What We Do for Patients with Headaches, and Why:
The end result of visiting Absolute Physical Therapy for headaches and neck pain generally leaves you with eliminated or significantly reduced pain levels, improved range of motion, improved strength and endurance, and a spine safe exercise program that can be performed in your home or at your fitness center.
Electrical Muscle Stimulation (EMS)
The treatment of headache pain with the use of EMS is serendipitous, so I (Chad) will add some background information on how I came about it. As shown by some of my blogs posted in the “Headaches” category, in the last year I’ve been especially interested in electric muscle stimulation (EMS) to help recovery by accelerating strength gains better than exercise alone. A number of my knee and back pain patients commented that the EMS helped with pain reduction better than my earlier use of transcutaneous electrical nerve stimulation (TENS), which is basically the same thing as EMS but with shorter pulses and/or lesser intensity; with the intention of TENS typically being to control pain rather than restore muscle.
I had a patient with low back pain that had a near full recovery of strength, but had a persistent 1/10 pain which was reduced, but not eliminated, when using TENS. I mentioned he might want an electric stim machine for home; I had just started using it for core strength and thought it might help him build strength since his pain level plateaued. After using EMS for 12 minutes to his abdominal muscles and low back, he said he was pain free for the first time. Soon after, I read a study using EMS for low back that I recently blogged on that used similar pad placement and parameters for patients with low back pain. Since then, I have been successfully using that method as part of my treatment for my low back pain patients. Around the same time I had a patient come in who had just suffered a stroke, and had severe neuralgia in one of her legs confining her to a wheelchair. She wasn’t able to tolerate any exercise with that leg because it was hypersensitive to pressure, so I figured I would try EMS on it and she would either like it or hate it. Turns out she loved it; it immediately and substantially decreased her pain, was walking later that hour, and had full recovery of leg strength, endurance, and gait in about a month. She asked me if it would work for headaches, so I said I would do some research and this is the first paper I came up with:
Peripheral Nerve Stimulation
This study is in regards to peripheral nerve stimulation (PNS), which is the surgical implantation of electrodes to stimulate various nerves and decrease pain. I’ve researched PNS before and applied it to my transcutaneous electric stimulation for headaches with good result. What researchers found was occipital nerve stimulation (ONS) (at the posterior upper neck/base of the skull region) had about 40% effectiveness on migraine headaches. While reasonably good, this was less effect than they found with PNS of other neuralgias. What they noticed was that migraine pain was more frontal, so they added supraorbital nerve stimulation (SONS) (on the forehead above the eyes) which raised the effectiveness for treating migraines to >90% which was about the same as they were achieving with PNS of other neuralgias.
With results that good, it makes you wonder why everyone suffering with severe headaches wasn’t having PNS. The problem is that the PNS electric stimulators were surgically implanted with wire leads placed alongside the occipital nerve at the base of the skull. There were a number of serious complications including infection and lead migration (when the wire planted alongside the nerve shifts), plus the surgically implanted battery pack only has a 3-5 year life span, and the rechargeable version a 10 year span. So while the PNS treatment seems very effective, I can’t imagine many headache sufferers would be willing to go that route.
Check out my blog to read more about Peripheral Nerve Stimulation and Headache Reduction
Headache Prevention and Electrical Current
In a 2014 study, the use of a type of electrical current, other than EMS, was used to determine if it could prevent cluster headache attacks. The researchers were using a type of electrical current that they wanted to be painful and testing for a blink response. Results showed that the cluster headaches went away with the use of this stimulation. Cluster headaches are a particularly painful and problematic variety, so it is good to see potential here from a treatment that is non-invasive and at least in this small sample seems to have worked quite well. The parameters used was a monophasic 200 Hz train of three 0.5 ms pulses, working up to 2.1 mA given on average, six times at two hour intervals.
I generally favor alternating current over the monophasic current used in this study, largely because it feels better; however it’s certainly an interesting finding and should perhaps be compared to alternating currents being applied transcutaneously to the supraorbital nerve. I would like to see how it compares to suboccipital stimulation, as well as the combination of the two for cluster headaches, migraines, tension, and cervicogenic headaches. I have been noticing a very good effect with the latter three. It is also interesting that the headache prevention may not be due to gate-control theory.
Check out my blog to read more about: Treating Cluster Headaches with EMS
Safety and Satisfaction of TENS Method for Reducing Headache Pain
Researchers demonstrated the safety of non-invasive supraorbital (forehead above the eyes) electric stimulation for headaches and found minimal, mild, and no serious side effects on 2313 patients. That is by far the largest population I have seen tested with any form of electric stimulation. They gave reasonably clear parameters with regards to TENS protocol used: a biphasic rectangular waveform, pulse duration of 250 uS, 60 Hz, and maximum intensity of 16 mA to be used 20 minutes per day, every day. I initially thought those parameters sounded weak, but when programming my own electric stimulation machines (both my Genesy 1100 and EV-906) to the same parameters , 16 mA turns to be pretty strong when electrodes are placed over the forehead. I’m very electric stimulation tolerant and was able to get to 16 mA without much trouble, but it felt intense. My office staff, all of which are female and some of which get headaches, were only able to tolerate 5-7 mA before being limited by pain/discomfort; so I don’t think weakness of the machine is a problem in the study. I think supraorbital and supratrochlear nerves being very close to the skin surface are relatively easy to reach with TENS, and thus not needing an especially powerful stimulator.
The researchers didn’t give any data with regards to how well the machine worked, except that 54.4% said they were happy enough to purchase it at $246 Euros over the rental costs during the study (full price was $295 Euros). However, there was no data given with regards to headache intensity, frequency, or disability over the course of the study. I would think that kind of data would be easy to gather with a survey, and though there was no control group it would be interesting to see if and how much the changes were from pre- to post-treatment for such a large number of people. To be fair, the same group of authors did give such data in another study, on a much smaller number of subjects. I intend to review that study next, but it would have been good to see some additional outcome data on this larger group.
This study gives great safety information and got FDA approval on some specific TENS outputs and pad placements that I can incorporate into my own electric stimulation treatments and research. I do suspect that outcomes could be improved by incorporating suboccipital (back of the neck) stimulation with the supraorbital stimulation. That set up is proving to be the most effective for chronic migraines headaches in the peripheral nerve stimulation studies, which I am currently gathering data on.
Check out my blog to read more about: The Safety and Satisfaction of Tens Method for Reducing Headaches
While neck strength training has been shown to be effective in improving neck muscle strength, reducing neck pain, and relieving headaches, it has also been shown to increase a patient’s health-related quality of life. The study providing these results was a randomized- controlled one-year follow up that looked at the effect of neck strength training and health-related quality of life in females with chronic neck pain. Subjects were divided into an endurance training group, a strength training group, and a controlled training group. The strength training group improved significantly in five of 15 dimensions, giving further confirmation that strength training for women with chronic neck pain is beneficial.
While this is another study showing that strengthening is more effective than stretch for the treatment of chronic neck pain, the improvements were significant; but not exceptional. The reason for this being, with spine injuries in particular, is that exercise, while beneficial, is not the entire answer. Motor control, ergonomics, and postural alignment are all part of recovery, and all part of my physical therapy programs for neck pain. In addition, I find electric muscle stimulation to be very effective at acutely decreasing pain while further increasing muscle strength and endurance just as well as it does with low back pain; thus complementing the active exercise, motor control, and postural improvements.
Check out my blog to read more about: Strength Training Improving Quality of Life
Patients with Post- Concussion Syndrome
A 2010 study evaluated the safety and effectiveness of aerobic exercise training for the treatment of post-concussion. At the follow up period, three months after the end of their exercise, 10 of the 12 subjects reported being symptom free. The following exercise program was done on a treadmill with a target heart rate of 80% of the threshold heart rate, five to six days per week. Subjects were told to terminate the exercise at the first point of symptom exacerbation or if they reached their goal duration, which was the same duration reached during the prior treadmill test. Balke Protocol treadmill tests were performed every three weeks until symptoms were no longer exacerbated by the test. It should be noted that there were only 12 subjects in the study, so results can’t be said to be universal. Treatment duration ranged from 11 to 112 days, with an average being 31.8 days. Exercise times on the treadmill increased from 9.75 minutes to 18.67 minutes.
I think this study is very promising, and seems to be the most effective treatment program I have been able to find when researching post-concussive syndrome. I has new physical therapy patient with this condition, and found this study to be helpful towards development of his treatment. This is especially important because I was seeing him for balance/vestibular troubles but I really had my doubts that vestibular rehabilitation, which works great for BPPV, was going to work for him. Because of this, I did a literature review on the subject and blogged on a study that found vestibular rehabilitation exercises had no effect on dizziness in adults with post-concussive syndrome. Though preliminary, overall these are very promising results for a problem that causes significant disabilities; for 15% of sufferers, the symptoms can last for years or be permanent. Based on this study, I put aerobic exercise in my post-concussion physical therapy protocols and will evaluate how well it works in real time.
Check out my blog to read more about: Treating Post- Concussion Syndrome with Aerobic Exercise
For treating patients experiencing reoccurring headaches, I think the best course of action is to implement:
1. Strength training, specific postural exercises, and biomechanical counseling (if cervical in origin).
Supine Chin Tucks and Flexion Holds
When I treat my physical therapy patients for neck pain (which is commonly paired with reports of cerviogenic headaches) with a largely exercise-based approach, they often report their pain levels decreasing from the beginning to the end of the workout. This decrease in pain happens before the application of EMS, which is my preferred modality for pain.
In a study examining the specific therapeutic exercise of the neck and induction of immediate local hypoalgesia, a supine neck flexion hold, where you lay on your back and hold your head no more than two cm off the table (which is an exercise I like), along with a supine (lying on your back) chin tuck, where you attempted to bring your chin toward the chest while keeping the back of your head flat on the mat both decreased neck pain were used as the exercise protocols. They did three sets of 10 reps, each rep with a three second hold and two second rest with 30 seconds between for the flexion holds, and the chin tuck was held for 10 seconds with 10 seconds rest in between for 10 reps.
This study showed an immediate local mechanical hypoalgesic response to specific exercise of the cervical spine. Although both exercises decreased participant’s neck pain, it was shown that the supine shin tuck exercise worked better. I imagine the difference might be due to the chin tuck increasing space for the spinal cord and nerves exiting the cervical spine, and perhaps it having a more immediate effect on improving posture once completed. The improved posture also increases space for the spinal cord and nerves exiting the cervical spine after the exercise, so it’s win-win. The other exercise would do more to increase cervical flexor strength and endurance, which would likely lead to gains further down the road; however, it does not immediately lessen stresses on cervical structures in the same way the chin tuck does.
Check out my blog to read more about: Decreasing Neck Pain with Supine Chin Tucks
Patients with Cerviogenic Headaches
A cervicogenic headache is one that originates from tissues in the neck, as opposed, for instance, to a migraine. These types of headaches are often the result of holding the neck and head in stressful daily postures, often looking down (cervical flexion) or a forward head posture (lower cervical flexion combined with upper cervical extension). Both of these postures increase muscular strain and strain on cervical joints and discs much more than a neutral cervical posture with the head level and centered (front to back) over the shoulders. Keeping a neutral posture requires a degree of awareness, and also some muscular strength and endurance. The researchers in this article found that both strength and endurance exercises helped to decrease headache intensity, as well as neck, shoulder, and arm pain more than stretching alone.
Results revealed that the strength group was slightly better off than the endurance group. The cervical strength exercises were all isometric against a theraband in all directions, while the endurance group did dynamic exercise in supine only. Both groups also did upper body weight training exercises with dumbbells, the endurance group for three sets of 20 reps with a 2 kg (4.4 lb) dumbbell, while the strength group did one set of 15 but with ever increasing intensities as they got stronger. Both groups also did bodyweight and core exercises including squats, sit-ups, and back extensions. All three groups did the same stretches.
With some of the differing variables it’s hard to say what part of the strength and endurance programs led to the reduction in headaches, so those with cervicogenic headaches have no reason to be apprehensive about weight training. While the results were good, the study was over a year long. I have noticed considerably faster reductions in pain in my physical therapy programs when I use the combination of my specific exercises and EMS.
Check out my blog to read more about: Reducing Headaches with Postural Strength Exercises
2. Ergonomic adjustments at home and in the work place.
Static posture is an important factor that Mckenzie does address in his books. Though in my opinion, his recommended lumbar supports are on the extreme side, resulting in an extended rather than a neutral spine. They can be as simple as a couple throw pillows on a couch, perhaps adding a thin lumbar support to your car seat (but not so much as to push your spine into extension beyond neutral), and adjusting the seat position so it’s close enough and upright enough that when your shoulders are back in the seat you can still rest your wrist over the top of the steering wheel. For cyclists, I would maybe suggest a higher handlebar position or to keep your elbows extended.
3. EMS; which helps a lot to decrease pain and increase strength in the near term while the patient is waiting for the exercises and ergonomic changes to take effect.
The study that I referenced to earlier, Peripheral nerve stimulation for the treatment of primary headache. Curr Pain Headache Rep. 2013 Mar;17(3):319. , is initially what got me thinking that EMS could be very beneficial for patients’ with headaches. I figured the occipital nerve is very superficial and should be easy to stimulate with my EMS unit by placing the electrodes high on the posterior aspect of the cervical spine. I was already using large rubber carbon electrodes rather than sticky gel electrodes, so there was no interference with the patients’ hair, and they are effectively held in place by a snug but not tight 4” wide elastic strap around the neck. I used my favorite EMS settings that worked for me better than TENS with the low back pain and neuropathic hypersensitivity. At worst I figured I would increase the strength of the suboccipital muscles and posterior cervical extensors, which would be better than nothing. I had a knee patient come in complaining of a 10/10 headache saying she didn’t think she would be able to do her exercises. I suggested we try EMS, and 12 minutes later her pain was gone and did not return. A few days later another patient being treated for low back pain had an 8/10 headache, I stimmed her suboccipital region and 12 minutes later it was a 2/10 and later resolved; so I started offering a free EMS treatment to anyone with a current headache and have been keeping and recording the results in a spreadsheet. This is my result thus far:
So far, nobody has reported increased pain and only one patient had no immediate improvement (we later found via MRI that this patient’s headaches were due to severe multi-level cervical stenosis), while twelve of the 21 had complete relief of headaches immediately following the treatment. Most patients comment that the EMS is comfortable and removes the aura associated with migraines as well as the headache. Some have said when they stim while first experiencing an aura it stops the migraine from coming on. Some have tried the EMS with lower intensity stimulation with modest effect and tried it again later with increased intensity to have their pain fully resolved. Pain reduction or elimination has ranged from relief lasting several hours, to several days, to headache pain not returning at all.
Since then, I have modified my treatment parameters to see if they improve results. I have been reading more papers, including some from back in the 80s when they were doing traditional TENS for headaches, and were finding positive results as well; though that research seems to have been forgotten. I’ll do some blogs on them to talk about what can be learned, good or bad, from prior and upcoming research as well as updates from my data collection. So far I’ve been collecting data with reference to immediate reductions in pain once the headache is there, but going forward I’ll also be looking at more at specific parameters in the older TENS and current PNS studies and combining that with my surface EMS to see if that affects frequency and intensity of future headaches.
In the meantime if anyone local to my office has a current headache and wants to be part of my study and see if EMS works for them please call the office and we’ll try to get you in for an immediate and free appointment to try it out. In the future I’ll likely be adding a placebo/control group to control for the power of suggestion, but at this point I’m collecting preliminary data you’re sure to get what I think works best.
What We Don’t Do for Patients With Headaches:
We Don’t Emphasize Stretching
Referencing back to the study mentioned earlier about Reducing Headaches with Strength Exercises in patients’ with cerviogenic headaches, it was found that both strength and endurance exercises helped to decrease headache intensity, as well as neck, shoulder, and arm pain more than stretching alone.