Via Research Recognition Day 2024 VCOM-Carolinas

Clinical Case-Based Reports

Efficacy Of Osteopathic Manipulative Treatment in Managing Chronic Migraines: A Case Study

Yassine Lahlou, OMS-III, Mariam Aamir, OMS-II, Victoria Shadiack, D.O. Edward Via College of Osteopathic Medicine - Carolinas, Spartanburg, S.C.

Introduction

Case Presentation

HPI: 27-year-old female presented with complaints of worsening chronic migraines with visual and auditory auras that began in 2018. Pt described migraines as debilitating to her normal activities of daily living (ADLs) - including walking, reading, watching T.V, and driving. Her main recurrent symptoms included nausea and head tightness. She noted that her main trigger was stress and migraine frequency was 3 5days/week with a pain scale of 8/10 up to 10/10. She mentioned using non pharmacologic treatment of a compression ice hat which provided temporary moderate pain relief. Pharmacologic therapy included Propranolol, Cymbalta, and Imitrex with varying results. At the worse patient had increased symptomology and negative side effects. At the best patient headache severity decreased to a 6/10 and frequency of 2-4 days/week for the last 3 years until January 2023, where she enrolled in a clinical trial for a new migraine drug. This required a medication wash out period, which caused headache severity and frequency to return to her baseline. She presented for OMT treatment during the first week of wash-out period as her headache was described as “severe, twisting, pulsating” located in her frontal bone and radiating to her ears bilaterally. Symptomatic Manifestations of the Patient's Migraine: Ͳ General: fatigue Ͳ Head: headache, dizziness Ͳ Ears: tinnitus Table 1. Osteopathic Screening Assessment Results and Associated Treatment Plan ‹Žƒ–‡”ƒŽ –‡”‘ Ž‡‹†‘ƒ•–‘‹† ‡†‡” ‘‹– ‘ˆ– ‹••—‡ ‡Ž‡ƒ•‡ Results:  ƒ —–‡ ”‡†— –‹‘ ‹ •‡˜‡”‹–› ‘ˆ •›’–‘• ˆ”‘ ͻǤͷȀͳͲ –‘ ͷȀͳͲ Osteopathic Exam Findings ʹ Ž Žǡ Ͷ Ž Žǡ ͹ ” ” ͳǦ͵ ›’‡ ͳ ”‘—’‡†ǡ Ž ” Ǧ ‡šƒ• ™‹•– ȋ ‹‰—”‡ ʹȌ ƒ•›‡–”‹ ƒŽ ƒ† †‡’”‡••‹‘ ‘””‡ –‡† ™‹–Š ˆ—ŽŽ ˆŽ‡š‹‘ ƒ† ‡š–‡•‹‘ ’ƒ––‡”• ƒŽš ‡”‡„”‹ ”‡•–”‹ –‹‘ ‘ ‹†Ž‹‡ •ƒ‰‹––ƒŽ •—–—”‡ ”‘–ƒŽ ‹ˆ– ”„‹–ƒŽ ‹ˆ– ™‹–Š ƒ•‹‘ †‹•–”ƒ –‹‘ Treatment ‹‰Š ‡Ž‘ ‹–› ‘™ ’Ž‹–—†‡ ȋ Ȍ Ͳ Eyes: diplopia, pulsatile vision, blurry vision Ͳ Neuro: numbness, tingling, paresthesia Ͳ GI: nausea, diarrhea, indigestion, heartburn Past Medical History: Complex Regional Pain Syndrome

Chronic migraines are a headache disorder that are primarily characterized as recurrent throbbing or pulsing headaches, that can also consist of systemic symptoms including nausea, movement sensitivity, photophobia, and sensory auras. In 2015, migraines were the leading cause of neurological disability causing a greater than 50% reduction in work productivity in affected individuals 3 . Due to the variety of complex symptoms and different migraine phases as seen in Figure 1, it is difficult to have a standardized treatment plan. According to the US Headache Consortium, a treatment plan should be focused on treating attacks to prevent recurrence, improve one’s functioning ability, reduce usage of rescue medications, be cost effective, and have minimal side effects 3 .

One Month Post Treatment Six Month Post Treatment

One Week Post Treatment

• Discontinued clinical trial due to brain fog and somnolence • Symptoms resolved immediately after discontinuing clinical trial • Nausea has persisted → only relief has been from additional OMT visits

• Migraine free for 3 days • ĞĐƌĞĂƐĞĚ migraine frequency to 1day/week • Pain character change “severe pounding” → “aching” • Increased ADLs performance without nausea • No visual or auditory auras

• No return of visual or auditory auras • Patient has begun clinical trial • Brain fog and nausea have returned

Conclusions

This case report highlights the efficacy of OMT as an intervention for treatment of chronic migraines. While conventional medications have been the primary approach for symptom management, OMT introduces a complementary aspect that considers the interconnectedness of the body’s systems. The results showed that using OMT to release physiological restrictions resolved the patient’s migraine symptoms for approximately one month. The patient experienced a notable change in the pain character, migraine frequency, and overall improvement in ADLs. According to the patient, this treatment has had longer sustaining results than her previous ‘ standard of care.' Therefore, OMT may be used as an adjunct therapy to pharmacological medication or in this specific case as stand-alone treatment given the patient's contraindication to medication before beginning a clinical trial. Due to the multifaceted nature of chronic migraines, the integration of OMT alongside current pharmaceutical options creates a comprehensive treatment plan. Therefore, further studies evaluating OMT alone as well as OMT in combination with pharmacological treatment would be beneficial to perform, not only to further demonstrate the efficacy of OMTbut to also provide patients with the best medical treatments available. These studies may lead to a reduced reliance on medications with side effects, significant cost savings 5 , a reduction in unnecessary procedures, and improved overall patient health. The integration of OMT into migraine management protocols has the potential to alleviate the global burden of this medical condition, offer these patients a way to enhance their quality of life and evolve the landscape of migraine research and treatment. Limitations in this case included a patient history of complex medication usage, participating in a clinical trial which caused an increase in headache symptomology and a possible misdiagnosis of the patient’s original headache pathology.

Figure 1. Mechanisms of migraine as a chronic evolutive condition 1 Migraines are a cyclic disorder characterized through different phases that include a variety of complex symptoms within each phase and may be a result of different triggers. Pharmacological interventions for chronic migraines encompass a range of medications. Pain relievers such as nonsteroidal anti-inflammatory drugs and triptans are used to provide immediate pain relief during migraine attacks. Preventive medications such as beta-blockers, antidepressants, and anticonvulsants aim to reduce the intensity and frequency of migraine episodes. Although, these pharmaceutical interventions can be effective in some individuals, they can also cause various side effects including gastrointestinal (GI) symptoms such as epigastric pain, nausea, GI bleeding and medication overuse headaches 4 . Furthermore, many patients may present with intolerance or may not respond well. As our understanding of chronic migraines expand, it becomes apparent that research for a more comprehensive treatment plan is necessary. An emerging alternative therapy, osteopathic manipulative treatment (OMT) is a non-pharmacological treatment that complements traditional medical care. OMT is a hands-on therapeutic technique that emphasizes the musculoskeletal system in order to restore the balance within the body. This technique is not only cost-effective when compared to pharmaceuticals, but also has limited side-effects in comparison primarily including temporary mild soreness. Osteopathic physicians are trained to manage chronic pain with OMT to treat the root issue rather than just symptoms as it considers the interconnectedness of the body's systems. Various studies have shown that OMT is effective in alleviating pain and reducing disability over 4 to 6 weeks 2 . Due to this, some individuals may find better relief through the combination of both approaches providing a more comprehensive treatment plan that offers improved symptom management and a better quality of life.

Figure 2. Texas Twist Patient is placed in the prone position. The practitioner positions hands in the direction of the restrictive barrier (opposite of osteopathic diagnosis) and a High Velocity Low Amplitude corrective thrust is applied.

References

1. Andreou, A.P., Edvinsson, L. Mechanisms of migraine as a chronic evolutive condition. J Headache Pain 20, 117 (2019). 2. Licciardone JC, Schultz MJ, Amen B. Osteopathic Manipulation in the Management of Chronic Pain: Current Perspectives. J Pain Res. 2020 Jul 20;13:1839-1847. doi: 10.2147/JPR.S183170. PMID: 32765058; PMCID: PMC7381089. 3. Ong JJY, De Felice M. Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action. Neurotherapeutics. 2018 Apr;15(2):274-290. doi: 10.1007/s13311-017-0592-1. Erratum in: Neurotherapeutics. 2018 Jan 8;: PMID: 29235068; PMCID: PMC5935632. 4. . Pardutz, A., & Schoenen, J. (2010). NSAIDs in the Acute Treatment of Migraine: A Review of Clinical and Experimental Data. Pharmaceuticals (Basel, Switzerland) , 3 (6), 1966 – 1987. https://doi.org/10.3390/ph3061966 5. Newman, L., Vo, P., Zhou, L., Lopez Lopez, C., Cheadle, A., Olson, M., & Fang, J. (2021). Health Care Utilization and Costs in Patients With Migraine Who Have Failed Previous Preventive Treatments. Neurology. Clinical practice, 11(3), 206 – 215. https://doi.org/10.1212/CPJ.0000000000001076

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2024 Research Recognition Day