for 'colicky behaviour'? How would this change our approach? If colic was now viewed as a
brain disorder what would this mean for contemporary chiropractic and medical theories about treating the condition?
Migraine illness represents a condition of undue sensitivity to both internal and external stimuli. Whether the stimulus is a flashing light, a loud noise or the distension of an internal organ such as the bowel, a migraineur's brain responds with increasing intensity. Many studies have catalogued the broad-spectrum sensitivities of migraine. But irritable bowel syndrome (IBS) is probably one of the better studied examples, and the most relevant to infant colic. Indeed, one could easily propose that IBS sits on the migraine disorder spectrum. Sufferers of IBS also exhibit a generalised sensitivity to non-bowel stimuli (6) , "
including back pain, migraine headaches, heartburn, dyspareunia and muscle pain in body regions somatotopically distinct from the gut. Collectively, these somatic symptoms suggest that IBS patients may also suffer from central hyperalgesic dysfunction" (7). This has been described as a failure of a central analgesic mechanism known as diffuse noxious inhibitory controls (DNIC) (8). As such, irritable bowel syndrome has been conceived as a problem of how the brain perceives the gut, rather than an intrinsic gut disorder itself. In just the same way, infant colic might represent an unduly sensitive brain that allows normal levels of gut distension to register as pain.

So what does this mean for chiropractors?

If migraine and colic exist on a continuum of brain disorders in which descending pain modulation is compromised, can we claim that spinal dysfunction somehow 'causes' colic or migraine headache? Probably not. However, spinal dysfunction may well act as a 'trigger' for acute episodes in just the same way that flashing lights, loud sounds or gut distension might. If this is the case, it would make sense that adjustments to the spine may reduce the burden of irritation flooding the sensory system that allow other noxious pathways from the gut to reach threshold. We could also conceive of a manipulation as a 'sensory lever' that alters modulation of the pain pathways and facilitates greater inhibition of pain from other sources - including the gut.

Something to think about...
Dr Matthew D. Long - BSc. M.Chiro


1. Gelfand, A. American Academy of Neurology (AAN) 64th Annual Meeting. Abstract 113. April 21 - 28, 2012. First results released February 20, 2012.
2. Carson, L., Lewis, D., Tsou, M., McGuire, E., Surran, B., Miller, C., & Vu, T.-A. (2011).
Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children. Headache, 51(5), 707–712. doi:10.1111/j.1526-4610.2011.01855.x
3. Al-Twaijri, W. A., & Shevell, M. I. (2002).
Pediatric migraine equivalents: occurrence and clinical features in practice. Pediatric neurology, 26(5), 365–368.
4. Wiberg, J. M., Nordsteen, J., & Nilsson, N. (1999).
The short-term effect of spinal manipulation in the treatment of infantile colic: a randomized controlled clinical trial with a blinded observer. Journal of manipulative and physiological therapeutics, 22(8), 517–522.
5. Wiberg, K. R., & Wiberg, J. M. M. (2010).
A retrospective study of chiropractic treatment of 276 danish infants with infantile colic. Journal of manipulative and physiological therapeutics, 33(7), 536–541. doi:10.1016/j.jmpt.2010.08.004
6. Piché, M., Arsenault, M., Poitras, P., Rainville, P., & Bouin, M. (2010).
Widespread hypersensitivity is related to altered pain inhibition processes in irritable bowel syndrome. Pain, 148(1), 49–58. doi:10.1016/j.pain.2009.10.005
7. Zhou, Q., Fillingim, R. B., Riley, J. L., Malarkey, W. B., & Nicholas Verne, G. (2010).
Central and peripheral hypersensitivity in the irritable bowel syndrome. Pain, 148(3), 454–461. doi:10.1016/j.pain.2009.12.005
8. Heymen, S., Maixner, W., Whitehead, W. E., Klatzkin, R. R., Mechlin, B., & Light, K. C. (2010).
Central processing of noxious somatic stimuli in patients with irritable bowel syndrome compared with healthy controls. The Clinical journal of pain, 26(2), 104–109. doi:10.1097/AJP.0b013e3181bff800

Sunday, June 10, 2012

Fibromyalgia (FM) - A new understanding

The following illustrates how research can dramatically improve outcomes for individuals suffering complex pain disorders.

Not long ago Fibromyalgia was thought to be an inflammatory condition of the muscles.  Individuals hurt pretty much all over.  They would also commonly have other conditions such as headache, gut disturbance and odd limb sensations and they would be prone to depression and anxiety.
These people were often labelled hypochondriacs and Dr shoppers and unfortunately the frustration and sense of helplessness often magnified the problem.

Now FM is classified as a genetically linked condition involving abnormalities in the dopamine pathways of the brain, resulting in widespread allodynia and multiple sensitivities.

Allodynia is a pain due to a stimulus which does not normally provoke pain so FM is actually a 'pain processing problem'

According to one FM website it still takes an average of 5 years for this collection of apparently unrelated symptoms (co-morbidities) to be recognised as manifestations of the single disorder.

What can a chiropractor offer?  There is a body of information regarding FM which should determine treatment choices irrespective of which profession the individual consults.

Officially there is actually a paucity of literature for the support of chiropractic care in the management of this condition.  According to Schneider et al "Strong evidence supports aerobic exercise and cognitive behavioral therapy. Moderate evidence supports massage, muscle strength training, acupuncture, and spa therapy (balneotherapy). Limited evidence supports spinal manipulation, movement/body awareness, vitamins, herbs, and dietary modification." (courtesy of CDI).

Perhaps the main role of physically based modalities in the co-managment of FM is to reintroduce normal movement in a non painful way.  Traditional spinal and joint manipulation is generally not tolerated well in these cases and usually leads to aggravation.  Gentle joint and muscle movements, often in areas of the body not badly affected are followed by more robust manouvers as tolerance increases.

Education and reassurance are vital while the individual gradually increases exercise and attends to any psychological issues which may exist.

What we have to offer is only part of a much broader approach and communication with the medical practitioner and other providers is essential to form a tailored, coherent and effective approach which gives the individual the tools to understand and effectively self manage their problem.

It's perhaps useful to consider that the brain is just one organ of the body and while it may malfunction we do possess the ability to control it's reactions.  Our responses to pain (technically nociception) is a function of many processes we cannot directly control however pain 'levels' are strongly determined by learnt responses.  In essence our minds experiences.

Ultimately we are in the drivers seat where the brain is concerned.