WHAT DOES THE LATEST RESEARCH ON NECK PAIN, HEADACHES, AND WHIPLASH REVEAL?
“Opioids appear to be over-prescribed.” From last October’s issue of Emergency Medicine Australasia (Use of and Attitudes to the Role of Medication for Acute Whiplash Injury: A Preliminary Survey of Emergency Department Doctors)
“The truth is that, among all diseases, headache is one of the hardest to diagnose and treat. It is, in fact a functional central nervous system disorder and no specific markers or organic alterations occur, except when headache is a symptom of another illness. Moreover, after trying several medical, paramedical, or all-but-medical approaches, most patients continue to suffer from their headache and, being often dissatisfied with the responses obtained, they try self-treatments and thus become pain-killer abusers…. This is even more true if we consider that while headaches can, indeed, be described, their description is hardly objective, and they therefore fall within the domain of subjectivity. The subjectivism of this pathology never fails to strike me. Patients describe their symptoms, but physicians can never verify them directly.” CHERRY PICKED words from Dr. Gennaro Bussone a ‘headache neurologist,’ from this month’s issue of Neurological Sciences (Clinical Issues of Headaches: A Personal View)
“Medication-overuse headache (MOH) is a common neurologic disorder with enormous disability and suffering and plays a significant role in the transformation from episodic to chronic headache disorders. Multiple terms have been used to describe MOH such as analgesic rebound headache, drug-induced headache or a medication-misuse headache. Patients with established primary headache disorders like migraine or tension-type headaches excessively overuse medication for their acute headache and inadvertently increase the frequency and intensity of their headache. In this manner, a vicious cycle of further drug consumption and increased headache frequency develops transforming the treatment for their headache to the actual cause of their disease (MOH).” From this month’s issue of STAT Pearls (Medication-overuse Headache (MOH)
With costs for managing CHRONIC PAIN (including headaches) continuing to soar on a parallel path with the ‘we-just-can’t-seem-to-get-a-handle-on-it’ OPIOID CRISIS, what else can be done? To help answer that, today we are going to take a look at some of the latest research concerning CHRONIC HEADACHES, CHRONIC NECK PAIN, and WHIPLASH — all of which are intimately related to the cervical spine.
In a study showing the power of PROPRIOCEPTION, this month’s issue of Musculoskeletal Science & Practice (Gait Speed and Gait Asymmetry in Individuals with Chronic Idiopathic Neck Pain) revealed that, “Individuals with chronic idiopathic neck pain had slower gait speed in all walking conditions compared to controls. In preferred walking and walking at maximum speed conditions, gait was found to be asymmetric in individuals with chronic idiopathic neck pain.” In other words, the neck cannot be separated from the rest of the body musculoskeletally. It’s all one organism, connected by the nervous system (HERE) and fascia (HERE).
As you might guess, there are increasing numbers of studies linking headaches to both stress (SYMPATHETIC DOMINANCE) and Gut dysfunction. While a dysfunctional gut can take on many characteristics, they can essentially be broken down into two; THE LEAKY GUT and THE DYSBIOTIC GUT. Listen to next month’s issue of Behavioral Pharmacology (Stress and the Gut Microbiota-Brain Axis). “Stress is a nonspecific response of the body to any demand imposed upon it, disrupting the body homoeostasis and manifested with symptoms such as anxiety, depression or even headache.” It’s why I’ve said repeatedly that if you want to restore HOMEOSTASIS, it all starts with GUT HEALTH, which usually takes us back to DIETARY FACTORS and ANTIBIOTIC USE / ABUSE (remember, however, that all drugs have gut-destroying antibiotic-like properties — HERE).
Speaking of dietary factors; when I have patients with chronic headaches, one of the things I usually suggest trying first — especially for the person who has seemingly tried ‘everything’ — is an ELIMINATION DIET. This lets us see whether or not certain foods might be driving the underlying inflammation / immune system responses, which are frequent drivers of headaches. I’ve spoken in the past about a brain-destroying “PARKINSON’S-LIKE” phenomenon that ravages the lower brain (cerebellum) called CEREBELLAR ATAXIA. A study from this month’s issue of the Journal of Oral & Facial Pain and Headache (Headache in Patients with Celiac Disease and Its Response to the Gluten-Free Diet) not only revealed that 6 of 10 CELIACS had abnormal cerebellar MRI’s, but that 42% had chronic headaches related to consuming GLUTEN. The only way to avoid the “white matter lesions” of the brain that these authors talked about? The GLUTEN-FREE diet of course. Just be aware that Non-Celiac Gluten Sensitivity (NCGS) is multiple times more common and can be equally as severe as Celiac Disease, although it’s not nearly as easy to test for using standard lab / blood tests.
Another study, this one from the same issue of the same journal (Headache in Patients with Celiac Disease and Its Response to the Gluten-Free Diet) looked at over 1,500 Celiacs with chronic headaches, describing them as mostly female (94%) with an average age of nearly 40…..
“Tension-type headache was the most prevalent headache type (52%), followed by migraine (48%). Of the included participants, 24% reported headache as the main symptom that resulted in the diagnosis of CD. Following initiation of a gluten-free diet, headache frequency and intensity improved significantly more in participants with migraine than tension-type headache. Compliance to the diet was higher among subjects with severe manifestations, and compliant individuals showed a 48% improvement in headache frequency. An association between food transgressions and headache was better recognized by migraineurs.”
What this tells me is that not only are headaches a common sequalae of Celiac Disease, but that with Celiacs struggling with tension-type headaches there are more likely to be secondary factors at play — probably mechanical factors like SUBLUXATION or ADHESED FASCIA. While these can and do play a frequent role in MIGRAINE HEADACHES, they are far more common in the tension headache sufferer. Another study — this one from the current issue of Pain and Therapy (The Relationship Between Musculoskeletal Pain and Picky Eating: The Role of Negative Self-Labeling) showed that of the more than 4,600 adults looked at, “The prevalence of musculoskeletal pain in every region was seen as consistently higher in subjects who self-identified as picky eaters than those who were non-picky eaters.” The number one painful association of picky eating was —- neck pain.
The latest copy of the journal Pain Medicine (Ingrowth of Nociceptive Receptors into Diseased Cervical Intervertebral Disc Is Associated with Discogenic Neck Pain) described a model almost identical to what you see on my CHRONIC PAIN PAGE, although their model was used to describe deteriorating spinal discs in the neck. There is a buildup or ingrowth of inflammation-sensitive fibers into degenerating discs and soft tissues that can make them absurdly pain-sensitive (FAMED NEUROLOGIST, CHAN GUNN, described this phenomenon as causing a neuro-chemical reactivity that could potentially make these tissues over 1,000 times more pain-sensitive than normal). BTW, this testing was done via biopsy instead of MRI. What about MRI findings for these sorts of patients?
I’ve previously shown you how futile MRI can be in many — maybe even the majority — of lumbar disc cases. This is because study after study has shown that somewhere between half to three quarters of the adult population is walking around with MRI-visible disc herniations in their low backs, but have no idea because they do not hurt (HERE — and the same thing is true of SHOULDERS AS WELL). Now we see that it’s also true of necks. A study from January’s issue of the Journal of Magnetic Resonance Imaging (Cervical Spine Findings on MRI in People with Neck Pain Compared with Pain-Free Controls: A Systematic Review and Meta-Analysis) looked at the findings of over 4,000 subjects from 32 studies, coming to these conclusions. Other than the fact that the cross-sectional area of a specific muscle — rectus capitus posterior — was smaller in people with chronic pain, “The remaining meta-analysis comparisons showed no group differences in MRI findings. Definitive conclusions cannot be drawn on the presence of MRI findings in individuals with whiplash-associated disorders or non-specific neck pain compared with pain-free controls.”
When it comes to chronic whiplash-related neck pain, what are the chief factors that indicate that a poor outcome might be on the horizon? Next month’s issue of the Clinical Journal of Pain (Precollision Medical Diagnoses Predict Chronic Neck Pain Following Acute Whiplash Trauma) answered that question after comparing 700 WHIPLASH PATIENTS to 3,600 controls. While I expected to see patients with a list of either AUTOIMMUNE or INFLAMMATORY diseases, what we saw instead was…
- People with “pre-collision pain“.
- People with “medically unexplained physical symptoms” (MUPS — many specialists say MUPS is the single biggest medical problem facing modern America).
- People with a “low threshold for contacting health care services” (people who live at the doctor).
As far as treatment of neck pain and headache, whether caused by whiplash or not, numerous studies showed exercise and stretching programs to generally be at least somewhat effective, but not as much so as you would think. The same thing was true of massage, with a study from eight authors found in this month’s issue of the Journal of Alternative and Complementary Medicine (Massage for Pain: An Evidence Map). After looking at 49 systemic reviews on the subject, the authors determined that “High quality reviews concluded that there was low strength of evidence of potential benefits of massage for labor, shoulder, neck, low back, cancer, arthritis, postoperative, delayed onset muscle soreness, and musculoskeletal pain.” Does this tell us that massage doesn’t work? Because the vast majority of those utilizing massage pay out-of-pocket for these services — something they would not continue if it didn’t work — I would argue that there is something inherently wrong with the study; something I’ve been hollering about in my EVIDENCE-BASED MEDICINE COLUMN for a decade. BTW, the exact same thing has been said of both chiropractic and physical therapy, which I’ll show you momentarily.
Speaking of the combination of adjustments and therapy, a study from last month’s Journal of Physical Therapy Science (The Effect of Massage Technique plus Thoracic Manipulation versus Thoracic Manipulation on Pain and Neural Tension in Mechanical Neck Pain: A Randomized Controlled Trial) showed that even though “The exact pathology of mechanical neck pain has not yet been fully elucidated but it has been suggested that it relates to various pain-sensitive structures, including the muscles, ligaments, zygapophyseal joints, uncovertebral joints, intervertebral discs, and neural tissue, a significant reduction in resting neck pain was seen in the thoracic manipulation plus massage group, compared to that achieved using thoracic manipulation alone. The use of thoracic manipulation and massage is recommended to reduce resting neck pain and increase pain-free neural tissue extensibility.” While it’s certainly not massage, I could say the same thing about the TISSUE REMODELING we do in-house.
A French study from this month’s issue of Frontiers in Psychiatry (Bright Light as a Personalized Precision Treatment of Mood Disorders) cemented some non-mainstream facts that I wrote about in my recent articles, OBESITY, LIGHT, LEPTIN RESISTANCE, AND THE BRILLIANT MADNESS OF JACK KRUSE and THE IMPORTANCE OF SUNSHINE BEYOND VITAMIN D. After mentioning headaches as a potential “transient, mild and rare” side effect, the authors revealed of bright light therapy…..
“Bright light therapy (BLT) has physiological effects by resynchronizing the biological clock (circadian system), enhancing alertness, increasing sleep pressure (homeostatasis), and acting on serotonin and other pathways. A growing body of evidence has been generated over the last decade about BLT evolving as an effective depression treatment not only to be used in seasonal affective disorder (SAD), but also in non-seasonal depression, with efficiency comparable to fluoxetine [Prozac], and possibly more robust in patients with bipolar disorders (BD). The antidepressant action of BLT is fast (within 1-week) and safe, with the need in BD to protect against manic switch with mood stabilizers.”
I brought this up because the latest issue of Current Treatment Options in Neurology (Antidepressants for Preventive Treatment of Migraine) talked about using, just as the title stated, antidepressants, as a “preventative” for MIGRAINE HEADACHES. The authors prefaced this by revealing that (whisper whisper), “SSRIs including fluoxetine [Prozac] are not effective for most patients...” If not using ultra-common SSRI’s, what are they using? SNRI’s like amitriptyline / nortriptyline (Elavil / Pamelor and Aventyl) — drugs with common nasty side effects). The authors prefaced their giddiness by letting readers know that “The side effect burden of antidepressants can be substantial. Patients should be particularly counseled about the possibility of a withdrawal effect from SNRIs.” Remember that we’ve seen just how ineffective these drugs really are for solving depression (HERE) as well as their SEXUAL SIDE-EFFECTS. You need to be aware of this (HERE) because “Antidepressants are commonly used as migraine preventives.”
But what happens when the medications, as is often the case, don’t work? Worse yet, what if your medications were actually causing the very problem you were using them to solve (a common problem with depression — HERE)? Although side-effects to all drugs are orders of magnitude greater than typically reported (HERE), when it comes to headaches, this particular phenomenon is so common that it has its own special name —- medication overuse headaches or simply “rebound“. How common are rebound headaches? Just days ago, Neurological Science (Epidemiology and Management of Medication-Overuse Headache in the General Population) answered that question by revealing that “Medication-overuse headache is a worldwide challenge as it affects 1-2% of the general population.” What do these numbers tell us? 160 million people worldwide — a number equivalent to about half the US population — are dealing with rebound headaches. It also means that in my little town of 3,000 people, there are probably 60 people stuck in this vicious cycle.
A title of a study from this month’s issue of Nature Reviews Neurology (Complete Withdrawal More Feasible and Effective than Restriction in Medication-Overuse Headache) said it all via it’s title — describing very same thing I promote for breaking sugar addictions (COLD TURKEY). A study from this month’s issue of Frontiers in Neurology (Negative Short-Term Outcome of Detoxification Therapy in Chronic Migraine With Medication Overuse Headache: Role for Early Life Traumatic Experiences and Recent Stressful Events) tried to predict which people would succeed with a headache medicine “DETOX PROGRAM” and which would fail.
“Among the most popular and disabling neurological disorders, migraine is at the top of the list. In most sufferers, attacks recur episodically, even if in a small—but significant—portion of migraineurs the disease evolves into a chronic pattern, that is, chronic migraine (CM). Transition from episodic to CM often occurs in association with a progressive increase in the intake of acute medications, so that the large majority of patients with CM also fulfill criteria for Medication Overuse Headache (MOH). Data suggest that early life traumas and stressful events have a negative impact on the outcome of the detoxification program in subjects overusing acute medication for headache. The history of emotional childhood traumas is associated to the failure to cease overuse, whereas recent very serious life events are associated to the persistence of headache chronicity.”
Last month’s issue of Frontiers in Neurology (Features of Primary Chronic Headache in Children and Adolescents) stated, “Chronic migraine (CM), chronic tension-type headache (CTTH) and new daily persistent headache (NDPH) are classified as CPH. Chronic primary headaches (CPH) are a disabling disorder for children, adolescents, and adults, with a reported prevalence of 2% in adults and .78% in adolescents, while the prevalence rises up to 1.75% when including medication overuse headaches.” Another study, this one from the February copy of Cephalgia (The Prevalence of Headache in German Pupils…) provided more detail of just how common and severe headaches are in the pediatric (under 18) population. So; what about treating children with headaches similar to adults with headaches as far as manual therapy is concerned?
This month’s issue of BMC Complementary and Alternative Medicine asked the same question of manual therapy for children that they did pertaining children and massage we looked at earlier. After looking at 50 studies on using manual treatment to affect a wide variety of problems, including back pain, neck pain, and headaches, the authors concluded that “Moderate-positive overall assessment was found for 3 conditions: low back pain, pulled elbow, and premature infants. Unfavorable outcomes were found for 2 conditions: scoliosis and torticollis. All other condition’s overall assessments were either inconclusive favorable or unclear. Adverse events were uncommonly reported.” In other words, sometimes it works and sometimes it doesn’t. The super cool thing, however, is the extremely low side effect profile — an especially big deal after what we’ve read about the freaky side effect profiles of some of the most commonly used headache and neck pain medications.
“Classical Conditioning” was a phrase coined by Russian physiologist, Ivan Pavlov, back in the late 1800’s. In his famous dog experiments he associated feeding time for his dogs with ringing a bell, discovering that even in the absence of food, tinkling his bell would cause the hounds to salivate profusely. Simply Psychology said this of the phenomenon as a form of treatment. “For classical conditioning to be effective, the conditioned stimulus should occur before the unconditioned stimulus, rather than after it, or during the same time. Thus, the conditioned stimulus acts as a type of signal or cue for the unconditioned stimulus.” Why is “before” such a big deal when compared to “during or after” — especially when it comes to headaches? This month’s issue of Current Headache Reports (Pavlov’s Pain: The Effect of Classical Conditioning on Pain Perception and its Clinical Implications) explains….
“It has been known for decades that classical conditioning influences pain perception. We first review studies regarding how classical conditioning alters pain perception with an emphasis on two phenomena where conditioning increases pain sensitivity (i.e., conditioned hyperalgesia) or decreases it (i.e., conditioned hypoalgesia). Specifically, we critically examine empirical studies about conditioned hyperalgesia and conditioned hypoalgesia, explore reasons why conditioning leads to these two seemingly opposite phenomena, and discuss the neural mechanisms behind them. We then highlight how conditioning contributes to the development and maintenance of chronic pain, and present neuroscientific evidence for maladaptive aversive conditioning in chronic pain patients. Moreover, we propose a framework for understanding how to exploit conditioning to optimize pain treatment, including minimizing conditioned hyperalgesia, maximizing conditioned hypoalgesia, and eliminating excessive fear and overgeneralization in chronic pain.”
I was not going to pay $40 to look at the whole study, but suffice it to say that “conditioning” may be driving your headaches and pain as opposed to being used as a tool against. What are some of the things that we know can adversely condition people’s pain levels beyond stress and inflammatory diets? Our national addiction to media (social media, porn, cell phones, computers, TV, etc, etc) has been in the news lately and is proving to be a HUGE PROBLEM in this arena, most particularly for children. It’s why I talk on my site so much about getting your mind right. After all, one of King Solomon’s proverbs (23:7) tells us that “as a man thinketh in his heart, so is he.”
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