CASE HISTORY - Female with Migraine

CASE - Female with Migraine

(not the actual patient)

A fifty year old executive female appears in my office with a 15 year history of migraine headaches.  She owns her business with 15-20 employees and puts in 60-70 hours per week minimum working her business. She presents me with a calendar of the previous two years wherein she records each time during the day that she does not have a migraine headache.  She has been to multiple doctors but never to a chiropractor.  She has tried many different prescription medications over the years with marginal results.  She has had MRI and CT of her head many times, each with negative results.  She has had physical therapy, massage and acupuncture.  She says that due to the severity of her headaches if she has heard of a possible solution she tries it.  She comes in today seeking relief regardless of whether her insurance covers the treatment or not.

My patient describes every headache beginning in the base of her skull where the neck and head “join”.  She relates multiple motor vehicle accidents prior to onset of her headaches 15 years ago.  At no time did any of the multiple doctors examine or X-ray her neck. 

I sent for copies of records from those doctors seen by my patient in the last two years.  I completed an in depth consultation of the headache episodes of the last two years. Her calendar reflected a 15 minute segment of one day every two weeks in which she did not have a headache.  She simply had learned to function and conduct her business in spite of the headaches.

Examination of my patient revealed a restricted ROM in the CSP with an overall reduction in normal ROM of 40%.  Reflexes of the UE were +2 bilateral.    Cervical compression tests were negative.  Shoulder depression tests positive bilateral.  Costoclavicular tests positive bilateral.  Palpable joint restrictions at C2, C5, C7, T2, T5. Palpable spasms in CSP & TSP.

The patient was advised of my findings and sent for X-rays of her neck.

The patient returned two days later with her X-rays.  I reviewed her X-rays with the patient.  There was a markedly reversal of the normal cervical curvature.  In addition there was a significant rotation of C2 on C3 cervical vertebrae.  Secondary misalignments at C5, C7, T2 and T5.  Amazingly there were very little degenerative changes in the joints of the neck.

My findings were discussed with the patient.  I suggested a short two week course of treatment to see whether chiropractic care could affect her headaches.  The patient agreed.  Treatment began today with a single adjustment to C2. The patient tolerated the procedure well.  She was instructed to return in two days.

Two days later the patient returned and reported very little change. She may have slept better.  Single treatment to the C2 subluxation was administered again.  The patient was instructed to return on Friday.

The patient returns on Friday and noted she went one hour without a headache following the second adjustment and then “everything” came back.  However, she definitely slept better.  Treatment to C2 and T2 was administered.  The patient was instructed to return on Monday.

Monday the intensity of her headaches was much improved but the frequency was the same (constant).  She was able to sleep all night long since the last treatment. 

I advised the patient to be seen for 6 more weeks at a frequency of 3 times per week. She agreed saying this is the only relief she has had in 15 years.

Over the course of treatment that lasted three months this patient obtained tremendous relief from her headache.  However, she continued to have a migraine type headache for 30 minutes every thirty days.  She celebrated with us by bringing in champagne and cake (Chocolate).


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