Can chiropractic care help my migraine headaches, I found myself wondering while sitting in the treatment room of Matthew Kowalski, D.C. for the first time. Why was I here? The reason was simple. Migraine was destroying my life. I weighed just 95 pounds soaking wet, I had stopped taking all pain relievers a few weeks prior to stop the rebound cycle, and I failed my first round of Botox (maybe because I was in a rebound cycle or because Botox takes several rounds to become effective.) I had just quit going to a provider who berated me for starting Lexapro, because in his world that interfered with “his treatment.” I had no faith that a new medical provider was going to fix me.
To my surprise, Dr. Kowalski did not promise to fix me. He did ask me about my medical history, which I gave to him on autopilot because I’ve given it out hundreds of times before. I remember wondering why he was wearing a suit and a tie. Did he have an important meeting afterwards? Later, I learned that I was the important meeting. All of his appointments were important and he dressed up for every treatment session. Unlike many providers before him who usually boasted during initial consultations that they would be able to cure me, he did not make any such promises. He simply said that he would try to help.
Referred By A Headache Specialist
I was referred to Dr. Kowalski by my headache specialist, Carolyn Bernstein, M.D., author of The Migraine Brain. They both work in the same office, The Osher Center at Harvard Medical School and Brigham & Women’s Hospital in the Boston area in Massachusetts.
I had googled if chiropractic care helps migraine headaches before coming to see him. I did not find a concrete answer, but I trusted my headache specialist. To my surprise and relief, the treatment started helping right away and I attended my appointments once a week for over a year even though his office was located an hour away from my home.
At Migraine Strong we believe in a multi modal approach to treating migraine. We call it the “Treatment Pie.” Chiropractic care is a perfect example of a treatment for migraine headaches that would fall into the “other” category in the Treatment Pie. In addition to chiropractic treatment I was following a migraine elimination diet (Heal Your Headache), taking my preventive medications, receiving Botox and nerve blocks, meditating, and taking supplements (Magnesium and Ginger). It turned out that chiropractic treatment helped me end my daily migraine headaches.
The following is my interview with Dr. Kowalski to provide you with more information about how chiropractic care can help migraine headaches so you can make your own decision whether to give it a try.
Question 1: Can you tell us about your experience as a chiropractor?
Dr. Kowalski: I graduated from the National University of Health Sciences in 1990 and continued my training in a two year multidisciplinary orthopedics residency. The residency program included rotations through spinal surgery, orthopedic surgery and rheumatology, as well as a strong focus on diagnostic imaging. That experience lit a fire in me. I wanted to practice collaboratively with other healthcare practitioners. In 1992, I returned to Boston with the mission of integrating chiropractic care into allopathic health care. I always believed that this was the best way to serve my patients.
In 1994, I was successful in gaining privileges at Braintree Rehabilitation Hospital, which was a first for a chiropractor in the Northeast. At the same time, I owned and operated several chiropractic offices under the name New England Spine Institute, PC. I worked collaboratively with physicians of many disciplines, including internists, primary care, neurologists, occupational medicine and orthopedists. It took a while, but we broke new ground in health care delivery. Physicians who previously criticized chiropractic treatment began working together with us for the benefit of our patients.
Question 2: Where do you currently work?
Dr. Kowalski: In 2000, I was invited to help develop an integrative care center within a Harvard teaching hospital, Brigham and Women’s Hospital. It was fascinating. Chiropractors, acupuncturists, massage therapists and other “non-traditional practitioners” collaborated with neurologists, psychiatrists, internists and rheumatologists to teach each other about our care approaches. Ultimately, we created the infrastructure for the Osher Clinical Center at Brigham and Women’s Hospital.
After 22 years of private integrative practice, I took a leap of faith and joined the Osher Clinical Center at Brigham and Women’s Hospital full time, closing my practices in 2017. It was time to focus my efforts on advancing integrative patient care through education and research.
I have had the pleasure of working collaboratively with Carolyn Bernstein, MD, the author of “The Migraine Brain,” for about 2 years.
Question 3: Do you experience migraine?
Dr. Kowalski: I suffer from ocular and vestibular migraine. I have been experiencing migraine since I was 14 years old. At times the attacks were debilitating and confined me to a dark room for a day or two. Over the years, I tried diets, herbs/supplements, acupuncture, massage, preventive medication, Botox, exercise and chiropractic care for migraine headaches. Similar to many migraine patients that I treat, I became my own experimental laboratory. At the same time, I was treating patients with migraine and getting great results. As any migraine sufferer can appreciate, there is no single formula.
Question 4: How much chiropractic treatment is recommended?
Dr. Kowalski: For patients under my care, I like to see a trend toward improvement within about 6 treatments. Keep in mind that successful outcomes are dependent on both the provider and patient doing their part. Exercises, stretches and lifestyle changes are a big part of the success.
I commonly treat patients 1-2 times weekly. The majority are once weekly. Treating a patient multiple times a week is rare in my practice.
I give a lot of homework assignments to my patients. Remodeling a poor posture or changing habits takes a lot of effort on the patient’s part. I look at my care as a combination of hands-on care and a guide in the migraine relief journey.
During our pilot study (discussed below), patients were provided 10 treatments over 14 weeks. A panel of chiropractors were consulted to examine our protocol and there was strong agreement that this number was sufficient to determine a treatment effect.
Some patients see results immediately. Some patients may need as many as 15-20 treatments to appreciate a solid effect.
Establishing Efficacy of Treatment
Sometimes, patients will need treatment twice weekly to establish the efficacy of treatment. At times, patients have intense muscle tension, joint dysfunction and difficulty properly accomplishing their home exercises without close guidance. Also, sometimes the spinal joints are remarkably restricted and require a greater effort to help them become optimally restored.
After a therapeutic trial has been completed, and the patient has reached a plateau in care, a conversation needs to take place that focuses on maintaining the appreciated gains. Care is typically tapered off. I usually tell my patients that we will find a “sweet spot” in their care; that is, a point at which the care frequency is enough to maintain the gains. If symptom deterioration occurs, the frequency may need to be altered. Many of my migraine patients request treatment every 3-6 weeks.
Question 5: What should a patient bring to an appointment with a chiropractor?
Dr. Kowalski: I like when patients come in with a well-documented log of their migraine days, even through some of the available apps. This is helpful because (1) the memory for pain is poor. A lot of people don’t recognize that they have appreciated relief until they see the actual numbers, and (2) improvement is sometimes slow and difficult to track. But, if treatment simply reduces the frequency by 2 migraines a month, that means that the patient had nearly one fewer month of migraine a year. This number might not seem like a big deal when someone is experiencing 20 migraine attacks monthly, but it is as good as some prescribed preventive medications.
Also, bring copies of any diagnostic imaging studies that have been performed. Make sure to write down your medications and nutritional supplements.
Question 6: What makes a migraine patient a candidate for chiropractic treatment?
Dr. Kowalski: That is a great question, one that we are working to figure out. I personally find that patients with primarily hormonal migraine to be the greatest challenge. I find patients with associated TMJ pain/dysfunction, neck or back discomfort to respond best.
There is no true “cure” for migraine. It is all about effective management. I have treated patients who were experiencing 15 migraine attacks monthly who reduced to a total of 1-2 per month with chiropractic treatment. There are “responders” and “non-responders” to every treatment approach. The key might be in combining therapies.
Question 7: Can a chiropractor help all types of migraine? Classic migraine? Vestibular migraine? Hemiplegic migraine?
Dr. Kowalski: It’s difficult to determine the therapeutic impact of chiropractic treatment for different sub-classifications of migraine. We simply don’t yet know the answer to that question. I don’t want to say “yes,” because there are people in all categories who respond, and the opposite is also true. In order to be academically honest about this, we need multi-site clinical trials.
Question 8: Do you have any recommendations for how to find a reputable chiropractic provider to treat migraine?
Dr. Kowalski: I think that forums such as this and the Migraine Strong Facebook group are a great way to sort out a reputable practitioner of any profession. Also, ask friends and your doctors. Some of the on-line rating services can be helpful, but keep in mind that they commonly represent comments from unsatisfied vocal few.
Question 9: What role does neck play in migraine?
Dr. Kowalski: About 60% of migraine sufferers experience neck and upper back pain and muscle tension; perhaps as a migraine trigger, a result of the migraine, or both. Muscle tension, joint pain and joint dysfunction may all contribute to a person’s pain burden and steal their reserves of energy, bringing them closer to the migraine threshold.
Chiropractic care works to correct spinal dysfunction, relieve joint and muscle strain and improve the function of the nervous and musculoskeletal systems. This is accomplished through a combination of exercise, postural correction, lifestyle changes, diet and hands on therapy. Hands on treatments usually include some form of chiropractic adjustments (spinal manipulative therapy) and soft tissue release therapy.
Take a look at this blog if you experience neck pain with migraine.
Question 10: What are upper cervical chiropractors and do you recommend their services? Are the results of these chiropractors any different?
Dr. Kowalski: Upper cervical chiropractors NUCCA (National Upper Cervical Chiropractic Association) concentrate on optimizing the function of the top two vertebrae in the neck. There isn’t one form of chiropractic treatment that has proven superior to the others with regard to migraine management.
My recommendation is this: if one form of chiropractic care doesn’t help your migraine headaches, don’t conclude “chiropractic treatment doesn’t work.” Try a different form. It’s much like medication management for migraine. If one fails to provide relief, we don’t say “medications don’t work.” In fact, the best results might be found in integrating therapies.
It is very common for me to find dysfunction in the upper neck. Actually, this is probably the most common area where I adjust migraine patients. A chiropractor doesn’t need to be a member of the NUCCA approach to deliver effective upper cervical adjustments.
Question 11. What types of techniques do you use during your treatments for your migraine patients?
Dr. Kowalski: I treat patients with hands on spinal manipulation and mobilization procedures. These were the foundation of the chiropractic profession and are the most universally used by chiropractors. The term manipulation refers to a very quick and small manually applied movement to a joint at its end range of motion. Commonly, a pop or click occurs as the joint mobilizes. Mobilization, on the other hand, does not include the quick movement. Rather, more oscillatory forces are applied to the joint.
Question 12: Do you require your patients to obtain X-rays or other films prior to beginning treatment?
Dr. Kowalski: I do not X-ray every patient before providing treatment. The decision to order an X-ray, or other diagnostic imaging procedure, is based on clinical need. For example, if the patient sustained substantial trauma, has suspicion of a tumor or disorder affecting the blood vessels in the neck or head, then the correct imaging is ordered.
Question 13: Do you recommend any home exercises or therapies for migraine relief?
Dr. Kowalski: Most of my patients will receive instruction/prescription for exercises and stretches. Also, I recommend a number of self care strategies such as breathing training, meditation, soft tissue release techniques, etc.
Two of my favorite postural correction exercises are: seated postural correction and wall angels.
I commonly recommend stretches using a foam roller. A lot of patients like using two tennis balls in a sock to release the tension at the base of the skull. Simply insert two tennis balls into a sock and tie it tightly. Lay on the back with the balls at the base of the skull. Move the head back and forth, and side to side, to massage the muscles.
The Theracane is a great tool to release tight muscles and trigger points in the neck and upper spine. Apply steady and increasing pressure to the point for for a minute, or so. Also, combine trigger point compression with stretching.
Many of my patients purchase a Massage Star for self, or partner, massage of painful trigger points and tight muscles.
Question 14: Are chiropractic procedures, namely cervical spine manipulation, associated with an increased risk of stroke or other possible harms?
Dr. Kowalski: The issue of safety always comes up when discussing chiropractic care. Many patients are told by their doctors not to allow neck adjustments. Most of this advice is based on erroneous information that has been passed from generation to generation. Often times, it is simply uninformed bias.
That being said, about 20% of patients may experience some post treatment soreness after the initial couple of therapy sessions. Some may experience short term lightheadedness or even a headache.
The risks of a serious adverse event from a chiropractic treatment is very rare. Some past medical literature reports occurrences of stroke or injury to an artery in the neck that leads to stroke after seeing a chiropractor. This has been reported to be one in several million patients. What is interesting is that the percentage of patients having such outcomes is about the same as going to a medical practitioner for the same complaint.
So, how is this explained? Migraine patients have a slightly higher risk of stroke than the general population. Some patients with migraine or neck pain will see their medical doctor, some will see their chiropractor. About the same number will have a stroke or arterial dissection (a condition where an artery in the neck develops a tear from the inside). This does not establish a causal relationship between the medical or chiropractic care and the stroke. What is thought to be occurring is that the head pain or neck pain that originally prompted the person to seek care was the symptom of a spontaneous arterial dissection.
I have had patients who had previously suffered a vertebral artery dissection years BEFORE coming to me for treatment of migraine. Did I adjust the patient’s neck? No. Chiropractors can offer other treatments for high risk patients. A few years ago, a well respected neurologist referred a patient to me who had suffered two previous vertebral artery dissections. My treatments focused on soft tissue therapies and patient generated postural corrective activities.
Also, last year, a patient who I previously treated for low back pain (2 years prior) contacted my office because he developed a new onset of neck pain and migraine. He never came to the appointment. I later learned that his migraine attack worsened while he was waiting to consult with me. He went to the emergency room and was diagnosed with a vertebral artery dissection.
Also, one of my colleagues told me that a new patient, who was scheduled to see her for the first time for headaches had a stroke while sitting at a stop light in front of her office, before ever coming in. Can you imagine what would have happened if he had been seen by a chiropractor? Can you imagine what would have been said about the cause of the dissection?
Question 15: What recommendations do you have for patients for whom chiropractic treatment triggers migraine attack?
Dr. Kowalski: Another great question. I have certainly had patients report a migraine attack after a treatment. The question is whether it is causally related or a coincidence. If it consistently occurs, and treatment is not helping….stop and change the treatment approach. If that doesn’t work…stop. I recently had a patient that did not even tolerate soft tissue therapies or adjustments without triggering a migraine attack. Exercises and stretches also triggered migraine attacks. I stopped treatments. I wasn’t helping her, rather, it certainly seemed to me that I was aggravating her condition. Not everyone is helped by what I do. The key is knowing when to stop.
On the other hand, I have had patients who report temporary and short-term aggravation of their migraine symptoms, but ultimately improve. It’s a careful “balancing act.”
Question 16: Have you done any studies on chiropractic care and migraine headaches?
Dr. Kowalski: I have had the pleasure of working collaboratively with Carolyn Bernstein, MD, the author of “The Migraine Brain,” for about 2 years. For many years previously, I’ve known of her incredible reputation of helping migraine patients and was blessed to have her join our suite at the Osher Center. One day, she knocked on my door and said “my patients keep telling me about you, we’ve got to work together.” We decided to study combining chiropractic treatment with usual care for migraine.
Here is Case Study that we published which illustrates an integrated model of care for migraine that combined standard neurological care with chiropractic treatment. The three patients used in this case study were observed to experience improvement in pain scores, increase in pain-free days, decreased medication usage, and patient reported decreased anxiety/dysthymia. Chiropractic treatment was one component in the treatment plan and, according to patient reports, appears to have contributed to the overall therapeutic outcome.
Just recently, we completed a pilot study comparing usual care to usual care plus chiropractic treatment for 60 episodic migraine patients. The results were impressive and have been submitted for publication in a Neurology Journal. Now, we need to study it further with a multi-site investigation, using different chiropractors and different chiropractic treatment “dosages”. We are submitting a grant request for it at this time.
Thank you so much, Dr. Kowalski for sharing your knowledge with us! My experience with chiropractic care for migraine headaches showed that it can become an effective tool in the Treatment Pie. Hopefully this interview gave you enough information to seek out this option and find out if it can work for you. My advice is find a reputable chiropractor who is knowledgeable in migraine management! Feel free to reach out to me with questions here, in our Facebook group, or on Instagram!