The Patient’s Struggle with Chronic Migraine

Today I saw a patient with migraine a week after our treatment at Ashirvad. She had been referred to me by her brother, a senior radiologist of Mumbai for this problem who had called me initially to discuss her of very severe migraine in detail because he was very worried about his sister who had become so disheartened by this pain that she had expressed the idea that she was even considering suicide as an option because of the daily misery of her pain.

This lady, around 50 yrs, travelled from outside Mumbai for our treatment. She had presented last week with a history of migraine with daily headaches around the eye, forehead and the temporal region more on the left side, and sometimes on the right side of head and face also. The pain was so severe that she was very very disheartened, fearful and highly anxious. Daily waking up in the morning with pain, which kept waxing and waning throughout the day reaching its zenith by evening and night. Fortunately, she was able to sleep for a few hours but only to wake up again with pain in the morning. Continuous daily headaches had made her feel that there was no way she could continue to live like this for the rest of her life.

The areas of the pain were so tender that neither she could touch her face or wash her face without pain, nor allow us to examine or touch the area around her left eye, temporal area, forehead, and even cheeks. She was very nervous about the pain. She did not complain much of any neck problems.

Explaining the Muscle Connection in Migraine

I explained to her, and her brother about our understanding at Ashirvad that migraine is expressed through muscles and the muscles involved in a patient like her might be the muscles around her eyes, forehead and cheek muscles or muscles of mastication which are involved in chewing and talking. And of course, the muscles of the front and back of the neck which would trap all the nerves to the neck and head in their tightened grip.

How Nerves Contribute to Chronic Migraine Pain

The face receives its nerve supply from the fifth cranial nerve called the trigeminal nerve, but the muscles of the front of neck that reflect their pain around the cheek and eye receive their nerve supply from another cranial nerve called the spinal accessory nerve and those at back of neck receive their nerve supply from cervical (C1,C2,C3) nerves. One of them is called the greater occipital nerve. Many Pain Specialist target the greater occipital nerve for migraine treatment. This lady also had received an injection for the greater occipital nerve but the injection itself did not give her long-term relief. She had partial relief for about probably a month.

Since the nerve treatment had not helped her, I told them that I would keep pulse radio frequency treatment for all the involved nerves mentioned above as a secondary treatment, if there was any residual pain after our main treatment which would systematically address all the muscles of face head and neck. She was also not very keen on doing nerve procedure since it had not helped her. I further clarified that if we decided later to do this Pulse Radio frequency (PRF) treatment, it would not be confined to just the greater occipital nerve, but the complex of C1, C2 and C3 nerve as well. These nerves and the trigeminal nerve usually act like two sides of the same coin. Problems of C1 C2, C3 are reflected in the trigeminal area (face) and patients with trigeminal neuralgia have problems in the muscles of neck supplied by C1, C2 and C3 nerves. This is because the trigeminal nerve has a part of it which descends into the cervical spinal cord called the descending nucleus and it is this descending nucleus that carries the pain fibres of the whole trigeminal nerve supply. So though the pain is coming from the face, it actually descends into the neck before going back to the brain.

Planned Treatment Approach: Targeting the Root Cause

I explained to her that after the Botox and needling If there is still some element of pain, then I might consider PRF. But right now, I would like to focus on the muscles of the neck and face after doing the check needing to see which are the muscles which are involved.

I further explained to them that I would be doing a check needling under vision with ultrasound guidance to see which of her muscles were most reactive to needling and also muscles replicates her pain when needle enters it. If her pain is provoked, that would definitely be the culprit, and I would target these reactive/painful muscles with Botox.

Check Needling Findings and Botox Injection

She agreed to this, and when we did the check needling, we found that the front of neck muscles did not provoke much pain in her face, but the back of neck muscles were very irritable even though they did not provoke her pain, but they were very irritable and painful in themselves. The interesting thing was that it was her forehead and masticatory muscles (the muscles of chewing and talking, which are supplied by the trigeminal nerve that were maximally involved in her pain). Though we had covered her with painkillers before doing check needling she said, this is exactly my pain when you’re putting this needle, and it’s extremely painful to me, She said that “look this is provoking my pain” So with this understanding that we had found which was the positive factor in her migraine, we visualized these muscles involved in the chewing and then systematically injected Botox into them. They have complex names like the medial and lateral pterygoid, masseter, temporalis and the digastric muscle. All these muscles were targeted with Botox. The doses were decided according to the amount of pain provoked or the muscle reactivity and it’s an ultra low-dose, This kind of a dozing only relaxes the muscle, but will not weaken it in anyway, so there is no risk of any problems coming because of the Botox. We also injected Botox into her neck muscles which were painfully reactive because they had shown a lot of irritability and would be a part of her pain as well.

Positive Early Results After One Week

Today, a week later, she came for a follow up. I was very happy to see her tentative hopeful smile. The frequency and intensity of pain had been reduced in that, the first 2 days after our treatment she had no pain but in the In the last five days, her migraine pain which was continuous every day had become about 30-40% less in intensity and there were periods when she was quite comfortable. Interestingly she said that, suddenly, in the morning my pain went up. I explained to her that this is because of the stress and fear of what she might hear from me when she came for the consultation. She was worried that I might say that her pain might remain at this new reduced level. I assured her that the Botox action had just started and was expected to increase so that the pain would come down even further in the next 2 to 3 weeks.

The Road Ahead: Continued Improvement Expected

Botox takes 2-3 weeks to act so which means in the next 2 weeks, her pain would come down even more about 50-60% of her original pain. This is because, we have used ultra low-dose Botox, which will only take out the most intensely painful muscle knots but the milder, less painful muscle knots will still persist. But when we fine tune the Botox effects with ultrasonography guided dry needling (USGDN) it would systematically target all these residual muscle knots and relax her painful muscles to make her more and more comfortable in the coming 2 weeks. That is the reason why at Ashirvad we always impress on the patients that we need to do post Botox needling to take out these small muscle and as a result, the whole muscle gives up its pain and becomes relaxed, and her migraine will be a lot less and disappear completely in another 2 to 3 weeks. However, since migraine is intimately related to emotional status, she might get occasional headaches for a few more months. When I say occasional, it may be once in a month or once in 15 days, but as she understands that stress and tension are her major triggers, she can control it with medication, relaxation, pranayama and mindfulness practices which we would teach her. In addition, I would also teach her certain acupuncture pressure points whereby applying pressure she can control her occasional headaches if it occurs.

Holistic Care: Mind-Body Approach and Patient Confidence

We did a session of USGDN for all her involved muscle and after this session and the comforting face and head and neck massage thereafter, her smile got bigger and brighter!

This kind of hand holding and personalized communication is essential not only to migraine patients but all chronic pain patients because they should feel confident that they have someone in their corner, someone who not only cares for them but also has the capability to find answers for them. It is this confidence that helps them more than any medicine or injection can. At Ashirvad we try our utmost to instill this confidence in our patients. When I see her next week I will ask her to write a small note to add to this .