TRANSCRIPT:

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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 sponsor, Lilly.

Molly O’Brien: Hello, and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about chiropractic care for migraine, and I’m very excited to introduce our guest today. We have board-certified functional neurologist with Imagine X Functional Neurology, Dr. Adam Harcourt, and Dr. Harcourt also serves as a specialty representative on AMD’s advisory board. Dr. Harcourt, thanks so much for joining us today.

Dr. Adam Harcourt: Thanks so much for having me Molly.

Molly: Super excited to have this conversation, and you have a very diverse background, but you started in chiropractic care, correct?

Dr. Harcourt: I did. And, actually, it goes further than that. My dad, my uncles, my grandpa, and my great-grandpa were all chiropractors, so they go back quite a ways. And so, obviously, being the rebellious child, there’s no way I was going into that, and then I did and then found functional neurology, and that’s how I got into everything else. But, yeah, it goes very far back.

Molly: Incredible. Well, I think that means you’ll be a good source for us.

Dr. Harcourt: I hope so, yeah.

Molly: Well, again, thanks so much for joining us today. Let’s start off with the super basics. What is chiropractic treatment?

Dr. Harcourt: Sure. Great question. And that gets kind of confused because when you talk about chiropractic, most people think about the manual therapies, so the adjustments and things like that. But that’s one modality that a chiropractor will use. So when you go to school, you learn all the diagnostics, all the imaging, all that stuff. And so some chiropractors will use nutrition, they’ll use exercise therapy, they’ll use massage techniques or myofascial release. But the one that kind of stands out is the manual therapy or what most people will call an adjustment.

And the idea, originally, back when we didn’t understand the brain very well, is we thought that these bones were pushing on these nerves and then you get the pressure off and people get better. But as we started to go away from what’s called the reticular theory and move to what’s now known as the neuron theory, we understand that it actually changes the way that the brain functions and it changes the understanding of where the body is in space when you free these restrictions. So say your neck or your back’s really tight. You get it moving again. Those signals get back up to the brain. You have a better idea of where you’re at in space, pain reduces, function increases, and that’s the basic idea of what we try to achieve as chiropractors.

Molly: That’s incredible, and it’s nice to be able to put something so complex so simply, make it understandable for the rest of us. How can chiropractic care or treatment help manage migraine?

Dr. Harcourt: Sure. So what I do like to say with any modality is I always say go back to the literature, and you can pick any therapy ever, and it has efficacy for migraine, right? And the reason for that is that migraine is multimodal but it also affects different parts of the brain. So every person that has migraine has a different reasoning or different area of the brain that may be affected. So, for some people, you may see that you change your diet and it’s like a miracle. Their migraines get so much better. And then their friend that has migraine does the exact same thing, and they don’t notice much of a change. It’s not because that diet was bad for that person. It just wasn’t their primary driver of the condition.

And so same thing with chiropractic. Some patients, their musculoskeletal dysfunction is the main thing that’s leading to their migraine. And so when they have aberrancies in the way that their neck or their head moves or the muscles are too tight or things like that, it drives that inflammatory response to the brain and it leads to more migraines.

And so what classic chiropractic can do is it helps increase the mobility, reduce the inflammation in those areas of the brain, and also, most importantly, because migraine is this hyperexcitable disorder, it stimulates certain parts of the brain to make them more stable and reduce their probability that they become hyperexcitable and lead to a migraine. So it’s a lot more complicated than we used to think, but it’s a very simple modality as far as going in, seeing your chiropractor, and getting treated.

Molly: Awesome. Again, yeah, a little bit more complicated, but it all makes sense. The way you put it, it makes a lot of sense. Living with migraine, I can understand that. 

Can you tell us what kind of chiropractic treatments are available for people with migraine? Like you said, a lot of people will think of the adjustments or the manual therapy. What else is there?

Dr. Harcourt: Yeah, great question. And, actually, this goes to not only the treatment, but the various types of chiropractors out there. So what I think is really exciting for our understanding of migraine is it now makes sense to me, as a practitioner, why you can have a chiropractor, for example, that does a technique where it looks like they’re barely touching, they’re barely doing anything, and it makes a huge difference, all the way up to people that look — man, that’s a really aggressive-type adjustment. I don’t know about that. But, man, it helps them so much.

Well, how can both of those be so effective? And it goes back to our understanding of the fact that with migraine patients, they all have different levels of fatigability and of stability of these different neuronal poles. So somebody that’s got a really unstable area that just needs a little bit of stimulation, they’re going to do fantastic with a lower-input type of adjustment. So something that’s just not really intense, they do great.

But, at the same token, let’s say a high-level athlete or somebody that’s doing a lot of movement, something like that may not even make a dent in changing the way the brain works. So they need something a little bit more intense. So what I like to say is if you’ve tried chiropractic, for example, if you did a classic, say, neck adjustment, and, “Man, after that I got a migraine. I’m not going back there. That was terrible.” 

And I always tell them, I say, “Look, it’s not that it was a bad thing. It was just too much of a thing that you need,” just like if you sprained your ankle, and you said, “I want to run again,” and your first rehab exercise is to run 10 miles, right? Your ankle is going to be terrible, but it’s not because of the running. You just did it too early.

So, in those cases, what we usually do is what I call low and slow. We start with lighter-type adjustment techniques, whether it’s an instrument, whether it’s low force, whether it’s a myofascial release technique. We start in the low back because you have less proprioceptive input from the low back than you do in the neck. And so if you can do well down there, we move up to the thoracic spine, then we might do some extremities, and then eventually the lower part of the neck, where you’re starting to get more input. And, eventually, we’ll work to the upper part of the neck.

And, at that point, if you can handle a manual adjustment in the upper part of the neck, you’re doing pretty darn well and you’re going to continue to do well with that modality. So it’s not that there’s one perfect way to do it or there’s one technique that’s best for you. What you have to figure out is what type of technique best serves your current state, and then try to progress from there, just like you wouldn’t start curling a hundred pounds, right? You would start at five and work your way up. It’s the exact same thing. 

So don’t be discouraged if (a) it doesn’t work and you tried something; and (b) on the other hand, don’t be discouraged if it actually makes you worse temporarily, because that means it’s actually stimulating the parts of the brain that you want to work on. It’s just way too much stimulation at that point.

Molly: Again, I think that’s a great point. We actually had quite a few follower questions on that, that people have had treatment but then it’s made things worse. So I think that really puts it in perspective, especially with the analogy of lifting weights or running 10 miles. It’s not how you want to jump in at all.

Dr. Harcourt: Absolutely not.

Molly: So we talked a little bit about some of the benefits, and you explained how chiropractic treatment and care can help with migraine. Can you talk a little bit more about the benefits, and, with that, are there any risks to seeking chiropractic care when you have migraine?

Dr. Harcourt: Sure. Great question. So what I usually say is, as far as risks go, what I try to avoid is if you’re, say, in the middle of a migraine, for example, or you’re about to get one. Over my years, I’ve had a very small percentage of patients that as they’re getting a migraine, if they get adjusted, they feel great. It’s really actually kind of unusual.

Normally, the people that benefit most are the ones that are having a cervicogenic headache, which presents differently than a migraine, and they do really, really great with adjustments. Most people, if you’re starting to have a migraine come on, that much input can actually drive those pathways and make it a little worse. Now, the reason I kind of temper that is because there are people that benefit a lot, so if you do, totally OK. But, in general, I try to avoid it if you’re in the middle or you just finished having a migraine. 

For those that are just kind of going throughout your day, you’re trying to prevent migraine, that’s where you want to see your chiropractor on a more regular basis. Just like exercise, it’s more beneficial, the more you’re exposed to it. 

As far as other risks, a little pain from not moving that joint for a long time. I liken it to the fact that if you have an exercise, like I hadn’t done a leg workout in quite a while, and I worked out, and I could barely walk up the stairs the other day. It’s not because exercise was bad for me. It’s just my body hadn’t been exposed to it for a while. 

It’s the same thing with this. If you had a joint or muscles that have been stuck in a position for a really, really long time, and you finally get movement in there, you might just be a little sore, a little achy for a day or two. That’s totally normal.

Now, that is going to create a little bit of inflammation, so I always recommend drinking lots and lots of water, and also try to avoid anything too strenuous that day, right, at least at first. Once you’ve been going for a while, you’re comfortable with it, then you can pretty much do whatever you want as soon as you get treated. 

So those are the main things I look out for, but as far as anything more serious, not really, unless you’re at really high risk. Say you’re an older person, you have a bone disorder. In those cases, we usually do the really low-force type techniques, and that’s something you would just discuss with your doctor before you got treated.

Molly: OK. And as you explain this, I think it really all falls in line with this new way of thinking on how migraine and your systems work, because I’m thinking back to when I’m in the middle of an attack, which is often, but I want that relief, right? I want that relief of an adjustment. But that goes back kind of to that old way of thinking, right, on how we thought migraine worked. So it makes so much more sense that you wouldn’t necessarily want to stimulate everything even more so in the middle of an attack.

Dr. Harcourt: Yeah, and this is why it gets so confusing, and we work with our patients to kind of figure out their combination, because it’s different for everyone, because many of my migraine patients also have cervicogenic headaches. And so let’s say the main driver of that migraine is that neck problem. Well, those people are going to do great with an adjustment, right? So you don’t want to say it’s a bad thing. It’s just not usually the most common reason for it, which is why I always back — and I have a whole pyramid that I explain to people of ways that you try to get rid of it and varying intensities of different therapies and all this stuff.

And we have protocols we’ve developed in our office that go from really light to a little bit more intense. And we’ve gotten to a point where we can pretty much get rid of migraine when it comes on without anything invasive pretty regularly, which is great. But each person has a different combination of things that they end up needing, and you just want to keep it kind of light and breezy until you go more intense.

Molly: Tricky, migraine. Everyone’s so different. 

Dr. Harcourt: I know it.

Molly: There’s no one-size-fits-all. Maybe someday, right?

Dr. Harcourt: Hopefully, yeah.

Molly: And so you talked a little bit about some of the protocols that you use within your office. If someone’s curious about seeking chiropractic care for their migraine, what’s something that they should look for in a provider or in a doctor? Because, again, people have different specialties. So what are some of the questions they might want to ask before seeking treatment?

Dr. Harcourt: Yeah, I’m still working on that, to be perfectly quite honest with you. And I even have family members and in-laws that live in different places. And they say, “Well, should I go to this guy or this guy?” And it’s like, “Well, it looks pretty good, but I don’t know for sure.” So, generally, what I recommend is the majority of people are going to have similar-type practices. A lot of them are more general. And so you go to somebody who has a good reputation, and you try them out, and you see if you like them.

And if, for example, you go and it’s, say, a little lighter-type technique and it’s fine, but it just doesn’t feel like it’s really helping you that much, that’s okay. Maybe find somebody that does more of a classic, say, diversified or Gonstead or CBP-type treatments. Whereas if you try one of those and, “Man, they were just too intense; I did not like that,” then you want to go find something that’s a little less intense, like an activator or an impulse or a NUCCA or an advanced orthogonal or something that’s on the lighter side of the stimulation spectrum.

So, again, there is no perfect method to do it, but you really just want to find somebody that looks reputable, that has a good reputation. Try them out, see if they fit with you, because another thing that I find is there’s tons of different personalities and there’s tons of different competing factors that will allow you to enjoy your experience, and it’s different for everyone. So I do encourage you to shop around a little bit and find someone you really connect with, someone that you really think is doing a great job.

Molly: Wonderful. Super helpful advice. And, yeah, it is hard because the same thing doesn’t work for everyone and not everyone meshes with certain people. 

OK, so if you are up for it, we have some questions from our followers, and I think you touched on a lot of this already, but we’ll go ahead and just kind of go over some of these questions, if that works for you.

Dr. Harcourt: Yeah, that’d be great.

Molly: OK. And you mentioned this a little bit, about benefits, but this person wants to know, “Is there a typical treatment plan or length, or is ongoing treatment usually the norm?”

Dr. Harcourt: So my theory on all treatments is you want to do the least amount of treatment without a regression of symptoms. And so what I usually find is early on — I mean, at this point, most of the people that I see have tried everything, they’ve been everywhere, and they’re typically having 15 to 30 migraines a month, right? They’re in pretty rough shape. And so, at that point, we know that they’re going to have musculoskeletal problems, which is why we’re doing chiropractic-type stuff. Hormonal, nutritional, neurological, they have all that.

So we do everything at once, and that — depending on where they’re located, right? If they’re local and we can see them in town, it might take four to six weeks of seeing them on a regular basis, changing their diet, doing hormonal testing, all these different therapies, to get to where you can move them down what I call the migraine spectrum or get the snowball rolling in the opposite direction, right, because that can be challenging when they’re having that many. And so you’ve got to stack it up front, just like exercising really hard to get your body in shape, and then you can back off.

And after we get them to where they’re starting to regress their symptoms, then what we do is we try to see them less and less and less until we get to a point where they say, “Man, I was doing great, great, great, great, and after I waited two months, it was just too long. I needed a tune-up.” And that’s where we’ll keep that person. Whereas I have others that — let’s say they have scoliosis and arthritis and they can’t really exercise that much — I may have to see them a little bit more often because they need that input into the system.

So, again, there’s no perfect, but I will say if you’re more of a chronic patient, think four to six to eight weeks of a little bit more intense regime. But if you’re having, let’s say, less than four a month, it’s going to take a lot less time in order to achieve those same results. So, again, each doctor is going to have their own approach, but that’s in general what I’ve found. 

Whereas if I see somebody from out of town, I’ll start with the nutrition and hormones first because you can do that remotely. And then when we see them, we’ll see them intensely for about a week, but we see them three, four, five times a day for different therapies. Now, we’re not doing manual therapies, chiropractic, for most of those visits, but it allows us to make that change in the brain really, really quickly so they can go home and then do it on their own. 

So, again, we’ve developed different ways to work with people out of town, out of the country, out of state, but for most of your local therapies, it’s going to be that few weeks to a month or two initial, and then decrease from there.

Molly: OK. That sounds pretty cool, though. It’s almost like a migraine bootcamp to get everything back in line.

Dr. Harcourt: That’s what I call it, yeah. And it’s a lot of fun because you can see such great changes in such a short amount of time. It’s really exciting. But the reason that I actually started doing the nutrition and hormones first is because I screwed up first and would have people do everything at the same time. And here they are detoxing off of foods or caffeine, and they’re just feeling miserable the whole week. It’s not a lot of fun. And so doing it this way makes it a lot more enjoyable.

Molly: OK, trial and error, that’s how we do [crosstalk] — 

Dr. Harcourt: We do our best, yeah. 

Molly: — it works, right?

Dr. Harcourt: That’s right.

Molly: And you kind of talked a little bit about this when we were discussing treatment types, but this person wants to know — they have hypermobility — but should people with hypermobility disorders steer clear of chiropractic care, or is it more about just finding the right provider and the right type of treatment?

Dr. Harcourt: Yeah, that’s a great question. So hypermobility is generally a contraindication for the more osseous, intense-type of adjustments. So with people that have hypermobility but I do want to stimulate those proprioceptive pathways, that’s where I’ll use an impulse device or an activator or something a lot less intense because that’s not going to really promote that hypermobility anymore.

Now, I would steer clear, generally, especially if it’s a more severe, like an Ehlers-Danlos or something like that, I would steer clear of osseous adjustments, say, in the neck or the back. But it does go back to, What am I trying to simulate in the brain? And if it is that pathway that requires muscle stretching and things like that, I just find different techniques to do that.

Now, not everyone does that, so if you do have a connective tissue disorder, you have hypermobility, you do want to make sure you find somebody that’s very familiar with that or comfortable with it and can make those adjustments as needed.

Molly: OK, wonderful. This person wants to know — and I think, again, everyone’s different — but is there actually a connection between migraine and stiffened neck, shoulders, upper back?

Dr. Harcourt: Yeah, great question. And so there is in the fact that, for example, there’s been research showing that trigger points in the SCM and even in the trapezius muscles are a huge indicator that you’re going to have more and more migraine. So what I found is I used to try to treat trigger points everywhere, right, because if you find them, you want to get rid of them. But the research is pretty clear that when it comes to migraine, it’s really just the SCMs and the traps. And so on my migraine patients, I try to narrow things down, and so we’ll go through and look for specifically trigger points in those areas. 

Now, a trigger point is different than a tight muscle, right? A tight muscle is just something that you got to work out, it’s kind of tight, it just hurts right there; whereas a trigger point, you push on it and you’ll find that it radiates to different parts of the head or the neck, and that’s a true trigger point, and that increases your chances of migraine.

There’s also studies to show that things like a cervical flexion test, where you bring your head all the way up and you turn it back and forth, if you’re restricted to one side or the other, your chances of having more migraine are way, way higher. So once you increase that range of motion, your chance of migraine goes down. 

But, again, that just goes to an increased stressor, right? It’s a lack of mobility. It’s a lack of proprioceptive input into the brain, which is going to lower the activity in the brain, which is going to make it not as stable. It’s also going to create inflammation, all those things that go along with not moving right, right? Real basic stuff. 

So the short answer is yes. The long answer is there’s many other things that contribute to that, and so we try to focus in on the ones that we know specifically affect migraine patients.

Molly: It is fascinating how it all works together and how you can train your body — and you’ve talked about this before — you can really train your body to get through this and to get better, which I think is just fascinating. 

All right, so I think we’ll wrap up with this question. Can chiropractic care affect any other migraine treatments?

Dr. Harcourt: As far as other medications, no, there’s no contraindications. Quite frankly, almost all of my patients that come in are on something, whether it’s a preventative, whether it’s abortive. That’s really common.

Now, when it comes to Botox, this is a really interesting one. So we started using a lot more low-level laser therapy because there was a study out of Brazil three or four years ago where they used a low-level laser, about 33 seconds, to all the different places where Botox is usually injected. And they followed it over eight weeks, and the reduction in symptoms was exactly the same as Botox. But once they stopped the Botox and the laser, the Botox maintained the reduction in pain, but the laser actually continued, even without doing any laser, to reduce the pain symptoms.

That was a tiny study. It was a really small one. It was the only one that I’ve seen like that. But we’ve been using a similar protocol. We’ve been kind of messing with it to dial it in, but we’ve seen the exact same thing. And, to me, understanding migraine, it makes way more sense why that would work, because what you’re doing with Botox is you’re reducing the input to that trigeminal nucleus into the areas that when they get overwhelmed, they fail, they become hyper excitable, you get a migraine.

Well, if you’re having a lot of that hyperexcitability coming from tight muscles and joints and things like that, and now you reduce it by putting Botox in there, short term, that’s going to be great, right? You’re not getting as much input. It can’t become hyperexcitable. 

The problem is those areas stay stable by activation. They produce more proteins when they’re activated. That’s what allows them to maintain their cell walls. It allows them to maintain all their organelles. And so when you stop stimulating them, they become more unstable. And this is why the studies now on Botox are showing after about three or four years, they kind of stop working because you’re no longer able to reduce that input as much as you need to to keep it from becoming hyperexcitable.

So our whole approach is the opposite way, where if you can do laser, which upregulates that activity, it does reduce inflammation, which reduces your migraine, which is great, but you’re also getting more input into those nuclei, which makes them produce more protein, makes them more stable, and reduces your chances of migraine. So even after you stop the treatments, you’re able to move more, you’re feeling better, you’re not having that reduction in proprioceptive input. So it makes sense that it would continue to reduce your symptoms over time. 

So what I usually try to do is I say, “Look, there is no such thing as a good or bad migraine treatment, because if it helps you, it helps you.” Right? That’s the deal. But something like Botox, I usually say, “Hey, that’s great to get you down to where you can function, you can do exercises, things like that. But once you’re feeling that way, let’s work on stimulating and stabilizing those areas so that now, long-term, you can eventually kind of wean yourself off of it. And, worst-case scenario, say, it comes back and you need it again; it’s always going to be there, right?”

And so that’s kind of how I try to go about it. So in a roundabout way, yes, it can be impacted by other therapies and surgeries and Botox and medications, but are there contraindications from any of those things? No. The only contraindication you would have is if you had, let’s say, a resection of maybe some muscle to decompress a nerve or you had a fusion in your neck or something like that. But most of the migraine interventions, medications, no contraindications whatsoever.

Molly: That is fascinating. I think that’s all I have to say about that. Absolutely fascinating, and I look forward to seeing some more results, I suppose, from the laser treatment going along with Botox. That’s so cool.

Dr. Harcourt: It’s super cool.

Molly: Well, Dr. Harcourt, is there anything else you want to share with our followers on chiropractic care and migraine?

Dr. Harcourt: No. I mean, I think we summed it up pretty well. I think the main thing is just try to find somebody that you’re comfortable with, and don’t be discouraged with little or too much results from a therapy. Try to find somebody that works for you.

And just keep in mind, chiropractic, as with any therapy, is dose-dependent. So find something that’s going to work. If you try it with an intense amount of input, and you try it with a little amount of input, and it really doesn’t help that much, it might not be the main thing that’s causing your problems, and that’s OK. But I would encourage you to try to explore that spectrum before you move on to the next thing, because, as we always talk about, that bucket, right, or that part of the brain that is going to be hyperexcitable has so many things contributing to it. 

So do your best to find something that works for you, right, because there’s no such thing as a migraine protocol. There is you as a migraine patient, and you’ve got to find what works best for you.

Molly: Awesome. Well, it’s been a wonderful discussion today. I would like to thank our guest for filling us in and giving us all the latest news and updates that you can possibly imagine on chiropractic care for migraine. Dr. Adam Harcourt, thank you so much for joining us today.

Dr. Harcourt: Thanks so much for having me.

Molly: It’s been a wonderful discussion. We really appreciate your time. And for all of you out there listening or watching, thank you for watching Spotlight on Migraine. I’m your host, Molly O’Brien. We’ll see you next time.

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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.