This case report describes the chiropractic care of a 44 year old female presenting for chiropractic care of low back, shoulder and neck pain with associated neuropathic itch and chronic migraines.
A 44 year old female presented for chiropractic care with low back, shoulder and neck pain with a medical diagnosis of neuropathic itch and chronic migraines. Symptoms included: dull, aching, sharp and throbbing pain with parasthesia, migraines without aura and limited range of motion. Previous unsuccessful care included prophylactic management of migraines. Examination revealed vertebral subluxations and associated muscle spasms associated with postural upper-cross syndrome.
Intervention and Outcome:
The patient attended a total of 5 visits over a period of 4 weeks, receiving chiropractic spinal manipulative therapy in the form of diversified technique along with active release technique. Notable improvements were noticed within one visit, improvements were measured by the visual analogue scale (VAS), and patients reports of decreased migraine medication reliance.
Successful treatment of a 44 year old female with low back, shoulder and neck pain with associated neuropathic itch and chronic migraines with conservative chiropractic care. This study opens the possibility that patients suffering from similar symptoms may benefit from chiropractic care. We support further research in this area of patient care.
Keywords: Chiropractic Care, Active Release Technique, Low Back Pain, Shoulder Pain, Neck Pain, Chronic Migraines, Conservative Care, Upper Cross Syndrome, Posture
Chiropractic Care of a 44 Year Old Female Suffering From Chronic Migraines: A Case Report
Migraines are defined as a common headache disorder that is recurrent in nature. Listed as the third most common disorder and the seventh-highest specific cause of disability in the Global Burden of Disease Survey. Three-times more common in females, migraine pain is described as moderate-to-severe, typically unilateral and pulsating and can last anywhere from 4-72 hours. An aura that can present as visual, verbal, motor or sensory disturbances can precede a migraine episode for 5-60 minutes. To be diagnosed, a migraine without aura, reoccurrence has to be greater than or equal to 5 episodes. Migraine with aura, requires greater than or equal to 2 episodes. Associated symptoms of migraines may include nausea, vomiting, photophobia and/or phonophobia. Migraines can be severely debilitating greatly impacting quality of life, business duties and school attendance (5).
Currently, it is estimated that migraines incur annual costs totaling $13 billion to $17 billion in the United States. The main cost are developed from medications, emergency department visits, hospitalization, primary and specialty physician services, laboratory and diagnostic services, and management of treatment side effects. Secondary factors to this estimate are a result of lost productivity in the workplace (6).
While migraines are usually managed by medication, some patients do not tolerate the side effects or prefer non-pharmacological management. Reviews have found supporting evidence suggesting that chiropractic spinal manipulative therapy, massage therapy, physiotherapy and relaxation techniques may be found equally efficient when compared to prophylactic management of migraines (3). In the interest of evidence based practice, we describe the chiropractic care of a 44 year old female suffering from chronic migraines and back pain.
A 44 year old female presented to Grove Spine & Sports Care (GSSC) for a chiropractic consultation and potential care after her dermatologist referred her for symptoms of neuropathic itch. The patient reported a chief complaint of low back, shoulder and neck pain with associated neuropathic itch. The patient reported that her low back pain was recent within the last 6 months. However, she has suffered from upper back and neck pain for the past year and has been experiencing migraines, as diagnosed by her neurologist, for an estimated 4 months. Prior to seeking chiropractic care the patient had seen her primary care physician, neurologist and dermatologist. Her goals for treatment included pain reduction, increased range of motion and improved quality of life.
The patient described her low back pain as dull, constant and throbbing and ranked the pain as a 4/10 on the visual analogue scale (VAS) with a pain frequency of 25-75% of the day, several days a week. The pain in the neck and shoulders can be described as a tightness, a dull ache or a sharp pain. This pain can range from a 5-9/10 on the VAS depending on the day. The neck and shoulder pain “limits range of motion and triggers migraines.” At times the symptoms can radiate down the right arm in to the fingers resulting in parasthesia. The patient reported she was experiencing migraines, without aura, 3-4 times a week. Triggers included: wine/alcohol, stress, bright lights and certain smells.
The patient has not experienced these symptoms before however, she has a history of gastrointestinal issues, irritable bowl syndrome (IBS), and pre-cancerous skin lesions. 9 months prior to her first visit at GSSC she had a partial hysterectomy with the hopes of alleviating some of the low back pain. Unfortunately, their was no change in symptoms. The patient on initial visit was currently taking medication for migraines including a 50mg tab of Sumatriptan (as needed) and 3, 25mg tabs of Topomax, daily for migraine prevention.
Physical examination of the patient included neurological, musculoskeletal and dermatological examination along with vital signs, no abnormalities were detected. Dry skin was noted over bilateral scapulae and the thoracic region. All muscle, neurological and sensory exams were demonstrated within normal limits. Postural observation revealed anterior head carriage with rounded shoulders bilaterally. Active range of motion of the cervical, thoracic and lumbar spine was performed within normal limits with the exception of, right lateral flexion of the lumbar spine provoking pain. Active range of motion of the shoulder was performed bilaterally within normal limits, with no pain.
On static and digital palpation, vertebral subluxations were found at the cervical levels C2 and C6, at the thoracic levels T2 and T9 and the right sacroiliac joint, with tenderness over the posterior superior iliac spine (PSIS). Notable orthopedic findings include a positive cervical distraction test, alteration of the radial pulse during costoclavicular maneuver on the right side, decreased fluid motion of the right sacroiliac joint. Muscle spasms/adhesions were noted in bilateral trapezius, rhomboids, pectoralis major/minor, subscapularis and in the right gluteus medius and infraspinatus muscles.
Based on the patients history and physical examination she was given the working diagnosis of SI joint dysfunction and postural upper-cross syndrome with the associated muscle adhesions and vertebral subluxations at the spinal levels C2, C6, T2, T9 and the right SI joint. The right SI joint was fixated posteriorly and inferiorly.
On the first visit the patient received chiropractic adjustments (CMT), Active Release Technique (ART) and rehabilitation exercises. CMT was performed manually to the cervical and thoracic vertebra utilizing diversified technique. Thompson drop was used to address the pelvic misalignment. Muscle adhesions found in bilateral trapezius, rhomboids, pectoralis major/minor, subscapularis and in the right gluteus medius and infraspinatus muscles were addressed with ART. ART is a soft tissue technique that reduces pain and dysfunction by manually treating the affected tissue with precisely directed tension while combining specific patient movements. The patient tolerated treatment well with decreased pain and increased ROM. Instructions to foam roll the upper thoracic region, gluteal group and perform the chest opener stretch, 2 times a day for approximately 3 minutes was added to the home rehab prescription.
The patients treatment plan consisted of 3 visits a week for the first week followed by 2 visits a week for a total of 6-8 visits. However, due to the patient’s work and home life, compliance resulted in 5 visits over the course of 4 weeks on average 1 visit a week.
On the patient’s follow-up subjective findings revealed the patient’s upper-back, neck and migraines felt “great” since the first visit. The patient was not experiencing any low back pain. However, the patient reported that between visits she experienced an episode of severe left flank pain that resulted in a visit to the emergency room. Abdominal and pelvic CT scans were unremarkable with the exception of an enlarged left ovarian cyst. Bloodwork including a CBC w/ differential, BMP, Urinalysis and HCG revealed a slight elevation in white blood cell count. The patient was placed on the steroid Methylprednisolone and Ultram anti-inflammatory. When this flank pain began she reports the pain was a 10/10 VAS, in the office patient reported the flank pain was down to 5/10 VAS. Observational findings revealed a swollen, tender anterior cervical lymph node under the right SCM with spasm of the left paraspinals in the thoracolumbar region . Palpation in the region lateral to the L1-L3 vertebra on the left revealed tight muscle fibers with reported tenderness. No signs of discoloration or increased temperature were noted. No restrictions of the right SI joint were noted on the second visit. Restrictions of spinal levels C6, T2 and T4 were found and addressed with diversified technique. ART was performed bilaterally to the suboccipital, levator scapula, scalenii, trapezius, rhomboid and pectoralis muscles. As well as, the left lumbar erector spinae and multifidii muscles. Kinesiology tape was applied to the lumbar spine to provide extra support to the guarded region within the vertebral levels of L1-L3. Imaging and bloodwork results were requested. The patient tolerated treatment well with decreased pain and increased ROM, reporting that the treatment “made her feel great and much better.” Patient was advised to follow-up with her OBGYN regarding the ovarian cyst.
The subsequent visits continued to result in subjective reports of no upper-back, neck pain and low back pain. The flank pain resolved within the week with no further signs of infection. Treatment continued with manual adjustments and drop technique as needed with ART. On two separate occasions a migraine was noted. One episode was reported during a week of heavy rain and storms that the patient attributed as a trigger, as a result the patient took her migraine medication and “the migraine responded well, which is unheard of for her.” The patient continued to report that,“in the past she would be a disaster with this sort of weather, with constant daily migraines.” The second episode was reported at a time of increased stress do to work, home life and lack of sleep. Once again, migraine medication was taken in the instance of the migraine, the patient not only responded to the migraine medication but only had to take one tablet as opposed to two.
While considering every factor in this case, research was conducted using the databases PubMed and EBSCOHost searching terms “headache,” “migraines” in Boolean combination with “chiropractic care,” “females > 40.”
Chaibi reported the care of a 52 year old female with a long term history of chronic migraines, with nausea, vomitting, and photophobia. The patient reported she did not use migraine medications due to prior complications. The patients history included a diagnosis of endometriosis. The patients initial migraine episode frequency was 1 per month with a duration of approximately 15 hours. Chiropractic treatment was performed 11 times over a 9 week period. The patient experienced gradual, progressive relief in her migraines which resolved after 9 weeks. The patient had not had one episode at the 6-month follow up (4).
Tuchin reported the care of a 72 year old female with a 60 year history of migraine headaches. The average frequency of her episodes was 1 to 2 times per week including nausea, vomiting, phonophobia and photophobia. The patient was treated with CSMT for 8 visits, 2 visits over the course of 4 weeks. The patient reported a dramatic improvement after her first treatment and within the initial month of treatment the patient reported having no migraines. The treatment plan was later elongated to further increase ROM and muscle tone. A 7-year follow-up revealed that the patient had still not had a migraine episode (8).
The Journal of Manipulative and Physiological Therapies published “Evidence Based guidelines For The Chiropractic Treatment of Adults With Headaches” after a systematic literature review of 21 articles that met inclusion criteria. This review found evidence that chiropractic care, including spinal manipulation, improves migraine and cervicogenic headaches. Furthermore, multimodal multidisciplinary interventions including massage are recommended for patients suffering from episodic or chronic migraine (2).
Furthermore, taking in to consideration the patients recent history, a relationship between hysterectomy and headaches was pursued. Arumugam reported on the debate that migraine potential worsens in women who undergo procedures such as cesarean sections and hysterectomy. Of 185 migraine patients 70 females met the inclusion criteria for the study. Results showed that surgeries including D&C, hysterectomy and cesarean section for delivery increased the prevalence of migraine in women. Unless essential, it is recommended that such procedures be avoided in patients prone to migraine headaches (1).
Lau presents a population-based retrospective cohort study of the association between migraine and irritable bowel syndrome. This investigation took place after taking in to consideration that migraines and IBS share many similarities including the periodic pain, trigger factors, lack of definable organic cause and comorbidities. The study concluded that migraine is associated with an increased risk of IBS (7).
We reported the successful treatment of a 44 year old female with low back, shoulder and neck pain with associated neuropathic itch and chronic migraines. This study opens the possibility that patients suffering from similar symptoms may benefit from chiropractic care. We support further research in this area of patient care.
If you have any questions regarding this case report or if you suffer from similar symptoms, feel free to reach out to Dr. Reilly at firstname.lastname@example.org or call for an appointment today (703)-760-8110!
- Arumugam, M., & Parthasarathy, V. (2015). Increased incidence of migraine in women correlates with obstetrics and gynaecological surgical procedures. International Journal of Surgery, 22, 105-109. doi:10.1016/j.ijsu.2015.07.710
- Bryans, R., Descarreaux, M., Duranleau, M., Marcoux, H., Potter, B., Ruegg, R., . . . White, E. (2011, June). Evidence-Based Guidelines for the Chiropractic Treatment of Adults With Headache. Journal of Manipulative and Physiological Therapeutics, 34(5), 274-289. doi:10.1016/j.jmpt.2011.04.008
- Chaibi, A., Tuchin, P. J., & Russell, M. B. (2011, February 05). Manual therapies for migraine: A systematic review. J Headache Pain The Journal of Headache and Pain, 12(2), 127-133. doi:10.1007/s10194-011-0296-6
- Chaibi, A., & Tuchin, P. J. (2011, February 18). Chiropractic spinal manipulative treatment of migraine headache of 40-year duration using Gonstead method: A case study. Journal of Chiropractic Medicine, 10(3), 189-193. doi:10.1016/j.jcm.2011.02.002
- DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 – . Record No. 114718, Migraine in adults; [updated 2014 Aug 01, cited June 8, 2016]; [about 25 screens]. Available from http://search.ebscohost.com.proxy.palmer.edu/login.aspx?direct=true&db=dnh&AN=114718&site=dynamed-live&scope=site. Registration and login required.
- Goldberg, L. D., MD, MBA. (2005, June). The Cost of Migraine and Its Treatment. The American Journal of Managed Care, 11(2), S62-S67. Retrieved June 8, 2016, from EBSCO host.
- Lau, C., Lin, C., Chen, W., Wang, H., & Kao, C. (2014). Association between migraine and irritable bowel syndrome: A population-based retrospective cohort study. Eur J Neurol European Journal of Neurology, 21(9), 1198-1204. doi:10.1111/ene.12468
- Tuchin, P. J. (2008, February 25). A case of chronic migraine remission after chiropractic care. Journal of Chiropractic Medicine, 7(2), 66-70. doi:10.1016/j.jcme.2008.02.001
Patient’s permission was received prior to posting this case report.