TRANSCRIPT:

Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you in part by our generous sponsors Amgen and Novartis.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about cranial sacral therapy and how it can be used for migraine. I’m very excited about this topic and hopefully going to learn a lot more.

So I’d like to introduce our guest today. He’s the president and owner of Healy Physical Therapy and Sports Medicine, Dr. Mike Healy. Thanks so much for joining us today.

Dr. Michael Healy: Molly, thank you for having me, and I would also like to thank the Association of Migraine Disorders for having me today.

Molly: We are very happy to have you with us. So we’re going to start off super basic and get a better understanding of what cranial sacral therapy is, and then we’ll get into how it can relate and be used for migraine. Work for you?

Dr. Healy: It certainly does.

Molly: Okay. So let’s start off with the most basic. What is cranial sacral therapy — or CST, if it’s a little bit of a mouthful — and how does it work?

Dr. Healy: Cranial sacral therapy is an osteopathic treatment modality that physical therapists, osteopaths use, as well as some occupational therapists and massage therapists and some MDs, in our treatment bag to help our patients feel better. Cranial sacral therapy is a light-touch, noninvasive treatment, and we’re usually using about 1 to 5 grams of pressure — more about 5 grams of pressure. And that’s about the weight of a nickel.

And what we’re doing while we’re doing it, we’re trying to improve the overall homeostasis of the patient’s body. Our brain and our spinal cord make up our central nervous system. Within that central nervous system, we have a cranial sacral system, which is the bones of our skull, the cerebrospinal fluid, as well as our sacrum and the membranes that attach from the skull down to the sacrum. Now, those membranes can become twisted or turned or in dysfunction through stresses and strains that are put on the body.

Molly: It’s fascinating to learn a little bit more about this and how the systems work in our body. So now that we have a little bit better understanding of what CST is, can you kind of walk us through the process of how a treatment like this could help with migraine and headache?

Dr. Healy: First, we’d evaluate the patient. We’ll take them into a private room, a quiet room, and we would do a complete medical evaluation, taking a look at their range of motion, their strength, their soft tissue, and their structural alignment. We’ll ask them a lot of past medical history to see if they have any comorbidities that may go along with their headaches that might be causing them, such as migraines or regular headaches. And we have to make a determination of what is causing what.

And then after we do our evaluation, we will try and find where the patient has those restrictions, and then we would use a multitude of different modalities to treat that patient. In this case, we’re talking about cranial sacral therapy. And what a patient should expect in a cranial sacral session is they’ll be treated anywhere from about 30 minutes to 45 minutes to an hour in a private, quiet room with low lighting because with our headache patients or our migraine patients, they suffer from issues with loud noises and bright lights. So we want to kind of make sure the environment is controlled for them so that they can actually be relaxed and they can enjoy the treatments.

Molly: All right. Dr. Healy, you did a great job explaining kind of what a session is like. Can you go into a little bit more detail on what a patient can experience and what the practitioner is actually doing during the treatment?

Dr. Healy: Yes, most certainly. As the practitioner, after I’ve evaluated the patient, I’m going to look for the areas where the lesions are. A lot of times when I start with my patient, I like to start at the ribs and treat the rib area, basically from what we call thoracic spine number 1, and I like to treat down through L2, or the lumbar segment in L2. 

The reason I like to work there first using light pressure, about 5 grams, is because that’s where our sympathetic nervous system is. Our sympathetic nervous system is the fight or flight of our body, and it’s what puts us in stress. Now, with migraine headaches and different types of headaches, stress is one of the causes of headaches. So if I can decrease the patient’s sympathetic overload or firing or fight or flight, I can get them to relax on the table and they’ll feel more comfortable with my hands. 

Then I’m going to take my finger pads, I’m going to lift them up, and I’m gently going to move the ribs towards me, and I’m going to feel for the motion, what we call amplitude. How does it move? And I’m looking for a sinusoidal curve, where it goes up and down. We all that an amplitude. So I’m looking for the amplitude of motion or the smoothness of the motion. And if there’s a restriction there, then I stay there until the body unwinds itself. 

So as I go through the ribs, I take the 12 ribs that are on the right and I balance those all off. Then I go on the left, balance all of those off. Then I’ll go down to their pelvis, and at S2, or sacral level 2, is where the parasympathetic nervous system is. And that actually calms our body down, it helps us digest our food, and it also helps us have a bowel movement. So I’ll treat in that area so I can try and improve the parasympathetic nervous system or kicking up of the parasympathetic nervous system to decrease the overload of the sympathetic nervous system. 

And I’ll make sure the pelvis is — a couple of different bones: your sacrum in the back, which makes up part of the cranial sacral system. Then when you get mad at your children, you put your hands on your hips? Those are called your iliums. And so I want to make sure that there’s enough motion between the sacrum and the ilium, and I’m getting those to balance because there should be a certain motion that occurs between those two bones. 

And so I want to also feel the rhythm of the cranial sacral system. When I put my hand on their occiput, which is the back of your skull, and I put my hand on their sacrum, there is a certain cranial sacral rhythm, kind of like a pulse in our wrist. We have beats that go about 60 to 80 beats per minute for our cardiac system, for our pulse. The cranial sacral system is anywhere from 6 to 8 to 12 rhythms per minutes. 

So I want to ascertain is the patient having those rhythms correctly in the area that I’m treating. So if the rhythm is too high, then I got to bring that rhythm back down to 8 to 12 or 6 to 12 rhythmic cycles per minute. And when I go to the ribs or the head, I’m ascertaining that as well. I’m looking to see if that cranial sacral rhythm is in balance. If it’s not in balance, I’m trying to put it back in balance, as well as getting the restrictions that are in that area to resolve. 

And then I’ll go up to the patient’s head, and I’ll start treating the patient’s neck and their skull. And at their brain stem, or in the back of their head, we have the second parasympathetic nervous system, so I’m going to work that area as well to try and get the patient’s body to calm down. 

Now, while I’m doing my cranial sacral treatment on the patient’s skull, my hands are on the various bones of their skull, as well as using intention down into their brain to try and figure out where they may have some more fine-tune restrictions with inside their brain or their brain stem. So that’s why the treatment will take 30 to 45 to 60 minutes.

So as we’re going through the patient’s body, we’re looking for areas of where they have increased stress or blockage, and then we want to try and open those areas up so that the patient will have better cerebrospinal fluid flowing from their brain down through their spinal cord. And, again, the cerebrospinal fluid, as well as the cranial system, its job is to surround, protect, and nourish the central nervous system, which, again, is the brain and the spinal cord. Once we do that, that helps put the body in homeostasis, or balance. Once we have the patient’s body in homeostasis or balance, the patient is relaxed, their pain is usually gone because when your body is in homeostasis and functioning correctly, the body shouldn’t have pain.

Molly: That’s so good to hear, and I appreciate you kind of walking us through step by step of what people can expect if they’re going to get this type of treatment.

How can one use this kind of therapy — how can we use it in our toolbox? Is it best for preventative treatment? Is it better to have it while you’re in the midst of attack?

Dr. Healy: My patients use both methods. They usually first come to see me because they’re in acute distress with headaches or neck pain. There are a lot of other comorbidities that go along with migraine headaches. Patients are depressed. They have anxiety. They have hormonal issues. 

And now when I’m talking about hormonal issues, I’m talking about — usually it’s female patients that are on their menstrual cycle. They have increased cramping, or they end up with increased migraine headaches. They’re taking birth control pills, which is a side effect that can give them headaches. And certain other mediations for high blood pressure can also give you headaches as well.

During pregnancy, your hormones can change, and also while you’re delivering the baby, your hormones will change also. So those hormonal issues that occur with our patients need to be looked at as well, and we need to treat the patients if they’re having headaches for that.

Molly: Wonderful. And you brought up a good topic, pregnancy. Is there one type of person who could benefit most from this, from cranial sacral therapy, or is there anyone that should avoid it, like, say, in pregnancy?

Dr. Healy: Cranial sacral therapy can be treated from womb to tomb, and a lot of female patients that are pregnant do really well with cranial sacral therapy. Again, it is a very gentle approach, using about 5 grams of pressure, which is about the weight of a nickel. So we’re able to release a lot of fascial strains that are inside the fascia, the muscles, the ligaments, the tendons, as well as in the cranial sacral system in the membranes. 

So, with pregnancy, this tends to work well, especially as the woman is progressing through her pregnancy. She’s gaining more weight. Her body positions are changing. We’re able to help with some of those pains that she’s experiencing during her pregnancy.

Molly: Is there anyone who might not benefit from CST or should avoid this type of treatment? Say someone has certain medical conditions.

Dr. Healy: Yes, there are definitely some contraindications to cranial sacral therapy. Number one, if a person is having an active brain bleed or stroke, you do not want to be doing cranial sacral therapy on them. Someone with a recent skull fracture, you do not want to be doing cranial sacral therapy on them as well. Someone with aneurysms in their brain, you do not want to be doing cranial sacral therapy on them as well. And individuals with encephalitis that don’t have a shunt, because you don’t want to increase the intrathoracic pressure inside their head, which could cause them to have some other medical issues.

Now, there is another contraindication that a lot of us tend to not remember. Using cranial sacral therapy, there is a release that we do, which is a suboccipital release behind the patient’s head. If the child is under the age of 11 or 12, that has to be done very gently or by a highly skilled practitioner because there’s a suture behind the head called the lambdoidal suture that is not fused until the age of 11 or 12. So if you treat that and you do it incorrectly, you could cause some significant biomechanical issues for that child.

Now, also the buyer needs to beware, or the patient needs to beware. Not everybody who is trained in cranial sacral therapy should be doing cranial sacral therapy. Now, the best individuals to go to see for cranial sacral therapy are either an MD; a DO, which is an osteopath; a doctor of chiropractic; someone like myself, who is a physical therapist; an occupational therapist; or a massage therapist. We are all trained in the body in anatomy and physiology and in pathology. 

Laypeople can actually go and take courses in cranial sacral therapy that don’t have a lot of knowledge in anatomy. And when they take one course, they can throw a shingle out and say, “I’m a cranial sacral therapist.” So when you’re going to receive cranial sacral therapy, you want to make sure the provider who’s giving it to you is well versed in doing that.

Molly: OK, and that’s an excellent point. I know I did want to make sure we find out who should we look for in a — and what should we look for in a provider, so definitely appreciate you giving us that information.

I want to ask, What are the limitations of this kind of treatment? Because from everything you’ve said, I’m thinking sign me up. This sounds like a great experience to have. But, of course, just like with anything, there has to be some limitations.

Dr. Healy: Well, in all modalities, each individual patient is individual to themselves. Not everybody’s going to feel exactly the same when we do cranial sacral therapy on them or they’re going to get the same benefits. It’s individually provided to the patient, and the patient has their own experience with it.

Now, are there limitations with cranial sacral therapy? Yes. And what are those limitations? That’s a great question. In my experience with it, the patients will receive relief of pain, relief of anxiety and stress, and they’ll have more energy. Now, that doesn’t last very long once we first start treating the patient, because you got to remember, when the patient comes in to see us, they’ve had a problem for a year, two years, three years, four years, five years. So they’ve had a lot of built-in compensations within their body. So the limitation is it’s not a one-treatment fix. So that’s the biggest limitation. 

And it’s going to take some time when we treat the patient to decrease those compensations that they had. And once we can make improvements in those compensations, then the patient is weaned off cranial sacral therapy and set up on a home exercise program. At least that’s what we do with physical therapy. And then we teach them how to do self-mobilizations to themselves so that they can actually have a program at home so they don’t become dependent on us to do the cranial sacral therapy for them every week.

Molly: Wonderful, and that’s so great to hear. We all have different expectations, and so we should make sure we’re realistic in those expectations. And everybody’s bodies are different. I know migraine patients totally understand that because everyone’s experience is unique and on their own.

So I do want to ask — and I’m sure it’s different everywhere — can this type of therapy be covered by insurance?

Dr. Healy: Some insurances cover it, depending on what the problem with the patient is. That’s why when you come into the office, we’re doing a medical evaluation on you from a physical therapy standpoint. If we find musculoskeletal structural deficits, then we’re treating those that are actually causing the headache. 

So what we do in physical therapy is we’re trying to find what we call the primary lesion, or what is causing the patient’s problem. Our job is to find that primary lesion, secondary, or tertiary lesion, which means their first, second, and third problem, and set them up in a hierarchy. And then we go after treating those dysfunctions.

Now, cranial sacral therapy could be a part of that, as well as using some other treatment techniques like muscle energy, Jones strain-counterstrain, therapeutic myofascial release, therapeutic exercising. And then with that, it would be covered by the insurance company because we’re treating the biomechanical structural deficits that we’re finding with our patients.

If you’re just coming in because you just want to get overall relief and have more comfort in your life, then, no, there’s no biomechanical deficits, then that is a self-pay. 

Now, there is definitely one insurance company that does not pay for cranial sacral therapy as a treatment by itself, and that’s Medicare.

Molly: OK, and that’s all good information to know. I know I kind of threw that out at you, and, of course, everyone is different. All insurances are different, which reminded me of another question. With physical therapy, you oftentimes have to get a referral. Do patients need a referral to have cranial sacral therapy?

Dr. Healy: That’s a great question, and the reason why that’s a great question, Molly, is because in Rhode Island, we have direct access, which means a patient can come see us without a physician prescription. And I believe now all 50 states allow direct access, which means a patient can go see their physical therapist. And currently in the United States, all physical therapy programs are a doctoral-level program. So all the physical therapists come out are doctors of physical therapy. 

Unfortunately, the insurance companies haven’t caught up to that yet, and the insurance companies are still mandating that we have to have a referral for them to come to physical therapy, at least in Rhode Island. Some states, in each state law differs, but definitely in Rhode Island, we need a physician’s prescription to have physical therapy to be reimbursed by your insurance company.

Molly: OK, and that’s good to know. And, again, it’s different everywhere, so it might be good to call your insurance, if you have insurance, ahead of time and kind of get a little bit more understanding. Insurance can be tricky sometimes. Better leave it to the experts.

All right, so, Dr. Healy, we love this conversation that we’re having, and we hope our viewers and listeners at home have learned a lot. We do have a few questions from our followers, and I think some of them we already got to within the conversation. But if it’s OK with you, I’ll ask you a couple questions that we got online. Does that work?

Dr. Healy: Certainly.

Molly: Awesome. OK, so our first question is, Can CST help with visual aura associated with migraine?

Dr. Healy: Now, cranial sacral therapy, again, is treating the central nervous system, which is your brain and your spinal cord, within the cranial sacral system itself, which is your cranial bones, the cerebrospinal fluid inside your brain going down through your spinal cord. And if there are structural deficits that we find that are causing the migraine headaches or the auras that we’re treating, then some of those auras and headaches may decrease with cranial sacral therapy.

If there is no structural abnormalities in the cranial bones or in the structures around the person’s brain where they’re getting the auras, then, no, cranial sacral therapy will not be effective. But if there are biomechanical structural issues that are there, then the answer is there is a chance that it would be helpful.

Molly: Wonderful. Thank you for that. And we talked about hormones a little bit earlier. We had a question from one of our followers that they want to know, Can CST help reset hormones? Which I assume they mean, Can it help get their hormones back into balance?

Dr. Healy: If we’re able to rebalance the cranial sacral system, the patient may have some benefits with their pituitary gland, which is the master gland which controls our hormones. If there’s a structural dysfunction that is preventing the pituitary gland from working optimally, then, yes, we can change the structures that are around there, and it should be helpful. If there is no lesion that is there that’s causing any structural abnormality there, then, no, it’s not going to help. Then it’s a hormonal issue purely itself. OK?

Molly: OK, that’s a great answer and good to make that clarification. One last question we had from one of our followers is — and we kind of touched on this — but how long can results from CST therapy last, and is there any way or anything you can do to help them last longer?

Dr. Healy: That’s a great question. As we said earlier, cranial sacral therapy, as well as all different types of therapy, are individualized to the patient. So each patient’s going to have their own experience, and depending on how long they’ve had the compensations will determine on how long they may take to get better. 

The majority of the patients, after you do your first cranial sacral session with them, they feel better. They either have much more relaxation or more energy. Now, taking that into consideration, the patient may need to come in — after we do our evaluation and we figure out what’s going on with them, they may come into therapy once a week, twice a week. And our programs usually run anywhere from four to six to eight weeks of treatment, and then usually the patient is discharged at that point.

Molly: Is there anything else that you want to share with us and our followers about CST and how it can help with migraine?

Dr. Healy: Well, CST is one type of osteopathic treatment that can be utilized to help with migraines. There are also other various modalities that we use in manual therapy as physical therapists, as well as osteopaths will do in their office while they’re treating you. So this is just one aspect that’s in our treatment bag that will help us help our patients get better.

So, again, that’s why the evaluation is really important, because we need to see which modalities we may need to use while we’re treating the patient. So, during that treatment, I could be doing some muscle-energy technique as well as some myofascial release with cranial sacral therapy. So I may be using different manual-therapy techniques throughout that entire session to help the patient get better faster.

Molly: What an amazing discussion. I so appreciate Dr. Mike Healy for joining us today. He’s the owner and president of Healy Physical Therapy and Sports Medicine. I’ve learned so much. I hope people at home have learned a lot as well. Dr. Healy, we’ve been so pleased to have you as a guest.

Dr. Healy: Molly, thank you for having me, and I would also like to thank the Association of Migraine Disorders for having me today.

Molly: And that wraps up this episode of Spotlight on Migraine. I’m Molly O’Brien, with the Association of Migraine Disorders. Thanks, everyone, for watching.

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Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.