Case Report: 19 year old female with migraine/muscle tension headaches Mark H. Street, D.C. jet@sonic.net Updated July 12, 1996 A 19 year old female entered our office on December 4, 1995 with the complaint of migraine/muscle tension headaches and dizziness. She was confused about what type of headaches they really were. The headaches started about 4 years ago. The patient states the problem is getting worse. She never feels good and is always in pain. The patient is currently taking the following perscription medications; Fiorinal, Vicoden, Avitan, Desogen. The patient denies any operations, accidents, falls, broken bones or dislocations. Patient states childhood diseases included chicken pox and pneumonia. Patient admits to the following symptoms; headache, chills, sweats, dizziness, loss of sleep, depression, pain, poor circulation, stiff neck, pain between shoulders, cramps and or backache with menses, the patient is not currently pregnant. The patients habits were rated indicating heavy, moderate, light, or none, they include; coffee - light, tea - light, alchohol - none, tobacco - none, exercise - light, sleep averages 6 hours per night. Hobbies include aromatheapy and crafts. Past History February 4, 1994 Patient was examined by her OB/GYN physician. Subjective complaints included, 17 year old female with long history of chronic headache. Patient had seen a neurologist last February and May of 1993. The neurologist feels the headaches are mostly migraine with some tension component. The neurologist recommended biofeedback. Patient feels the headaches are slightly worse recently occuring several times each week. Patient has not paid much attention to whether the headaches are associdated with menses. Patient has had a complete neurological exam including MRI, all results are negative. Patient weighed 127 lbs., blood pressure was 90/60. Patient is taking the following medications; Amytriptaline, Calen. An assessment of complex migraines was made at this time. The plan was to continue the medications. The patient was to consult with ther neurologist one more time to see if any further changes in medications would be appropriate. A referral for biofeedback was given. Followup in 2 months. Chart menses and headaches, consider hormonal therapy and acyclical anti-depressants. September 8, 1994 Check up with OB/GYN. Subjective complaints of headache which began 4 days ago as a usual headache, tension in neck and back with nausea. Headache is worse today, no fever. Some throbbing behind the right eye. Patient tried to get some relief by taking Caffergot, it did not help. Patient took some Fiorinal last night. DHE helped alot once. No response to Imitrex in the past. Mild photophobia. Objective findings included pulse 80 and regular, PERRLA, fundi benign, cranial nerves 2-12 intact, grips strong and equal, reflexes symmetric. Assessment migraine headache. Plan send patient to ER for DME and Compazine. September 13, 1994 Check up with OB/GYN. Refill of OCP, Loestrin. September 27, 1994 Check up with OB/GYN. Recheck OCP, spotting continuously on Loestrin, headaches much improved about 1 per week. Discontinue Loestrin, try Desogen 28 day. December 2, 1994 Check up with OB/GYN. Recheck OCP, problems with spotting, irregular bleeding, BP 110/70. April 28, 1995 Check up with OB/GYN. Subjective complaints; stress, migraines for 2 weeks, getting a cold. Patient states she is having migraine headaches from ovulation until her period off and on. Pain is in the center of her head. Patient has vomitted, very sound sensitive. Patient has taken a few Vicoden which have helped a little. Patient states this is the third month of migraines at the end of her cycle. Medications include Calan, Amytriptaline, Desogen. Objective signs BP 110/70, temp 99 degrees, no exam performed. Assessment of increased headaches from PMS. Plan patient prefers not to go off of OCP's. Try natural progesterone 200mg. BID from day 14 until menses for 2 cycles. If no improvement go off OCP's. Continue other meds. Rx for Vicoden. May 26, 1995 Phone call with OB/GYN. Patient states she is 5 days late starting her period. NMC requested patient end progesterone this month. Continue perscription next cycle. per NMC June 12, 1995 Rx of Vicoden 5/500 #20 refilled instead of #40, pt. needs appt. Cancelled June 5, left msg so call for appt. August 1, 1995 OV (Mark Street's note; these notes are hard to make out I will do my best translation.) Assessment, tried Inderal for migraines. Plan, Inderal 20mg #30 qd RFx2 to GAGS- re-ev here in 1 mo. August 8, 1995 Immunization update - MMR discussed with mother, BP 108/80. Plan chem 20 TfTs, CBC -- all normal MMR tomorrow. August 9, 1995 Tetnus Toxoid 5cc given in Left arm. August 15, 1995 GAGs Desogen 28d X 3mo. Oral Contraceptives October 10, 1995 wt 126, BP 112/78 Subjective complaints Late breakthrough bleeding on Desogen, depression acute with +FH. Plan Trial of Trinorinyl #2 pkgs, trial Paxil(sp) 20 1/2qdx3d then qd, Re-eval in 2-4 weeks. November 6, 1995 Subjective, here for flu, no breakthrough bleeding since going to Trinorinyl from Desogen, Migraines q week since starting Inderal 20mg qd.. Persists with muscle tension, insomnia. Assessment, Migraines, Insomnia, Muscle Tension, Contraception. Plan, continue Trinorinyl, Increase Inderal to 20mg X bid, hot towel to neck, Trial Ambion 5mg x qd #20, use sparingly, Re-eval in 2 weeks by phone. December 4, 1995 The patient enters our office with subjective complaints of neck muscle tension and migraine headaches of 3 years duration. Oral Contraceptives have not helped in ridding her of headaches. She craves salt and sweets during the middle of her cycle, she states a particular craving for green olives. The patient states she is always cold, her doctor tested her thyroid 3 months ago and nothing was abnormal. Blood pressure in the left arm was tested twice and revealed a pressure of 120/86 and 120/88. The patient takes Fiorinal, Codeine, Vicaden, and shots of Elavil when the headaches get bad. She states they are of limited value in decreasing her symptoms, the relief they do give is short lived. The type of pain is described as stiff and tight. The patient states she had a massage a few weeks ago which really helped relieve her pain. The patient has been experiencing approximately 5 (five) headaches per week, described as a continuous headache. She sometimes experiences an aura, and nausea, but not always. She does not wear corrective lenses. She states for the last 2 days she is dizzy when she stands up. The patient takes a generic multivitamin for nutritional support. The patient denies any previous problems with her jaw. Spinal examination revealed a left handed female with spinal tenderness at the levels of C1, C2, C5. Range of motion studies revealed pain with flexion from C2-C5, tight muscle feeling, left lateral flexion revealed right sided muscle tension, right lateral flexion revealed less muscle tightness than noted on left, cervical extension was decreased with associated muscle tension from C2-C5. Right and Left cervical compression with lateral flexion caused pain in the cervical spine. Most noteable on spinal palpation examination was a very prominent left transverse of C1, which was very sore and sensitive to touch. Manual muscle spasm examination revealed left cervical paraspinal muscle spasm, graded by this examiner on the 0-10 scale as 6/10. Most notable is the patient is a manicurist and laterally flexes her head to the right for long periods during the day to work on clients. Trigger points were noted at C1 suboccipital muscles on the left, and the superior vertebral border of the left scapula, in the area of levator scapula insertion. Working diagnoses of migraine type headaches, muscle tension headaches, quite possibly due to hormonal factors as yet unanswered. Possible left lateral C1,atlas subluxation, C2 subluxation, and C5 subluxation with associated soft tissue compensation and spasm. Plan of trial of chiropractic spinal manipulative therapy to the cervical and thoracic spine. Dietary and symptom diary during monthly cycle to identify possible triggers for headaches. The first treatment was administered on December 6, 1996, passive stretch to the cervical spine, adjustment to C1 Left lateral very easy just to passively stretch the joint, no thrust, suboccipital muscle trigger points were addressed to patient tolerance, pressure on these points made the headache worse. December 6, 1995 Patient reports a headache today with more muscle sorness and spasm noted bilaterally in the cervical spine. The patient rates the symptoms as the same with pain and tenderness noted in the cervical spine and thoracic spine with associated headache. Trigger points were addressed in the left trapezius and levator scapula muscle. The rhomboid muscles were addressed bilaterally using a technique by which the arm is brought behind the back and rested just above the sacral base, the elbow rests on the doctors knee as he works above, the the shoulder is held with the doctors ipsilateral hand grasping the front of the glenohumeral joint and lifting it posterior, the doctors contralateral hand works the vertebral border of the scapula along the spine and under the scapula up to the superior border of the scapula and out to the lateral supraspinatus fossa, then back down the vertebral border around the apex of the scapula and up the lateral border of scapula up to the insertion of the rotator cuff muscles (very painful trigger points can often be found at this point). This technique involves moving the scapula on the thorax in motions which the trigger points and muscle spasms can be effectively addressed, it can involve inferior traction of the scapula with the doctors contralateral hand contacting the superor medial border of the scapula and tractioning down. A clockwise motion can be applied with the ipsilateral hand holding the anterior glenohumeral joint to facilitate working with the soft tissues. Another motion which can be helpful is tracitoning the scapula off of the thoracic rib cage by getting underneath the scapula with the contralateral hand and lifting gently along the entire vertebral border. Passive stretch was applied to the cervical spine in flexion, lateral flesion and rotation, the upper thoracic spine was adjusted with a double thenar diversified adjustment at T5-T6, C5 was adjusted from the left, National listing PRI-L, C2 was adjusted from the right, National listing PLI-L, both were adjusted using the modified rotary break adjustment as taught at Palmer -West Chiropractic College. Intersegmental traction was applied to the entire length of the spine for 10 minutes. Assessment at this time is that the condition is of a chronic nature, continue treatment. Plan and treatment goals are symptom relief, strengthen and stabilize the cervical and thoracic spine and associated musculature. Prognosis too soon to tell. December 8, 1995 Subjective symptoms same, headache today rated 71 on a blind analog scale of 100. Associated bilateral muscle spasm and tension in the cervical spine, patient notes less spasm and tension compared to previous. Trigger points were addressed in the thoracic and cervical spine as well as the suboccipital area bilaterally. C1 was adjusted left lateral using the modified rotary break, an adjustment was made straight lateral with little or no rotation. C2 was adjusted from the right, National listing PLI-L, C5 was adjusted from the left, National listing PRI-l. Passive stretch of cervical spine was performed in flexion, lateral flexion, and rotation, using manual traction techniques. Assessment, progress as expected due to chronicity continue treatment. December 11, 1995 Subjective symptoms; headache better today 48 on a blind analog scale of 100. Muscle spasm encompassing the left paraspinal area from left occiput to left trap and levator scapula, graded as an 8 on scale of ten by this doctor, graded as an 86 on blind analog scale by patient. Trigger points noted in the occipital region today are very active and tender. Trigger point therapy was performed on active trigger points, and passive stretch was performed on the cervical spine. The patient was blocked category 3, T6 was adjusted using the double thenar diversified technique. C1 was adjusted from the left lateral using modified rotary break, C2 was adjusted from the right, National listing PLI-L, C5 was adjusted from the left, National listing PRI-L. Patient was place on full spine intersegmental traction for 10 minutes. Treatment plan goals still include relief, stabilization, and strengthen the cervical and thoracic spine. December 13, 1995 Subjective complaints include headache rated on a blind analog scale at 15 on a scale of 100, muscle spasm and soreness rated at 45 on blind analog scale of 100, patient rates symptoms overall better, no headaches. The suboccipital trigger points were addressed bilaterally, passive stretch of cervical spine in flexion, lateral flexion, and rotation, T6 was adjusted using the double thenar diversified technique, C1 was adjusted from the left using the modified rotary break, straight lateral with little or no rotation, C2 was adjusted from the right, National listing PLI-l using the modified rotary break technique, C5 was adjusted from the left, National listing PRI-L using the modified rotary break technique. Assessment, progress as expected, chronicity an instability, continue treatment. December 29, 1995 Subjective complaints, no headaches, rated a 1 on a blind analog scale of 100. Muscle sorness and spasm rated a 4 on a blind analog scale of 100. Trigger points in the suboccipital area are mild now rated a 3-4 on scale of 10, when the patient was asked verbally, whereas the patient rates them as a 10 when treatment was commenced. Patient has been noticing popping and cracking in the thoracic spine and cervical spine when turning and moving the last 3-4 days. The left C1-occiput upper cervical region feels tight and tender to the patient Patient rates the symptoms as substantial better with mild headache symptoms, for which she took Kafrogot. Trigger points were addressed in the suboccipital region and upper thoracic region, patient was blocked category 3, T4 was adjusted using the double thenar diversified technique, C6 was adjusted from the right, National listing PLI-L using the modified rotary break technique, C5 was adjusted from the left, National listing PRI-L using the modified rotary break technique, C2 was adjusted from the right, National listing PLI-L using the modified rotary break technique, C1 was adjusted from the left, left lateral with little or no rotation using the modified rotary break technique. Stretches were prescribed for home and work ---------------------------------- Case will continue.