Menstrual Migraine and Manual Cervical Therapy

The title will cause some angst, but why should it when…

“Several direct and indirect hormonal and non-hormonal mechanisms have been proposed to explain this cycle-dependent variation in women, but the exact underlying pathophysiological mechanisms are still not completely understood.”^{1(p. 2)}

and,

“Although there is great wealth about neurobiological processes underlying menstrual migraine and its symptoms, the mechanism by which an attack starts during the menstrual cycle remains baffling, and the disease is still untreated.”²

Evidence-informed practice (EIP) can be defined as i) the integration of Research Evidence alongside ii) Practitioner Expertise and iii) the People Experiencing the Practice.

Let’s critique each of these facets concerning Menstrual Migraine (MM):

Research has shown that:

1. the trigemino cervical complex (TCC) is sensitised in those with MM³
2. conditioned pain modulation influences are normal in MM⁴
3. Allodynia (a clinical presentation of sensitisation of the TCC) is more prevalent in those with MM than non-menstrually related migraine^5,6
4. the triptans abort MM^7,8 (by desensitising the TCC^9-11)
5. noxious cervical afferents are capable of sensitising the TCC^12,13
6. Manual cervical therapy desensitises the TCC¹⁴

Practitioner Expertise

 Since 1991, I have consulted exclusively with those experiencing headache, migraine, and comorbid conditions. Over that time, I have seen almost 14,000 patients; approximately 80 percent have been female, with an average age in the mid-30s. ‘Pure’ Menstrual Migraine (PMM) affects one in five to one in seven women, and up to 60 percent experience menstrual-related migraine (MRM).

Disappointingly, I have not kept specific statistical records, but a conservative extrapolation puts the number of patients I have consulted with PMM between 1000 -1500.

Is that enough experience? (Malcolm Gladwell – author of ‘Blink: The Power of Thinking Without Thinking’ – would suggest insufficient – expertise requires 10000 hours…  should we add those with MRM? )

(PS. Menstrual Migraine is subdivided into two types:

1. ‘Pure’ Menstrual Migraine (PMM) is a migraine that occurs around two days on either side of Day 1 and not at any other time in the cycle.
2. Menstrually-related Migraine (MRM), like MM, occurs around two days on either side of Day 1 but also at other times in the cycle (typically, but not necessarily confined to mid-cycle.

“Migraine disease [I am not a fan of ‘disease’] is a debilitating brain disorder [aka a sensitised TCC]. Menstrual migraine, both pure menstrual migraine and menstrually-related migraine, is more resistant to treatment.^{15(p. 4)})

Patient Experience

The most powerful demonstration of cervical relevancy is the ability to reproduce accustomed head pain when sustaining an examination technique of one of the 0-C3 segments. This will occur in at least 80 per cent of patients. This experience, along with a non-jargonistic neuroscientific explanation (aka patient education),

… completes the three pillars of evidence-informed practice (EIP).

EIP contributes to evidence-based practice by offering a more comprehensive, flexible approach to integrating evidence into clinical care. It enhances the applicability and relevance of evidence-based practice, ensuring it remains holistic and patient-centred.

I’ll return to the beginning: Why the Angst When Introducing Cervical Afferents into the Mire of ‘Menstrual Migraine’?

I am steadfast in my perspective for the above reasons and experiences… and because “fluctuations in oestrogen levels do not explain menstrual migraine pathophysiology completely. More likely, there are other factors involved.”^{15(p. 45)}

References:

1. Vetvik KG, MacGregor EA. Menstrual migraine: a distinct disorder needing greater recognition. Lancet Neurol. Apr 2021;20(4):304-315.
2. Cupini LM, Corbelli I, Sarchelli P. Menstrual migraine: what it is and does it matter? J Neurol. Jul 2021;268(7):2355-2363.
3. Varlibas A, Erdemoglu AK. Altered trigeminal system excitability in menstrual migraine patients. J Headache Pain. Aug 2009;10(4):277-282.
4. Teepker M, Kunz M, Peters M, Kundermann B, Schepelmann K, Lautenbacher S. Endogenous pain inhibition during menstrual cycle in migraine. Eur J Pain. Aug 2014;18(7):989-998.
5. Vetvik KG, Benth J, MacGregor EA, Lundqvist C, Russell MB. Menstrual versus non-menstrual attacks of migraine without aura in women with and without menstrual migraine. Cephalalgia. Dec 2015;35(14):1261-1268.
6. Melhado EM, Thiers Rister HL, Galego DR, et al. Allodynia in Menstrually Related Migraine: Score Assessment by Allodynia Symptom Checklist (ASC-12). Headache. Jan 2020;60(1):162-170.
7. Mannix LK, Files JA. The use of triptans in the management of menstrual migraine. CNS Drugs. 2005;19(11):951-972.
8. Maasumi K, Tepper SJ, Kriegler JS. Menstrual Migraine and Treatment Options: Review. Headache. Feb 2017;57(2):194-208.
9. Kaube H, Katsarava Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache: possible sensitization of neurons in the spinal trigeminal nucleus? Neurology. Apr 23 2002;58(8):1234-1238.
10. Hoskin KL, Kaube H, Goadsby PJ. Sumatriptan can inhibit trigeminal afferents by an exclusively neural mechanism. Brain. Oct 1996;119 ( Pt 5):1419-1428.
11. de Tommaso M, Guido M, Libro G, Sciruicchio V, Puca F. Zolmitriptan reverses blink reflex changes induced during the migraine attack in humans. Neurosci Lett. Jul 28 2000;289(1):57-60.
12. Watson D. Pers. experience 2018.
13. Busch V, Jakob W, Juergens T, Schulte-Mattler W, Kaube H, May A. Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes. Cephalalgia. Jan 2006;26(1):50-55.
14. Watson DH, Drummond PD. Cervical referral of head pain in migraineurs: effects on the nociceptive blink reflex. Headache. Jun 2014;54(6):1035-1045.
15. Ansari T, Lagman-Bartolome AM, Monsour D, Lay C. Management of Menstrual Migraine. Curr Neurol Neurosci Rep. Aug 8 2020;20(10):45.