"OF PAIN YOU COULD WISH ONLY ONE THING: THAT IT SHOULD STOP." - George Orwell, 1984
Although research about cold therapy (cryotherapy) in patients with migraine is limited, one thing is known, as the pain begins, many of us reach for the cold pack. In an article by Sprouse-Blum, et al., (2013), the authors report, "of all self-administered pain-relieving maneuvers, cold therapy is the most common maneuver applied in migraine without aura and the second most common maneuver applied in migraine with aura second only to compression" (p. 237). Before we take a look at the possible physiological effects of cold therapy, and some of our respective methods of application, let's have a quick review of helpful things to know about headache and neck pain in migraine.
We need to be aware that migraine is a genetic neurological disease and headache is a phase of a migraine attack (a person may have an attack without headache). Headache is commonly unilateral, pulsating, moderate to severe intensity, and may be aggravated by movement. However, pain may be felt all over the head (on one or both sides and in the middle of the head), including the eyes, frontal, occipital and neck areas (Kelman, 2005; ICHD-3 beta, 2013; Burstein et al., 2015). The headache phase is thought to begin with activation of meningeal receptors at the origin of the trigeminovascular system. As the headache progresses, in activation and sensitization of the trigeminovascular pathway, a number of complicated electrical and chemical events take place, including the involvement of neurotransmitters, neuropeptides and inflammatory mediators. In the process, we may experience a wide variety of autonomic, affective, cognitive, and sensory symptoms, including allodynia. The clinical manifestations of cephalic allodynia may include scalp and muscle tenderness and sensitivity to touch (Burstein et al., (2015).
It is important for us to know neck pain is commonly reported as a symptom with a migraine attack and may be experienced before (premonitory symptom), during and after the headache phase. While not conclusive and further studies are indicated, it is thought that neck pain may be an integral part of the migraine process ( Calhoun et al., 2010; Ashina, et al., 2015; Maniyar et al., 2015; Lampl,et al., 2015). In a population study assessing neck pain in migraine and tension-type headache, (Ashina et al., 2015), the authors report neck pain may play a role in the pathophysiology of migraine and tension-type headache and may arise because of convergent input from the first division of the trigeminal nerve and the upper cervical roots to the trigeminal complex (p. 212). Clinical implications from this study that are beneficial for us to know are:
- "Neck pain is highly prevalent in the general population and is more prevalent in individuals with migraine and tension-type headache.
- Neck pain has the highest prevalence in coexistant migraine and tension-type headache.
- Myofascial pericranial tenderness is significantly increased in individuals with neck pain compared to individuals without neck pain.
- Neck pain may have a shared pathophysiological mechanism with primary headaches.
- Neck pain may result in increased disability in headache sufferers and treatment may also be directed to the neck," (p. 218).
Additionally, we should be aware Maniyar et al., (2015), report "patients with neck stiffness do not respond as well to triptan treatment as patients without neck stiffness during acute migraine headache, suggesting a phenotype-mechanism dissociation" (p. 611). And, Lampl et al., (2015), indicate "prevention and treatment of neck pain could be important in the prevention of future chronic migraine" (p. 6/9).
Now, keeping these things in mind, let's take a look at the possible physiological effects of cold therapy for symptomatic relief in migraine. In general, local cold therapy is thought to cool skin, decrease temperature, decrease blood flow (vasoconstriction), reduce inflammation in adjacent tissues, relieve pressure on affected nerves, decrease muscle spasm and muscle tension, and numb pain. That said, let's review some of the proposed pathophysiological mechanisms of action in migraine.
In a study by Robbins, (1989), where a cold wrap was placed around the head with an elastic bandage and in a study by Ulcer et al., (2006), where cold was administered by gel cap, in a discussion of effectiveness, both study authors report, local anesthesia is important in the use of cold therapy in migraine. They go on to suggest cold sensations overwhelm and block transmission of the pain stimuli into the cerebral cortex and ice reduces the release of some substances including histamines, vasoactive substances and enzymes that stimulate nerve endings. Robbins adds a more thorough discussion, including the conduction velocity of peripheral nerves is decreased as the temperature is lowered. As well, Robbins mentions the major effect of ice is to decrease blood flow to the area (vasoconstriction) and a further effect is to reduce metabolism and oxygen demand. More recently, in a study by Sprouse-Blum, et al., (2013), where an adjustable wrap containing two freezable ice packs targeting the carotid arteries at the front of the neck was used to evaluate targeted cooling in the migraine patient by cooling the blood passing through the intracranial vessels, in a discussion of effectiveness, the authors report:
- it is possible blood passing through the carotid arteries was cooled enough to decrease release of inflammatory mediators from the walls of the intracranial vessels, decrease vascular permeability, and decrease local pain stimulation;
- there may have been a contribution of cold induced physiologic vasoconstriction similar to that observed with triptan type medications albeit through a different mechanism (the authors note the role of vasoconstriction in migraine remains unclear);
- a minimal contribution of analgesia associated with the small diameter myelinated fibers located around the cranial vessels is proposed, and
- there may be a minimal contribution of decreased metabolic activity in locally cooled areas (page 239).
Little is written about the contraindications of cold therapy in migraine. In the study by Ucler et al., (2006), the authors report one patient could not use cold therapy because of cold intolerance and another patient due to vertigo. Robbins, (1989), reports contraindications may include Raynaud's phenomenon and cold sensitivity. As well, Robbins, (1989), notes ice may cause some problems in rheumatoid conditions and in patients with paroxysmal cold hemoglobinuria. Taking these factors into consideration, in addition, if you have circulatory problems, are diabetic, are pregnant or are nursing, you should discuss individual concerns about cold therapy with your doctor.
Today, there are a number of products on the market designed to meet our individual cold therapy needs and comfort levels, including gel packs, pillows, caps, hats, and collars. For example, a hat that covers the entire head may be appropriate for one person, while another person may like something that covers the eyes.
In my case, since my migraines escalated to chronic migraine and then remitted to infrequent episodic migraine, I have become increasingly sensitive to hats or anything tight around my head, or neck, because of allodynia. As well, when I do have an attack, neck pain has become a troublesome symptom for me in the premonitory phase, throughout the headache phase, and into the postdrome.
Recently, I was introduced to the Migraine Hat by Lisa Jacobson, founder of The Daily Migraine, who created the hat at a good price point, with the intent of using the proceeds to raise migraine awareness. My first impression was that along with being adjustable so I could regulate the pressure, it was light enough that I could use it for a head wrap and flexible enough that I could use it for my neck. That said, I have been using the hat for the last few months, mostly for neck pain. I find if I catch the neck pain early enough, along with breathing, slow and easy, in and out, some biofeedback exercises, and meditation, I can often prevent or lessen the severity of an impending headache. To get the maximum benefit from the Migraine Hat, when I apply it to my neck I:
- fold the Cryo-gel ice pack in half,
- insert it into the cloth cover and close the Velcro tabs,
- with the the seam side of the cloth cover down and Velcro closure to the front of my neck, where I can easily access it for adjustments, I turn the two top corners down and fasten the lower portion just at, or slightly below, the level of my clavicle .
This way the contact of the Cryo-gel ice pack is at the back of my neck and base of my skull, not the sides and front of my neck. If the pain moves to my head, I can remove the hat from my neck, readjust the Cryo-gel pack to its original size, and place it where it hurts, including around my head, top of my head, or over my eyes.
In addition to the flexibility of the Migraine Hat, I am impressed with the versatility of the well designed cooler, which comes as a gift. Because I don't eat fast food and avoid foods with MSG, preservatives and artificial ingredients, I often take a healthy snack or sandwich with me when I am away from home. Along with two Cryo-gel ice packs, I am able to tuck in my food choice and keep it cool for the day.
Ashina, S., Bendtsen, L., Lyngberg, A., C., et al., (2015). "Prevalence of neck pain in migraine and tension-type headache: a population study." Cephalalgia. Mar;35(3):211-9.
Burstein, R., Noseda, R., & Borsook, (2015). "Migraine: Multiple Processes, Complex Pathopysiology." The Journal of Neuroscience. April;35(17):6619-6629.
Calhoun, A., H., Ford, S., Millen, C., et al., (2010). "The prevalence of neck pain in migraine." Headache. Sep;50(8):1273-7.
Lampl, C., Rudolph, M., Deligianni, C., et al., (2015). "Neck pain in episodic migraine: premonitory symptom or part of the attack?" The Journal of Headache and Pain. Sep;16:80.
Maniyar, F.H., Sprenger, T., Monteith, T., et al., (2015). "The premonitory phase of migraine-what can we learn from it?" Headache. May;55(5):609-20.
Robbins, L., D., (1989). "Cryotherapy for Headache." Headache: The Journal of Head and Face Pain. Oct;29(9).
Sprouse-Blum, A., S., Gabriel, A., K., Brown, J. P., et al., (2013). "Randomized controlled trial: targeted neck cooling in the treatment of the migraine patient." Hawaii JMed Public Health. Jul;72(7):237-41.
Ulcer, S., Coskun, O., Inan, L., E., et al., (2006). "Cold Therapy in Migraine Patients: Open-label, Non-controlled, Pilot Study." Evid Based Compliment Alternat Med. Dec;3(4):489-493.
Sharron Murray, M.S., R.N. is the author of Migraine: Identify Your Triggers, Break Your Dependence On Medication,Take Back Your Life. San Francisco: Conari Press, 2013.
This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified healthcare professional.
Copyright October 29th, 2016, Sharron E. Murray