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1.  Chiropractic spinal manipulative treatment of migraine headache of 40-year duration using Gonstead method: a case study 
Journal of Chiropractic Medicine  2011;10(3):189-193.
Objective
The purpose of this article is to present a case study of chiropractic spinal manipulative treatment (CSMT) using the Gonstead method for a patient with migraines.
Clinical Features
The patient was a 52-year-old married woman with a long-term history of chronic migraines, which included nausea, vomiting, and photophobia. The patient had endometriosis, but did not relate the migraines to her menstrual cycles. She also reported not using medication for her migraines due to previous drug-related issues. The average frequency of episodes before treatment was 1 per month, and her migraines often included an aura. The pain was moderate, was located on the right side, was pulsating, and lasted for approximately 15 hours. The numeric pain scale for an average episode was 8 out of a possible 10. The aura involved nausea, photophobia, and visual disturbances including black dots in the visual field lasting for approximately 10 minutes.
Intervention and Outcome
The patient reported all episodes being eliminated following CSMT. At 6-month follow-up, the patient had not had a single migraine episode in this period. The patient was certain that there had been no other lifestyle changes that could have contributed to her improvement.
Conclusion
This case adds to previous research suggesting that some migraine patients may respond favorably to CSMT. The case also provides information on the Gonstead method. A case study does not represent significant scientific evidence in context with other studies conducted; this study suggests that a trial of CSMT using the Gonstead methods could be considered for chronic, nonresponsive migraines.
doi:10.1016/j.jcm.2011.02.002
PMCID: PMC3259914  PMID: 22014909
Migraine disorders; Chiropractic; Manipulation, spinal
2.  TREATMENT OF ACUTE ATOPIC ECZEMA BY CHIROPRACTIC CARE 
Objective: To investigate a patient with atopic eczema and assess how they responded to chiropractic care.
Method: The study was run over a 7 week period with chiropractic treatments (diversified technique) on a once weekly schedule.
Outcome Measures: To measure the effect of treatment, a rating system was developed and the intensity of a range of symptoms was recorded (through a questionnaire) on a twice weekly basis.
Results: The results attained showed there was a marked improvement in the eczema symptoms following the chiropractic care. The patient reported an improvement in eczematous symptoms of excoriation, pruritus, oedema and general psychological ease. These findings were also confirmed by photographic evidence which documented the change in the lesions.
Discussion: The case is presented to assist practitioners making a more informed decision on the treatment of choice for eczema. The outcome of this case is also discussed in relation to recent research that concludes that chiropractic spinal manipulative therapy has a role in the treatment for some people with non-neuromusculoskeletal conditions.
Conclusion: It appears that chiropractic care may have assisted this patient with eczema. However, more research is required to investigate the role that chiropractic has in the treatment of patients with eczema, and the potential mechanisms that could explain the improvement.
PMCID: PMC2051093  PMID: 17987197
Eczema; dermatitis; atopic; chiropractic; case report
3.  A case of chronic migraine remission after chiropractic care 
Abstract
Objective
To present a case study of migraine sufferer who had a dramatic improvement after chiropractic spinal manipulative therapy (CSMT).
Clinical features
The case presented is a 72-year–old woman with a 60-year history of migraine headaches, which included nausea, vomiting, photophobia, and phonophobia.
Intervention and outcome
The average frequency of migraine episodes before treatment was 1 to 2 per week, including nausea, vomiting, photophobia, and phonophobia; and the average duration of each episode was 1 to 3 days. The patient was treated with CSMT. She reported all episodes being eliminated after CSMT. The patient was certain there had been no other lifestyle changes that could have contributed to her improvement. She also noted that the use of her medication was reduced by 100%. A 7-year follow-up revealed that the person had still not had a single migraine episode in this period.
Conclusion
This case highlights that a subgroup of migraine patients may respond favorably to CSMT. While a case study does not represent significant scientific evidence, in context with other studies conducted, this study suggests that a trial of CSMT should be considered for chronic, nonresponsive migraine headache, especially if migraine patients are nonresponsive to pharmaceuticals or prefer to use other treatment methods.
doi:10.1016/j.jcme.2008.02.001
PMCID: PMC2682939  PMID: 19674722
Migraine; Chiropractic; Spinal manipulative therapy
4.  THE EFFICACY OF CHIROPRACTIC SPINAL MANIPULATIVE THERAPY (SMT) IN THE TREATMENT OF MIGRAINE 
Objective: To test the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine, using an uncontrolled clinical trial.
Design: A clinical trial of six months duration. The trial consisted of 3 stages: two months of pre-treatment, two months of treatment, and two months post treatment. Comparison was made to initial baseline episodes of migraine preceding commencement of SMT.
Setting: Chiropractic Research Centre of Macquarie University.
Participants: Thirty two volunteers, between the ages of 23 to 60 were recruited through media advertising. The diagnosis of migraine based on a detailed questionnaire, regarding self reported symptoms or signs, with minimum of one migraine with aura per month.
Interventions: Two months of SMT provided by an experienced chiropractor at a university clinic.
Main Outcome Measures: Participants completed diaries during the entire trial noting the frequency, intensity, duration, disability, associated symptoms and use of medication for each migraine episode. In addition, clinic records were compared to their diary entries of migraine episodes.
Results: A total of fifty nine participants responded to the advertising, with twenty five being excluded or deciding not to continue in the trial. Two participants (5.9%) withdrew during the trial, one due to alteration in work situation and one following soreness after SMT. The Chiropractic SMT group showed statistically significant improvement (p < 0.05) in migraine frequency and duration, when compared to initial baseline levels. Only one participant (3.1%) reported that the migraine episodes were worse after the two months of SMT, and this was not sustained at the two month post treatment follow up period.
Conclusion: The results of this study suggest that Chiropractic SMT is an effective treatment for migraine with aura. However, due to the cyclical nature of migraine with aura, and the finding that episodes usually reduce following any intervention, further research is required. A prospective randomised controlled trial utilising detuned EPT (interferential), a sham manipulation group and an SMT group is nearing conclusion. It is anticipated this trial will provide further information of the efficacy of Chiropractic SMT in the treatment of migraine with aura.
PMCID: PMC2050630  PMID: 17987148
Migraine; chiropractic; spinal manipulation; clinical trial
5.  A TWELVE MONTH CLINICAL TRIAL OF CHIROPRACTIC SPINAL MANIPULATIVE THERAPY FOR MIGRAINE 
Objective: To assess the efficacy of Chiropractic spinal manipulative therapy (SMT) in the treatment of migraine.
Design: A prospective clinical trial of twelve months duration. The trial consisted of 3 stages: two month pre-treatment, two month treatment, and two months post treatment. Comparison of outcomes to the initial baseline factors was made and also 6 months after the cessation of the study.
Setting: Chiropractic Research Centre of Macquarie University.
Participants: Thirty two volunteers, between the ages of 20 to 65 were recruited through media advertising. The diagnosis of migraine was based on a self reported detailed questionnaire, with minimum of one migraine per month.
Interventions: Two months of chiropractic SMT at vertebral fixations determined by the practitioner, through orthopedic and chiropractic testing.
Main Outcome Measures: Participants completed diaries during the entire trial noting the frequency, intensity (visual analogue score), duration, disability, associated symptoms and use of medication for each migraine episode.
Results: The initial 32 participants showed statistically significant (p < 0.05) improvement in migraine frequency, VAS, disability, and medication use, when compared to initial baseline levels. A further assessment of outcomes after a six month follow up (based on 24 participants), continued to show statistically significant improvement in migraine frequency (p < 0.005), VAS (p < 0.01), disability (p < 0.05), and medication use (p < 0.01), when compared to initial baseline levels.
In addition, information was collected regarding any changes in neck pain following chiropractic SMT. The results indicated that 14 participants (58%) reported no increase in neck pain as a consequence of the two months of SMT. Five participants (21%) reported a slight increase, three participants (13%) reported mild pain, and two participants (8%) reported moderate pain.
Conclusion: The results of this study support the hypothesis that Chiropractic SMT is an effective treatment for migraine, in some people. However, a larger controlled study is required.
PMCID: PMC2051091  PMID: 17987194
Migraine; chiropractic; spinal manipulation; prospective trial; neck
6.  Chiropractic management of essential tremor and migraine: a case report 
Journal of Chiropractic Medicine  2012;11(2):121-126.
Objective
The purpose of this case report is to describe the chiropractic management of a 39-year-old woman with essential tremors and migraine headaches.
Clinical Features
A 39-year-old woman presented with essential tremors and migraine headaches, which occurred 2 to 3 times per week. The essential tremor was diagnosed in 2000, and migraine headaches with aura were diagnosed when she was 10. Both diagnoses were made by her general medical practitioner. Previous treatments for migraine included propranolol, isometheptene, dichloralphenazone, acetaminophen, sumatriptan, and over-the-counter pain relievers.
Intervention and Outcome
The patient received high-velocity, low-amplitude chiropractic spinal manipulation to her upper cervical spine using the Blair Upper Cervical chiropractic technique protocol. There was improvement in her tremors and migraine headaches following her initial chiropractic treatment, with a sustained improvement after 4 months of care.
Conclusion
This case study demonstrated improvement in a woman with essential tremors and migraine headaches. This suggests the need for more research to examine how upper cervical specific chiropractic care may help mitigate tremors and migraine headaches.
doi:10.1016/j.jcm.2011.10.006
PMCID: PMC3368974  PMID: 23204956
Tremor; Migraine; Spinal adjustment, Chiropractic
7.  Chronic migraine and chiropractic rehabilitation: A case report 
Abstract
Objective
To describe the use of chiropractic rehabilitation, functional assessment methods, and outcome measures in treatment of a single case of chronic recurrent migraine headache.
Clinical Features
A 22-year-old woman had migraine, recurrent duration 2 years. She had no history of trauma and the symptoms persisted despite multiple medical interventions. She had head pain, primarily left frontal retro-orbital, accompanied by nausea and visual aura of “spots” when severe.
Intervention and Outcome
This subject was managed with rehabilitative exercises in combination with chiropractic manipulation. Outcome measures, including the Headache Disability Index, are described.
Conclusion
The chronic recurrent migraine resolved over a 12-week period with use of chiropractic rehabilitation in this patient. More research is necessary to determine whether this approach is consistently reproducible and how it compares with spinal manipulation alone and other forms of treatment. Further investigation of combining rehabilitation with chiropractic manipulation for some migraine patients should be considered.
doi:10.1016/S0899-3467(07)60043-3
PMCID: PMC2646959  PMID: 19674596
Migraine; Headache; Rehabilitation; Chiropractic Manipulation; Cervical Spine; Headache Disability Index
8.  Chiropractic treatment of chronic episodic tension type headache in male subjects: a case series analysis 
Objective:
To assess effectiveness of chiropractic management, primarily cervical adjustment, in the treatment of chronic episodic muscle tension type headache in male patients.
Design:
Prospective case series analysis with pre-treatment baseline. Sixteen sessions of chiropractic care were provided to each patient over an eight week period. Data was also collected during a two week no-treatment baseline period prior to initiation of care. The subjects took no pain medication or had any other treatment for the entire duration of the study.
Setting:
A large chiropractic teaching clinic: Palmer College of Chiropractic-West Outpatient Clinic.
Participants:
Eleven male outpatients between the ages of 18-40 years old with a self-reported history of chronic headache at least six months duration and an average of at least weekly headache episodes were recruited. There was one dropout due to moving out of the area before study completion.
Interventions:
Primary: high velocity, short lever cervical adjustment (Diversified technique). Secondary: myofascial trigger point therapy using ischemic compression to the cervical and thoracic musculature; thoracic and lumbar adjustment if indicated (Diversified technique); moist hot packs to cervical and thoracic spine regions.
Outcome measures:
Pain diary measuring frequency, duration, and intensity of head/neck pain; and McGill Pain Questionnaires.
Results:
Mean pre-treatment to post-treatment headache frequency changed from 6.4 episodes per two week period to 3.1, a statistically significant change (p < 0.01). Mean pre-treatment to post-treatment headache duration changed from 6.7 hours per episode to 3.88 hours which was statistically significant (p < 0.05). Mean anchored pain scale intensity ratings changed from 5.05 to 3.37 but this was just beyond statistical significance (p = 0.059). There were no significant changes in any McGill pain questionnaire scores pre and post treatment.
Conclusions:
In this case series analysis of episodic tension headache in 10 male patients, typical chiropractic interventions of adjusting, muscle work and moist heat significantly reduced self-reported frequency and duration of headache episodes following 12 treatments over an 8 week period. No significant effect was observed in self-reported pain intensity, however a trend of reduction may indicate that a larger sample size might show increased significance. The McGill Pain Questionnaire did not appear to provide any useful information in assessing change in this sample. This may lend support to the result that little or no effect is obtained in reducing intensity of individual headache episodes with this treatment approach. These findings are limited by the small sample size and suggest a need for a larger study population as well as specific treatment comparison studies. These results may further be limited in that all subjects were male.
PMCID: PMC2485120
tension-type headache; muscle contraction headache; vertebrogenic headache; chiropractic; spinal manipulation
9.  Anatomical Alterations of the Visual Motion Processing Network in Migraine with and without Aura 
PLoS Medicine  2006;3(10):e402.
Background
Patients suffering from migraine with aura (MWA) and migraine without aura (MWoA) show abnormalities in visual motion perception during and between attacks. Whether this represents the consequences of structural changes in motion-processing networks in migraineurs is unknown. Moreover, the diagnosis of migraine relies on patient's history, and finding differences in the brain of migraineurs might help to contribute to basic research aimed at better understanding the pathophysiology of migraine.
Methods and Findings
To investigate a common potential anatomical basis for these disturbances, we used high-resolution cortical thickness measurement and diffusion tensor imaging (DTI) to examine the motion-processing network in 24 migraine patients (12 with MWA and 12 MWoA) and 15 age-matched healthy controls (HCs). We found increased cortical thickness of motion-processing visual areas MT+ and V3A in migraineurs compared to HCs. Cortical thickness increases were accompanied by abnormalities of the subjacent white matter. In addition, DTI revealed that migraineurs have alterations in superior colliculus and the lateral geniculate nucleus, which are also involved in visual processing.
Conclusions
A structural abnormality in the network of motion-processing areas could account for, or be the result of, the cortical hyperexcitability observed in migraineurs. The finding in patients with both MWA and MWoA of thickness abnormalities in area V3A, previously described as a source in spreading changes involved in visual aura, raises the question as to whether a “silent” cortical spreading depression develops as well in MWoA. In addition, these experimental data may provide clinicians and researchers with a noninvasively acquirable migraine biomarker.
A structural abnormality in the network of motion-processing areas could account for, or be the result of, the cortical hyperexcitability seen in people who have migraine.
Editors' Summary
Background.
Migraine is a disabling brain disorder that affects more than one in ten people during their lifetimes. It is characterized by severe, recurrent headaches, often accompanied by nausea, vomiting, and light sensitivity. In some migraineurs (people who have migraines), the headaches are preceded by neurological disturbances known as “aura.” These usually affect vision, causing illusions of flashing lights, zig-zag lines, or blind spots. There are many triggers for migraine attacks—including some foods, stress, and bright lights—and every migraineur has to learn what triggers his or her attacks. There is no cure for migraine, although over-the-counter painkillers can ease the symptoms and doctors can prescribe stronger remedies or drugs to reduce the frequency of attacks. Exactly what causes migraine is unclear but scientists think that, for some reason, the brains of migraineurs are hyperexcitable. That is, some nerve cells in their brains overreact when they receive electrical messages from the body. This triggers a local disturbance of brain function called “cortical spreading depression,” which, in turn, causes aura, headache, and the other symptoms of migraine.
Why Was This Study Done?
Researchers need to know more about what causes migraine to find better treatments. One clue comes from the observation that motion perception is abnormal in migraineurs, even between attacks—they can be very sensitive to visually induced motion sickness, for example. Another clue is that aura are usually visual. So could brain regions that process visual information be abnormal in people who have migraines? In this study, the researchers investigated the structure of the motion processing parts of the brain in people who have migraine with aura, in people who have migraine without aura, and in unaffected individuals to see whether there were any differences that might help them understand migraine.
What Did the Researchers Do and Find?
The researchers used two forms of magnetic resonance imaging—a noninvasive way to produce pictures of internal organs—to examine the brains of migraineurs (when they weren't having a migraine) and healthy controls. They concentrated on two brain regions involved in motion processing known as the MT+ and V3A areas and first measured the cortical thickness of these areas—the cortex is the wrinkled layer of gray matter on the outside of the brain that processes information sent from the body. They found that the cortical thickness was increased in both of these areas in migraineurs when compared to healthy controls. There was no difference in cortical thickness between migraineurs who had aura and those who did not, but the area of cortical thickening in V3A corresponded to the source of cortical spreading depression previously identified in a person who had migraine with aura. The researchers also found differences between the white matter (the part of the brain that transfers information between different regions of the gray matter) immediately below the V3A and MT+ areas in the migraineurs and the controls but again not between the two groups of migraineurs.
What Do These Findings Mean?
This study provides new information about migraine. First, it identifies structural changes in the brains of people who have migraines. Until now, it has been thought that abnormal brain function causes migraine but that migraineurs have a normal brain structure. The observed structural differences might either account for or be caused by the hyperexcitability that triggers migraines. Because migraine runs in families, examining the brains of children of migraineurs as they grow up might indicate which of these options is correct, although it is possible that abnormalities in brain areas not examined here actually trigger migraines. Second, the study addresses a controversial question about migraine: Is migraine with aura the same as migraine without aura? The similar brain changes in both types of migraine suggest that they are one disorder. Third, the abnormalities in areas MT+ and V3A could help to explain why migraineurs have problems with visual processing even in between attacks. Finally, this study suggests that it might be possible to develop a noninvasive test to help doctors diagnose migraine.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0030402.
The MedlinePlus encyclopedia has several pages on migraine
The US National Institute of Neurological Disorders and Stroke offers patient information on migraine and other headaches
The NHS Direct Online contains patient information on migraine from the UK National Health Service
MAGNUM provides information from The US National Migraine Association
The Migraine Trust is a UK charity that supports research and provides support for patients
The Migraine Aura Foundation is a site about aura that includes a section on art and aura
doi:10.1371/journal.pmed.0030402
PMCID: PMC1609120  PMID: 17048979
10.  A CASE STUDY OF CHRONIC HEADACHES 
The following paper is a case study of a patient with a history of chronic headaches (originally diagnosed as migraine without aura) who was being treaded at the Macquarie University Chiropractic Outpatients Clinic for cervical spine dysfunction. The treatments successfully reduced the upper neck and thoracic pain that the patient was experiencing and for which they had initially presented at the clinic. During the treatments, the patient also showed a significant subjective reduction in prevalence and intensity of headaches over a four month period. Analysis of the outcome is complicated by the fact that it is not clear whether the patient’s headaches were initially misdiagnosed as common migraine when in fact, they were cervicogenic. There may be some overlap between the two conditions, and a possible causative relationship between cervical spine dysfunction and common migraine. Furthermore, this case study discusses the validity of chiropractic treatment of organic disorders such as chronic headache or migraine.
PMCID: PMC2050613  PMID: 17987139
Chiropractic; headache.
11.  Chiropractic Management of a Patient with Migraine Headache 
Abstract
Objective
To describe the use of chiropractic care for a patient with migraine headache.
Clinical Features
A patient suffered from migraine headaches after an automobile accident. Neck disability scores, visual analog score, and algometry scores were used to track patient progress.
Intervention and Outcome
The patient's range of motion, flexibility, and strength improved following a regimen of spinal manipulation and active and passive therapeutic care. After 12 weeks of treatment, the duration, frequency, and intensity of her migraines decreased.
Conclusion
This case offers an example of the potential effects of chiropractic and rehabilitative treatment for migraine headache sufferers.
doi:10.1016/S0899-3467(07)60109-8
PMCID: PMC2647030  PMID: 19674643
Migraine; Manipulation, Chiropractic; Musculoskeletal Manipulations; Exercise Movement Techniques
12.  Can weight loss improve migraine headaches in obese women? Rationale and design of the WHAM randomized controlled trial 
Contemporary clinical trials  2013;35(1):133-144.
Background
Research demonstrates a link between migraine and obesity. Obesity increases the risk of frequent migraines and is associated with migraine prevalence among reproductive-aged women. These findings are substantiated by several plausible mechanisms and emerging evidence of migraine improvements after surgical and non-surgical weight loss. However, no previous study has examined the effect of weight loss on migraine within a treatment-controlled framework. The WHAM trial is a RCT to test the efficacy of behavioral weight loss as a treatment for migraine.
Study design
Overweight/obese women (n=140; BMI=25.0–49.9 kg/m2) who meet international diagnostic criteria for migraine and record ≥3 migraines and 4–20 migraine days using a smartphone-based headache diary during a 4-week baseline period, will be randomly assigned to 4 months of either group-based behavioral weight loss (intervention) or migraine education (control). Intervention participants will be taught strategies to increase physical activity and consume fewer calories in order to lose weight. Control participants will receive general education on migraine symptoms/triggers and various treatment approaches. Both groups will use smartphones to record their headaches for 4 weeks at baseline, after the 16-week treatment period, and at the end of a 16-week follow-up period. Changes in weight and other potential physiological (inflammation), psychological (depression), and behavioral (diet and physical activity) mediators of the intervention effect will also be assessed.
Conclusion
The WHAM trial will evaluate the efficacy of a standardized behavioral weight loss intervention for reducing migraine frequency, and the extent to which weight loss and other potential mediators account for intervention effects.
doi:10.1016/j.cct.2013.03.004
PMCID: PMC3640582  PMID: 23524340
migraine; headache; obesity; weight loss; randomized controlled trial
13.  Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial 
Trials  2013;14:18.
Background
Low back pain is a prevalent and debilitating condition that affects the health and quality of life of older adults. Older people often consult primary care physicians about back pain, with many also receiving concurrent care from complementary and alternative medicine providers, most commonly doctors of chiropractic. However, a collaborative model of treatment coordination between these two provider groups has yet to be tested. The primary aim of the Collaborative Care for Older Adults Clinical Trial is to develop and evaluate the clinical effectiveness and feasibility of a patient-centered, collaborative care model with family medicine physicians and doctors of chiropractic for the treatment of low back pain in older adults.
Methods/design
This pragmatic, pilot randomized controlled trial will enroll 120 participants, age 65 years or older with subacute or chronic low back pain lasting at least one month, from a community-based sample in the Quad-Cities, Iowa/Illinois, USA. Eligible participants are allocated in a 1:1:1 ratio to receive 12 weeks of medical care, concurrent medical and chiropractic care, or collaborative medical and chiropractic care. Primary outcomes are self-rated back pain and disability. Secondary outcomes include general and functional health status, symptom bothersomeness, expectations for treatment effectiveness and improvement, fear avoidance behaviors, depression, anxiety, satisfaction, medication use and health care utilization. Treatment safety and adverse events also are monitored. Participant-rated outcome measures are collected via self-reported questionnaires and computer-assisted telephone interviews at baseline, and at 4, 8, 12, 24, 36 and 52 weeks post-randomization. Provider-rated expectations for treatment effectiveness and participant improvement also are evaluated. Process outcomes are assessed through qualitative interviews with study participants and research clinicians, chart audits of progress notes and content analysis of clinical trial notes.
Discussion
This pragmatic, pilot randomized controlled trial uses a mixed method approach to evaluate the clinical effectiveness, feasibility, and participant and provider perceptions of collaborative care between medical doctors and doctors of chiropractic in the treatment of older adults with low back pain.
Trial registration
This trial registered in ClinicalTrials.gov on 04 March 2011 with the ID number of NCT01312233.
doi:10.1186/1745-6215-14-18
PMCID: PMC3557195  PMID: 23324133
Aged; Chiropractic; Education; Professional; Electronic health records; Family practice; Integrative medicine; Interprofessional relations; Low back pain; Therapy
14.  Symptomatic improvement in function and disease activity in a patient with ankylosing spondylitis utilizing a course of chiropractic therapy: a prospective case study 
Background
There is limited outcome measure support for chiropractic manipulative therapy in the management of ankylosing spondylitis. An improvement in specific indices for both function and disease activity during chiropractic therapy for ankylosing spondylitis has not previously been reported.
Objective
To measure changes in function and disease activity in a patient with ankylosing spondylitis during a course of chiropractic therapy. The clinical management of ankylosing spondylitis, including chiropractic manipulative therapy and the implications of this case study are discussed.
Clinical Features
A 34-year-old male with a 10 year diagnosis of ankylosing spondylitis sought chiropractic treatment for spinal pain and stiffness. His advanced radiographic signs included an increased atlantodental interspace and cervical vertebral ankylosis.
Intervention and outcome
The Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), finger-tip-to-floor distance and chest expansion were assessed during an 18 week course of chiropractic spinal manipulation and mobilization therapy. There was a 90% improvement in the disease activity index and an 85% improvement in the functional index from the pre-treatment baseline, as measured by the BASDAI and BASFI respectively. Spinal flexibility and chest expansion also improved.
Conclusion
To the authors knowledge this is the first study to incorporate ankylosing spondylitis specific indices, for both disease activity and function, to objectively support the use of chiropractic manipulative therapy in the management of ankylosing spondylitis. More intensive research is suggested.
PMCID: PMC1840019  PMID: 17549197
ankylosing spondylitis; chiropractic; manipulation; Bath Ankylosing Spondylitis Functional Index (BASFI); Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
15.  Increase in self-reported migraine prevalence in the Danish adult population: a prospective longitudinal population-based study 
BMJ Open  2012;2(4):e000962.
Objective
It is uncertain whether migraine prevalence has increased in modern society. The aim of this study was to assess any change in migraine prevalence over an 8-year period among the adult population in Denmark.
Design
Prospective longitudinal population-based study.
Setting
30 000 twin individuals were invited to participate in two cross-sectional questionnaire surveys containing validated questions to diagnose migraine in 1994 and 2002. The twins are representative of the Danish population with regard to migraine and other somatic diseases.
Participants
The 1994 cohort comprised 28 571 twin individuals aged 12–41 years and the 2002 cohort 31 865 twin individuals aged 20–71 years.
Outcome measures
Sex-, age- and subtype-specific incidence and lifetime prevalence as well as 1-year prevalence of migraine.
Results
1-year prevalence in 2002 was 12.3% for migraine, 4.1% for migraine with aura and 8.2% for migraine without aura. Lifetime prevalence of migraine was 16.1% in 1994 (aged 12–41 years) and 25.2% in 2002 (aged 20–71 years). Lifetime prevalence of migraine for age 20–41 was increased from 1994 to 2002 (18.5% vs 24.5%) by 32.2% (95% CI 27.0% to 37.3%; p<0.001). The difference was primarily seen in the population older than 32 years. The increase was especially evident in migraine with aura (5.6% vs 9.4%, p<0.001) but also a significant increase in migraine without aura was found (13.0% vs 15.1%, p<0.001). Eight-year period incidence rate of migraine was 0.141 corresponding to an average annual incidence rate of 17.6 per 1000 person-years.
Conclusions
Lifetime prevalence of migraine in Denmark increased substantially from 1994 to 2002. Part of the increase may be due to increased medical consultation resulting in increased rate of physician diagnosis or awareness due to previously participation in the 1994 survey. It is pertinent to study the environmental causes of the increase and to implement preventive measures.
Article summary
Article focus
Has migraine prevalence increased in modern society?
Key messages
Self-reported migraine prevalence increased substantially in the Danish young adult population.
Sex- and age-specific prevalence and incidence of migraine and its subtypes were estimated in a large population-based sample.
Strengths and limitations of this study
Large sample size made it possible to differentiate between migraine with aura and migraine without aura using the validated diagnostic questions and furthermore subdivide between men and women and to distinguish between age groups.
The validation of the two questions used to identify migraine cases showed that self-reported migraine was only correct in 74.5% of cases, and furthermore, approximately 23.8% of the migraine patients were not identified. Thus, our estimates would tend to be conservative.
doi:10.1136/bmjopen-2012-000962
PMCID: PMC3391377  PMID: 22761284
16.  Combination of acupuncture and spinal manipulative therapy: management of a 32-year-old patient with chronic tension-type headache and migraine 
Journal of Chiropractic Medicine  2012;11(3):192-201.
Objective
The purpose of this case study is to describe the treatment using acupuncture and spinal manipulation for a patient with a chronic tension-type headache and episodic migraines.
Clinical Features
A 32-year-old woman presented with headaches of 5 months' duration. She had a history of episodic migraine that began in her teens and had been controlled with medication. She had stopped taking the prescription medications because of gastrointestinal symptoms. A neurologist diagnosed her with mixed headaches, some migrainous and some tension type. Her headaches were chronic, were daily, and fit the International Classification of Headache Disorders criteria of a chronic tension-type headache superimposed with migraine.
Intervention and Outcome
After 5 treatments over a 2-week period (the first using acupuncture only, the next 3 using acupuncture and chiropractic spinal manipulative therapy), her headaches resolved. The patient had no recurrences of headaches in her 1-year follow-up.
Conclusion
The combination of acupuncture with chiropractic spinal manipulative therapy was a reasonable alternative in treating this patient's chronic tension-type headaches superimposed with migraine.
doi:10.1016/j.jcm.2012.02.003
PMCID: PMC3437348  PMID: 23449932
Acupuncture; Acupuncture analgesia; Headache disorders; Migraine headaches; Tension-type headaches
17.  Epigone migraine vertigo (EMV): a late migraine equivalent 
SUMMARY
Migrainous headache is determined by pathogenetic mechanisms that are also able to affect the peripheral and/or central vestibular system, so that vestibular symptoms may substitute and/or present with headache. We are convinced that there can be many different manifestations of vestibular disorders in migrainous patients, representing true different clinical entities due to their different characteristics and temporal relashionship with headache. Based on such considerations, we proposed a classification of vertigo and other vestibular disorders related to migraine, and believe that a particular variant of migraine-related vertigo should be introduced, namely "epigone migraine vertigo" (EMV): this could be a kind of late migraine equivalent, i.e. a kind of vertigo, migrainous in origin, starting late in the lifetime that substitutes, as an equivalent, pre-existing migraine headache. To clarify this particular clinical picture, we report three illustrative clinical cases among 28 patients collected during an observation period of 13 years (November 1991 - November 2004). For all patients, we collected complete personal clinical history. All patients underwent standard neurotological examination, looking for spontaneous-positional, gaze-evoked and caloric induced nystagmus, using an infrared video camera. We also performed a head shaking test (HST) and an head thrust test (HTT). Ocular motility was tested looking at saccades and smooth pursuit. To exclude other significant neurological pathologies, a brain magnetic resonance imaging (MRI) with gadolinium was performed. During the three months after the first visit, patients were invited to keep a diary noting frequency, intensity and duration of vertigo attacks. After that period, we suggested that they use prophylactic treatment with flunarizine (5 mg per day) and/or acetylsalicylic acid (100 mg per day), or propranolol (40 mg twice a day). All patients were again recommended to note in their diary the frequency and intensity of both headache and vertigo while taking prophylactic therapy. Control visits were programmed after 4, 12 and 24 months of therapy. All patients considerably improved symptoms with therapy: 19 subjects (68%) reported complete disappearance of vestibular symptoms, while 9 (32%) considered symptoms very improved. The subjective judgement was corroborated by data from patients diaries. We conclude that EMV is a clinical variant of typical migraine-related vertigo: a migraineassociated vertigo, headache spell independent, following a headache period, during the lifetime of a patient.
PMCID: PMC3970230  PMID: 24711685
Headache; Migraine vertigo; Epigone migraine vertigo; Motion sickness; Aura
18.  Migraine and psychiatric comorbidity: a review of clinical findings 
The Journal of Headache and Pain  2011;12(2):115-125.
Migraine is an extremely common disorder. The underlying mechanisms of this chronic illness interspersed with acute symptoms appear to be increasingly complex. An important aspect of migraine heterogeneity is comorbidity with other neurological diseases, cardiovascular disorders, and psychiatric illnesses. Depressive disorders are among the leading causes of disability worldwide according to WHO estimation. In this review, we have mainly considered the findings from general population studies and studies on clinical samples, in adults and children, focusing on the association between migraine and psychiatric disorders (axis I of the DSM), carried over after the first classification of IHS (1988). Though not easily comparable due to differences in methodology to reach diagnosis, general population studies generally indicate an increased risk of affective and anxiety disorders in patients with migraine, compared to non-migrainous subjects. There would also be a trend towards an association of migraine with bipolar disorder, but not with substance abuse/dependence. With respect to migraine subtypes, comorbidity mainly involves migraine with aura. Patients suffering from migraine, however, show a decreased risk of developing affective and anxiety disorders compared to patients with daily chronic headache. It would also appear that psychiatric disorders prevail in patients with chronic headache and substance use than in patients with simple migraine. The mechanisms underlying migraine psychiatric comorbidity are presently poorly understood, but this topic remains a priority for future research. Psychiatric comorbidity indeed affects migraine evolution, may lead to chronic substance use, and may change treatment strategies, eventually modifying the outcome of this important disorder.
doi:10.1007/s10194-010-0282-4
PMCID: PMC3072482  PMID: 21210177
Migraine; Comorbidity; Psychiatric disorders; Depression; Meta-analysis
19.  Migraine and psychiatric comorbidity: a review of clinical findings 
The Journal of Headache and Pain  2011;12(2):115-125.
Migraine is an extremely common disorder. The underlying mechanisms of this chronic illness interspersed with acute symptoms appear to be increasingly complex. An important aspect of migraine heterogeneity is comorbidity with other neurological diseases, cardiovascular disorders, and psychiatric illnesses. Depressive disorders are among the leading causes of disability worldwide according to WHO estimation. In this review, we have mainly considered the findings from general population studies and studies on clinical samples, in adults and children, focusing on the association between migraine and psychiatric disorders (axis I of the DSM), carried over after the first classification of IHS (1988). Though not easily comparable due to differences in methodology to reach diagnosis, general population studies generally indicate an increased risk of affective and anxiety disorders in patients with migraine, compared to non-migrainous subjects. There would also be a trend towards an association of migraine with bipolar disorder, but not with substance abuse/dependence. With respect to migraine subtypes, comorbidity mainly involves migraine with aura. Patients suffering from migraine, however, show a decreased risk of developing affective and anxiety disorders compared to patients with daily chronic headache. It would also appear that psychiatric disorders prevail in patients with chronic headache and substance use than in patients with simple migraine. The mechanisms underlying migraine psychiatric comorbidity are presently poorly understood, but this topic remains a priority for future research. Psychiatric comorbidity indeed affects migraine evolution, may lead to chronic substance use, and may change treatment strategies, eventually modifying the outcome of this important disorder.
doi:10.1007/s10194-010-0282-4
PMCID: PMC3072482  PMID: 21210177
Migraine; Comorbidity; Psychiatric disorders; Depression; Meta-analysis
20.  Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers 
Objectives
Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services?
Methods
A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage.
Results
The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.
Conclusions
The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians.
doi:10.1016/j.echu.2013.07.001
PMCID: PMC4111075  PMID: 25067927
Chiropractic; Medicare; Spinal manipulation; Public policy; Health policy; Health care reform
21.  Migraine Care Among Different Ethnicities: Do Disparities Exist? 
Headache  2006;46(5):754-765.
Objective
Evaluate whether, in a primary care setting, Caucasians (C) and African Americans (AA) with moderately to severely disabling migraines differed in regards to: utilizing the health-care system for migraine care, migraine diagnosis and treatment, level of mistrust in the health-care system, perceived communication with their physician, and perceived migraine triggers.
Background
Research has documented ethnic disparities in pain management. However, almost no research has been published concerning potential disparities in utilization, diagnosis, and/or treatment of migraine. It is also important to consider whether ethnic differences exist for trust and communication between patients and physicians, as these are essential when diagnosing and treating migraine.
Methods
Adult patients with headache (n = 313) were recruited from primary care waiting rooms. Of these, 131 (AA = 77; C = 54) had migraine, moderate to severe headache-related disability, and provided socioeconomic status (SES) data. Participants completed measures of migraine disability (MIDAS), migraine health-care utilization, diagnosis and treatment history, mistrust of the medical community, patient–physician communication (PPC), and migraine triggers. Analysis of covariance (controlling for SES and recruitment site), chi-square, and Pearson product moment correlations were conducted.
Results
African Americans were less likely to utilize the health-care setting for migraine treatment (AA = 46% vs. C = 72%, P < .001), to have been given a headache diagnosis (AA = 47% vs. C = 70%, P < .001), and to have been prescribed acute migraine medication (AA = 14% vs. C = 37%, P < .001). Migraine diagnosis was low for both groups, and <15% of all participants had been prescribed a migraine-specific medication or a migraine preventive medication despite suffering moderate to severe levels of migraine disability. African Americans had less trust in the medical community (P < .001, η2 = 0.26) and less positive PPC (P < .001, η2 = 0.11). Also, the lower the trust and communication, the less likely they were to have ever seen (or currently be seeing) a doctor for migraine care or to have been prescribed medication.
Conclusions
Migraine utilization, diagnosis, and treatment were low for both groups. However, this was especially true for African Americans, who also reported lower levels of trust and communication with doctors relative to Caucasians. The findings highlight the need for improved physician and patient education about migraine diagnosis and treatment, the importance of cultural variation in pain presentation, and the importance of communication when diagnosing and treating migraine.
doi:10.1111/j.1526-4610.2006.00453.x
PMCID: PMC2443411  PMID: 16643578
migraine; ethnicity; health-care disparities; utilization; migraine diagnosis and treatment; patient–physician communication
22.  A replication of the study ‘Adverse effects of spinal manipulation: a systematic review’ 
Objective
To assess the significance of adverse events after spinal manipulation therapy (SMT) by replicating and critically reviewing a paper commonly cited when reviewing adverse events of SMT as reported by Ernst (J Roy Soc Med 100:330–338, 2007).
Method
Replication of a 2007 Ernst paper to compare the details recorded in this paper to the original source material. Specific items that were assessed included the time lapse between treatment and the adverse event, and the recording of other significant risk factors such as diabetes, hyperhomocysteinemia, use of oral contraceptive pill, any history of hypertension, atherosclerosis and migraine.
Results
The review of the 32 papers discussed by Ernst found numerous errors or inconsistencies from the original case reports and case series. These errors included alteration of the age or sex of the patient, and omission or misrepresentation of the long term response of the patient to the adverse event. Other errors included incorrectly assigning spinal manipulation therapy (SMT) as chiropractic treatment when it had been reported in the original paper as delivered by a non-chiropractic provider (e.g. Physician).
The original case reports often omitted to record the time lapse between treatment and the adverse event, and other significant clinical or risk factors. The country of origin of the original paper was also overlooked, which is significant as chiropractic is not legislated in many countries. In 21 of the cases reported by Ernst to be chiropractic treatment, 11 were from countries where chiropractic is not legislated.
Conclusion
The number of errors or omissions in the 2007 Ernst paper, reduce the validity of the study and the reported conclusions. The omissions of potential risk factors and the timeline between the adverse event and SMT could be significant confounding factors. Greater care is also needed to distinguish between chiropractors and other health practitioners when reviewing the application of SMT and related adverse effects.
doi:10.1186/2045-709X-20-30
PMCID: PMC3502141  PMID: 22998971
MeSH; Chiropractic; Spinal manipulative therapy; Adverse effects
23.  Hearing voices: does it give your patient a headache? A case of auditory hallucinations as acoustic aura in migraine 
Objective
Auditory hallucinations are generally considered to be a psychotic symptom. However, they do occur without other psychotic symptoms in a substantive number of cases in the general population and can cause a lot of individual distress because of the supposed association with schizophrenia. We describe a case of nonpsychotic auditory hallucinations occurring in the context of migraine.
Method
Case report and literature review.
Results
A 40-year-old man presented with imperative auditory hallucinations that caused depressive and anxiety symptoms. He reported migraine with visual aura as well which started at the same time as the auditory hallucinations. The auditory hallucinations occurred in the context of nocturnal migraine attacks, preceding them as aura. No psychotic disorder was present. After treatment of the migraine with propranolol 40 mg twice daily, explanation of the etiology of the hallucinations, and mirtazapine 45 mg daily, the migraine subsided and no further hallucinations occurred. The patient recovered.
Discussion
Visual auras have been described in migraine and occur quite often. Auditory hallucinations as aura in migraine have been described in children without psychosis, but this is the first case describing auditory hallucinations without psychosis as aura in migraine in an adult. For description of this kind of hallucination, DSM-IV lacks an appropriate category.
Conclusion
Psychiatrists should consider migraine with acoustic aura as a possible etiological factor in patients without further psychotic symptoms presenting with auditory hallucinations, and they should ask for headache symptoms when they take the history. Prognosis may be favorable if the migraine is properly treated. Research is needed to explore the pathophysiological mechanism of auditory hallucinations as aura in migraine.
doi:10.2147/NDT.S29300
PMCID: PMC3333787  PMID: 22536065
auditory hallucination; acoustic aura; migraine; psychosis; DSM-IV; case report
24.  Selectivity in Genetic Association with Sub-classified Migraine in Women 
PLoS Genetics  2014;10(5):e1004366.
Migraine can be sub-classified not only according to presence of migraine aura (MA) or absence of migraine aura (MO), but also by additional features accompanying migraine attacks, e.g. photophobia, phonophobia, nausea, etc. all of which are formally recognized by the International Classification of Headache Disorders. It remains unclear how aura status and the other migraine features may be related to underlying migraine pathophysiology. Recent genome-wide association studies (GWAS) have identified 12 independent loci at which single nucleotide polymorphisms (SNPs) are associated with migraine. Using a likelihood framework, we explored the selective association of these SNPs with migraine, sub-classified according to aura status and the other features in a large population-based cohort of women including 3,003 active migraineurs and 18,108 free of migraine. Five loci met stringent significance for association with migraine, among which four were selective for sub-classified migraine, including rs11172113 (LRP1) for MO. The number of loci associated with migraine increased to 11 at suggestive significance thresholds, including five additional selective associations for MO but none for MA. No two SNPs showed similar patterns of selective association with migraine characteristics. At one extreme, SNPs rs6790925 (near TGFBR2) and rs2274316 (MEF2D) were not associated with migraine overall, MA, or MO but were selective for migraine sub-classified by the presence of one or more of the additional migraine features. In contrast, SNP rs7577262 (TRPM8) was associated with migraine overall and showed little or no selectivity for any of the migraine characteristics. The results emphasize the multivalent nature of migraine pathophysiology and suggest that a complete understanding of the genetic influence on migraine may benefit from analyses that stratify migraine according to both aura status and the additional diagnostic features used for clinical characterization of migraine.
Author Summary
Migraine is among the most common and debilitating neurological disorders. Diagnostic criteria for migraine recognize a variety of symptoms including a primary dichotomous classification for the presence or absence of aura, typically a visual disturbance phenomenon, as well as others such as sensitivity to light or sound, and nausea, etc. We explored whether any of 12 recently discovered genetic variants associated with common migraine might have selective association for migraine sub-classified by aura status or nine additional migraine features in a population of middle-aged women including 3,003 migraineurs and 18,180 non-migraineurs. Five of the 12 genetic variants met the most stringent significance criterion for association with migraine, among which four had selective association with sub-classified migraine, including one that was selective for migraine without aura. At suggestive significance, all of the remaining genetic variants were selective for sub-classifications of migraine although no two variants showed the same pattern of selectivity. The selectivity patterns suggest very different contributions to migraine pathophysiology among the 12 loci and their implicated genes. Further, the results suggest that future discovery efforts for new migraine susceptibility loci would benefit by considering associations with sub-classified migraine toward the ultimate goals of more specific diagnosis and personalized treatment.
doi:10.1371/journal.pgen.1004366
PMCID: PMC4031047  PMID: 24852292
25.  Migraine and cognitive decline among women: prospective cohort study 
Objective To evaluate the association between migraine and cognitive decline among women.
Design Prospective cohort study.
Setting Women’s Health Study, United States.
Participants 6349 women aged 65 or older enrolled in the Women’s Health Study who provided information about migraine status at baseline and participated in cognitive testing during follow-up. Participants were classified into four groups: no history of migraine, migraine with aura, migraine without aura, and past history of migraine (reports of migraine history but no migraine in the year prior to baseline).
Main outcome measures Cognitive testing was carried out at two year intervals up to three times using the telephone interview for cognitive status, immediate and delayed recall trials of the east Boston memory test, delayed recall trial of the telephone interview for cognitive status 10 word list, and a category fluency test. All tests were combined into a global cognitive score, and tests assessing verbal memory were combined to create a verbal memory score.
Results Of the 6349 women, 853 (13.4%) reported any migraine; of these, 195 (22.9%) reported migraine with aura, 248 (29.1%) migraine without aura, and 410 (48.1%) a past history of migraine. Compared with women with no history of migraine, those who experienced migraine with or without aura or had a past history of migraine did not have significantly different rates of cognitive decline in any of the cognitive scores: values for the rate of change of the global cognitive score between baseline and the last observation ranged from −0.01 (SE 0.04) for past history of migraine to 0.08 (SE 0.04) for migraine with aura when compared with women without any history of migraine. Women who experienced migraine were also not at increased risk of substantial cognitive decline (worst 10% of the distribution of decline). When compared with women without a history of migraine, the relative risks for the global score ranged from 0.77 (95% confidence interval 0.46 to 1.28) for women with migraine without aura to 1.17 (0.84 to 1.63) for women with a past history of migraine.
Conclusion In this prospective cohort of women, migraine status was not associated with faster rates of cognitive decline.
doi:10.1136/bmj.e5027
PMCID: PMC3414433  PMID: 22875950

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