Menstrual Migraine and Cervical Afferents: The Cross-Examination
Dr Dean Watson PhD Musculoskeletal Physiotherapist
International Educationalist Watson Headache? Institute; Adjunct Senior Lecturer UniSA; Educating in and Identifying Cervical Afferents in Cervicogenic and Primary Headache; Clinical Consultant Watson Headache? Clinic
The Quasi-Peace
As Watson continues to muse over the discussion with Angela (see Edition 32 - Those Poor Hormones Get Blamed For Everything ), to his surprise, his colleague returns with Angela, perplexed, her paradigm shaken. Watson feels relief, realising there might be a chance to defuse and rationalise the discussion.???
“There might be some unanswered questions in the medical model, but what is the science behind your perspective?” queries Angela, Watson’s colleague, predicting there will be more challenging moments, ordering more coffee (when he would really like a scotch!).??
‘Curiosity killed the cat, but?satisfaction brought it back.’
“As mentioned, Menstrual Migraine (MM) is one of my favourite conditions to treat because the prognosis is successful, and yes, I get the temporal relationship between (pure) MM and oestrogen withdrawal. However, seminal research has shown that hormonal profiles do not differ between women with menstrual migraine and those without. On top of that, how is a systemic (hormonal) influence directly responsible for unilateral and alternating head pain? This piqued my interest – what differentiates those women with MM from those without?” Watson quietly explains. ?
The Gauntlet
Angela ponders Watson’s rhetorical query as Watson’s colleague returns with coffee (perhaps his has a dash of scotch!).
?“Ok, I get that, but how do you justify assessing and treating the upper cervical spine in those with hormonally related headache?” comes Angela’s challenging reply.
Watson, predicting the question and trying to maintain an amicable discourse, carefully explains that research has shown that the trigemino-cervical complex (TCC) in those with MM is sensitised, and that is why the ‘triptans’ are now recommended practice for MM and that the triptans’ abortive effect in migraine is DE-sensitisation of the TCC.
Watson’s colleague nervously interjects, “Yes, Angela. Watson and I have discussed before that upper cervical afferents are in the mix as a sensitising source of the TCC.”
“Yes, but why the temporal relationship with oestrogen?” Angela enquires.
The Norm
“I am glad you have asked Angela”, replies a restrained Watson.? “When oestrogen drops, there is a corresponding fall in oxytocin and serotonin, which leads to disinhibition of the TCC.? Furthermore, serotonin levels also affect another biochemical – calcitonin gene-related peptide (CGRP).”
“Yes, I am aware of the new migraine medication, which is essentially a CGRP antagonist,” acknowledges Angela.
“Yes, this is where it gets interesting. CGRP is pronociceptive and a powerful vasodilator. When serotonin drops, CGRP levels increase, increasing sensitivity to nociception (and compounding the fall in oxytocin) and noise in the trigeminal system,” elaborates Watson. “Wow, that sounds like a perfect storm!” exclaims Angela. “Yes, this explains why pure MM is typically more severe, lasts longer, is more likely to be associated with nausea and vomiting, and generally more calcitrant to treatment.”
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The Epiphany: Oestrogen Not Guilty
“Ah!” comes the reaction from Watson’s colleague.
Watson, wanting to maintain the momentum, hurriedly continues, “Yes, but this happens for every woman; these are normal events, so why do some women experience MM and others not?”?
Watson’s colleague sits back with arms behind his head. “Now I get it.” “What,” probes Angela. “Perhaps the difference is that the TCC is sensitised...?” comes the reply.
Watson seizes the moment. “Yes, by determining the relevancy of addressing noxious cervical afferents and desensitising the TCC, the sum of the normal hormonal trigger of biochemical events remains subthreshold, effectively disarming MM.”
Watson silently recalls an old proverb, ‘Speech is silver, silence is golden’, then pauses...
Until next time...
Regards
Dr Dean Watson PhD
Watson Headache? Institute
Email [email protected]
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