Shared by: webinfo@chiroviewpresents.com

Multimodal Management of Chronic Headache ‚ Part II

Donald R. Murphy, DC, DACAN  4-23-01
Clinical Director
Rhode Island Spine Center
Clinical Teaching Associate
Brown University School of Medicine
Providence, RI
RISpine@aol.com  


So because all chronic headaches share a common pathophysiology, 
and because this pathophysiology is multifactorial, it is essential 
that a multidimensional approach be taken to diagnosis and 
treatment.  This involves delineating the most important somatic, 
biochemical and behavioral factors in each patient, and devising a 
management strategy must that addresses each of the components.  
This strategy must be applied in a manner that is specific to each 
patient, depending on the specific deficits that are present.  The 
understanding of chronic headache pathophysiology that I have laid 
out here has allowed me to devise an evidence-based multimodal 
approach to the headache patient.  This approach is described in 
more detail in the headache chapter in my book, Conservative 
Management of Cervical Spine Syndromes (McGraw-Hill, 1-800-262-
4729, ISBN # 0838563864).

The biochemical component must, of course, be treated 
biochemically.  There are a number of medications that are 
commonly prescribed for patients with chronic headache, and many 
of them have good evidence of effectiveness.  Each of these 
medications fall into one of 2 categories ‚ abortive and prophylactic.  
Abortive medications are those that are designed to stop a headache 
that has begun.  They are taken at the first sign of the onset of the 
headache.  Prophylactic medications are designed to prevent 
headache and are taken on a regular basis.  

It must be noted, however, that there are a few non-medication 
substances that have been demonstrated to be effective in the 
prophylaxis of chronic headache.  These, are natural products and, as 
such, have a low complication rate and a favorable drug interaction 
profile.  These include high dose riboflavin, high dose magnesium and 
the herb feverfew.  So these represent the first line of the 
biochemical approach to headache management.  

The somatic component to the management strategy in directed 
toward those specific dysfunctions that were found to be significant 
on examination.  It may include manipulation, trigger point therapy, 
McKenzie, postisometric relaxation, postfacilitation stretch , Active 
Release, sensorimotor training or cervical stabilization training (9).  
Of course, in most patients a combination of these methods is 
required.  

To address the descending pain inhibition dysfunction, some form of 
psychospiritual approach is taken.  This may include behavioral 
therapy, meditation, hypnosis, relaxation training or formal 
psychotherapy.  

By taking this multimodal approach, based on the current model of 
headache pathophysiology and the specific factors that are present 
in each patient, I believe that we can maximize patient outcome.  We 
are currently in the process of investigating the effectiveness of 
this approach scientifically, and it is hoped that through this 
investigation, clinical improvements can be made in the best 
interests of the many patients with headache that desperately need 
effective treatment.

References

1. Nelson CF. The tension headache, migraine headache continuum: a 
hypothesis. J Manipulative Physiol Ther 1994; 17(3): 156-167.

2. Bogduk N. The anatomical basis for cervicogenic headache. J 
Manipulative Physiol Ther 1992;15(1):67-70.

3. Marcus DA. Serotonin and its role in headache pathogenesis and 
treatment. [Review]. Clin J Pain 1993;9(3):159-67.

4. Appel S, Kuritzky A, Zahavi I, Zigelman M, Akselrod S. Evidence for 
instability of the autonomic nervous system in patients with 
migraine headache. Headache 1992;32:10-7.

5. Bendtsen L. Central sensitization in tension-type headache-
possible pathophysiological mechanisms. Cephalagia 2000;20 
(5):486-508.

6. Murphy DR. Dysfunction in the cervical spine.  In: Murphy DR, ed. 
Conservative Management of Cervical Spine Syndromes.  New York: 
McGraw-Hill, 2000:71-104.

7. Murphy DR. Protocols for the management of cervical spine 
syndromes.  In: Murphy DR, ed. Conservative Management of Cervical 
Spine Syndromes.  New York: McGraw-Hill, 2000:691-700.

8. Murphy DR. Evaluation of posture and movement patterns involving 
the cervical spine. In: Murphy DR, ed. Conservative Management of 
Cervical Spine Syndromes. New York: McGraw-Hill, 2000:307-328.

9. Nelson C, Murphy DR, Fowler J, Wilterdink J, Tabamo R. Headache.  
In: Murphy DR, ed.  Conservative Management of Cervical Spine 
Syndromes.  New York: McGraw-Hill, 2000:169-188.