Numerous over-the-counter headache medications are freely available and widely utilized. Prescription medication use is on the rise. When seeking headache relief, many people look first to medications, before exploring natural, less invasive approaches such as normalizing sleep habits, eliminating caffeine, exercising, taking up meditation, or seeing a chiropractor.

Medications risk making headaches worse
As reported in The New York Times ("A Hidden Cause of Headache Pain"), four percent of Americans suffer headaches daily, and "a growing number of headaches are being caused by the very medications taken to alleviate them." The statistics are alarming. "Half of chronic migraines " and as many as 25 percent of all headaches, are actually 'rebound' episodes triggered by the overuse of common pain medications." Both prescription and over-the-counter drugs have been implicated. Stephen Silberstein, MD, professor of neurology at Thomas Jefferson University in Philadelphia notes that, "If a patient's headaches have grown markedly worse or more frequent, the problem is almost always medication overuse." Headache specialist Robert Kunkel, MD, adds, "Overuse has less to do with how many pills you take than with how often you take them."

The Times also reports that two prescription medications with a high likelihood of causing rebound and dependence, Fiorecet and Fiorinal (both of which combine aspirin, caffeine, and the barbiturate butalbital) have been banned in Germany but are still frequently prescribed in the United States. But even over-the-counter drugs, particularly those with caffeine, like Excedrin, are often associated with rebounding. And between coffee, tea, colas, and other soft drinks, caffeine intake can easily add up. Regarding caffeine, New York pain specialist James Dillard, DC, MD, CAc, is emphatic, "Many headache sufferers don't actually get completely off all caffeine beverages. And they will not get better until they do."

A matter of perspective
If pain is seen as an unwelcome intruder or a dangerous enemy, it seems reasonable to do whatever is necessary to eliminate it quickly. From this angle, attacking the pain with strong weapons from the medical arsenal is logical.

But is this the best perspective from which to consider pain? Practitioners of natural healing arts including chiropractic, massage therapy, and acupuncture say there is a better way, asserting that pain is a meaningful signal, a potentially helpful message from the body that highlights the need for a change in behavior or removal of an irritant. This perspective calls on the patient, in partnership with his or her doctor, to look for ways to remove the cause of the headache rather than suppressing its symptoms.

This is the hallmark of methods broadly categorized as holistic, natural, alternative, complementary, or integrative. Patients are asked to become active participants in their health care rather than passive recipients of treatment, as doctors and patients join forces to probe deeply for possible causes of imbalance. With headaches, there can be numerous causes or combinations of causes, including spinal joint dysfunction (subluxation), muscular imbalance and tension, negative reactions to certain foods or medications, sleep disturbances, emotional stress, or environmental causes such as chemical irritants in the water or air. A truly holistic approach considers all the possibilities.

Chiropractic vs. medication for headaches: two studies
Suppressing headache symptoms with medications may not be safest or most effective approach for many headache sufferers. When chiropractic adjustment (manipulation) of the neck was compared to a widely utilized medication (amitriptyline) in two head-to-head trials, it demonstrated superior long-term benefits.

In a landmark study¹ published in the Journal of Manipulative and Physiological Therapeutics, Patrick Boline, DC, and colleagues at Northwestern University of Health Sciences compared these two approaches for patients with tension-type headaches, which generally start in the neck and may radiate to the front or sides of the head. Each group was treated for one month, after which the treatments were discontinued.

The results were fascinating. During the treatment phase of the trial, pain relief (decreased intensity, duration and frequency of headaches) among those treated with medication was similar to the chiropractic group. But revealingly, the chiropractic patients maintained their levels of improvement after treatment was discontinued, while those taking medication returned to pre-treatment status in an average of four weeks following its discontinuation. This strongly implies that while medication suppressed the symptoms, chiropractic addressed the headaches at a more causal level. A subsequent trial² by the same group of researchers found that migraines were also responsive to chiropractic adjustments and that adding amitriptyline to chiropractic treatment provided no additional benefit.

In an influential, wide-ranging article³ in Annals of Internal Medicine ("Chiropractic: A Profession At the Crossroads of Mainstream And Alternative Medicine"), William Meeker, DC, MPH, and Scott Haldeman, DC, MD, PhD, included a summary of research on spinal manipulation in the treatment of headaches. Seven of nine controlled trials showed positive results.

Normalizing sleep cycles
Research on the relationship between sleep cycles and migraine⁴ conducted by Anne Calhoun, MD, and colleagues at the University of North Carolina demonstrated that normalizing sleep cycles results in significantly decreased headache frequency. Among their other findings, one that stands out dramatically is that three-quarters of the patients were overusing medication.

How were sleep cycles brought back to normal? As reported by WebMD, the women were "told to schedule eight hours of time in bed each night, not to read or watch television or listen to music in bed, and to limit their fluid intake beginning two hours before bedtime." They also were taught how to use visualization to fall asleep quickly and were instructed to move dinnertime to four hours before bed to ensure sounder sleep.

The women assigned to the control group were told to schedule dinner at a consistent time each night and were taught to use an acupressure point that had no known relationship to headache.

Acupuncture
Acupuncture has long been reputed to be helpful for headaches. A recent study⁵ published in the journal Headache explored whether adding 10 acupuncture treatments to standard medical management would improve patient outcomes among people with chronic daily headaches. Medical care alone offered no measurable benefit, while supplementing medical management with acupuncture resulted in improvements in health-related quality of life and reports by patients that they suffered less from headaches.

Massage
Massage therapy may also be helpful for tension headaches. In a small study⁶ involving four patients published in the American Journal of Public Health, Christopher Quinn and colleagues showed a decrease in the number and duration of headaches using methods including trigger point therapy, myofascial release and manual neck traction.

Yoga
Last but by no means least, yoga has been shown to help people suffering from migraines. A 2007 study⁷ published in the journal Headache compared people practicing yoga for three months to a comparison 'self-care' group. Headache intensity and frequency, three different pain indexes, anxiety and depression scores, and medication use were all significantly lower in the yoga group compared to the self-care group.

The bottom line on headaches? Medication should be the choice of last resort, not first. Chronic, long-term use should be considered overuse, even if the medication dosage is not abnormally high. Natural methods are safer and, in many cases, more effective.

Daniel Redwood, DC, is Editor-in-Chief of Health Insights Today.

REFERENCES

1. Boline PD, Kassak K, Bronfort G, Nelson C, Anderson AV. Spinal manipulation vs. amitriptyline for the treatment of chronic tension-type headaches: a randomized clinical trial. J Manipulative Physiol Ther. Mar-Apr 1995;18(3):148-154.
2. Nelson CF, Bronfort G, Evans R, Boline P, Goldsmith C, Anderson AV. The efficacy of spinal manipulation, amitriptyline and the combination of both therapies for the prophylaxis of migraine headache. J Manipulative Physiol Ther. 1998;21(8):511-519.
3. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. Feb 5 2002;136(3):216-227.
4. Calhoun AH, Ford S. Behavioral sleep modification may revert transformed migraine to episodic migraine. Headache. Sep 2007;47(8):1178-1183.
5. Coeytaux RR, Kaufman JS, Kaptchuk TJ, et al. A randomized, controlled trial of acupuncture for chronic daily headache. Headache. Oct 2005;45(9):1113-1123.
6. Quinn C, Chandler C, Moraska A. Massage therapy and frequency of chronic tension headaches. Am J Public Health. Oct 2002;92(10):1657-1661.
7. John PJ, Sharma N, Sharma CM, Kankane A. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache. May 2007;47(5):654-661.