473- Spinal Manipulation Efficacy in Managing Tension Type Headaches

Welcome to the Evidence Based Chiropractor where each week we deliver the latest chiropractic research and marketing strategies all in the time it takes to get to your office. Now here's your host, Dr. Jeff Langmaid.

Hello and welcome to the Evidence Based Chiropractor. I'm your host, Dr. Jeff Langmaid. This week we are talking research. It is all about spinal adjustments, butalbital prescriptions and medication overuse headaches in adults with tension type headaches. This is a great study, lot of clinical pearls and hopefully some information that's new to you because it certainly was new to me. Before we get started I wanna say a few words about neck care. The best objective assessment tools of the cervical spine out there, bar none. Reliable assessments and exercises for neuromuscular control, proprioception, range of motion, sensorimotor integration. Check it all out@neckcare.com that link is down below. But as I said at the top, today's episode, all about research. Brand new study that came out in.

2024 and it is titled association between spinal manipulation butalbital prescription and and medication overuse headache in adults with tension type headache. A retrospective cohort study. I'll drop a link to this down in the show notes but this study is a good one. And let's pick it up with those tension type headaches. This is the most common type of headache. The prevalence of this, a whopping 26%. So there are a lot of people in your town, in your community, maybe even in your house, depending upon how many people live there that might have tension type headaches going on literally right now. Characterization, bilateral pressing, tightening, head pain and it occurs with neck pain in almost 90% of people. So clearly you can see why and how tension type headaches, cervical spine issues so intertwined. That is good news for us because as chiropractors, movement based healthcare pros, that stands to reason that we're gonna be able to make a significant impact on the quality of life for individuals struggling with these headaches. And that's what this study continues to show. So tension type headaches, they are occasionally treated with a medication prescription called butalbital and it is second line treatment, not first line treatment. And why is that? Well, most practice guidelines have discouraged the use of these medications because of poor efficacy. They just don't work very well. That's a good reason. And then there's complications. Hippocratic oath do no harm. Unfortunately in a lot of healthcare practices that gets thrown out the window. But there are complications such as withdrawal overuse and of course, as we talked about medication overuse headaches, which is totally nuts to think about a prescription that has been done done for decades, that is now guideline discordant. We'll talk about where and how it's still being provided to people, but it.

Doesn'T work very well.

It has a lot of side effects and well, guess what, when you stop taking it, your chances are, or you're taking too much of it, chances are you're gonna get more headaches. It's like, this is nuts. But it is quite often what people have to deal with in a traditional healthcare setting, which is why it's so important for you listening to, to get out there to tell your story, to ensure the people in your community know who you are and what you do. So at least they have an option to be able to do something different. First line medications for tension type headaches, acetaminophen, aspirin, tend to be those first line ones. BAL is a barbiturate, it's a sedative. That is why it is a second line therapy, of course, because of those ineffectiveness overall in those complications as well. So it has cognitive impairment that can come with this risk of that dependence and addiction. And again, it can make acute headaches become chronic because of that medication overuse. And let's talk about that for a moment. It's described as a worsening of the primary headache after overuse or discontinuation of the acute headache medication. And that occurs at least 15 days per month. That's how they define a medication overuse headache. Now important there because they're not just saying it's the overuse, they're saying it's also just the discontinuation of taking it. So somebody might be taking this because it was prescribed because they think they're doing the right thing by what their doctor told them. And then they end up with worsening symptomatology. Or acute becomes chronic with these headaches as a result of doing what they thought was the right thing. That's a massive problem and that's something where you can make an impact again in your community. Also, these medications typically also include things like caffeine and they might also include acetaminophen or aspirin. And they have not been demonstrated to be effective compared to any other treatment or even against placebo. That is a major problem. And there have been several studies that show Balbatol is commonly prescribed still despite all that for tension headaches, as a matter of fact, opioids or barbiturates were prescribed in approximately 15% of people when a study looked at a data set from ambulatory visits for non serious, 9 non migraine headaches. So up to 15% of people that end up with an ambulatory visit for a 9 non migraine headache, excuse me, are going to end up with an opioid or a barbiturate. That is staggering. It's wrong and it needs to change. Stagnant studies like this start that process. And according to data from a single US academic headache center, nearly one in five patients was currently using either opioids or barbiturates. With more than half of those individuals have been prescribed an opioid or a barbiturate. This is a problem. These things need to be looked at at a scale that we've never seen before. But that scale can start in your town. By understanding this information, by communicating it to your patients and making sure that you're getting good information. Are you asking for who their primary care doctors are? Are you communicating with their doctors so that you have a mutual understanding and that you can find out those docs where you're like, this person's just not doing a good job, let's just call.

It what it is.

And you can help other patients avoid going to that provider because they're trusting you and your ability to highlight the doctors that are making good decisions, that, that are doing what is guideline concordant, that dare I say, really actually care about their patients by not just doing what they've always done, but by understanding things do evolve, things do change. And that quite often what might have been a best option for headaches 20, 30 years ago might not even be on the radar today. So I'll get off my soapbox there. But important when we talk about relationship building for those facts and just being able to take care of people in your community. Now here's the good news. There have been systematic reviews as they highlight that have found evidence that spinal adjustments may reduce tension type headache intensity and frequency compared with sham interventions or no treatment at all. And spinal adjustments are recommended for tension type headaches by the US Centers for Disease Control. So in this study they took a look at the US TriNetX network. Over 124,4 million individuals with 89 academic medical centers and their affiliated centers are in this. Now that's the good news. The bad News is approximately 145,000 unique patients received chiropractic adjustments at the time of their query. 145,000 out of 124 million there is no shortage of opportunity for you to grow in your community. And people need you more now more than ever. That is for sure. So before matching, they had about 3,000 patients in the adjusting cohort and about 140,000 in the non adjustment cohort. And once they went through their matching, they basically ended up with shade over 3,000 patients in each cohort, one who had received spinal adjustments or manipulation, the other cohort, those who didn't. Well, guess what? Drum roll please. The incidence of betalbitol prescriptions through two years follow up from the index date was lower in the spinal adjustment cohort compared with the non spinal adjustment cohort. And after propensity matching, they found 1.7% of the spinal adjusting cohort had a butalbital prescription, compared with 3.8% in the non spinal adjustment cohort. So if you received spinal adjustments, you were literally half as likely to to have that medication than if you had not. That is a big cut. That is a big, big deal. Now, additionally, after propensity matching, about a.

Half of half of percent, half of.

1% of the spinal adjustment cohort had been diagnosed with a medication overuse headache, compared to 1.2% in the non spinal adjustment cohort. What does that tell us? Just about the same thing. You're half as likely to use a medication if you had received spinal adjustments. And going right in line with that, you're a little bit more than half as likely to have a medication overuse headache. Why? Cause you're probably not using the medications to begin with. So these are really, really big deals that add up to massive quality of life changes. This is not something where we're again, shaving off 1 or 2%, you're 1% less likely, you're 10. I mean, 10% less likely would be a big deal, 20 to 25% massive deal, 50 plus. But you are half as likely. This is a big, big deal. You need to be aware of it, as many people in your community need to be aware of this as possible. Because I can tell you right now, unless you live in a town of only you, there are people in your community right now taking medications or headaches that are either having bad results, poor efficacy, they're sick of taking the medication, they want to avoid it, and they're looking for another option. And they just don't know what else to do. So the only question is, are you going to be the one getting out there, informing them, educating them, being their doctor, their teacher, and highlighting that there are other options? Now follow up Visits, of course with the spinal adjustment group were had and those came in at a mean of 15 visits and a median of nine visits. So these findings suggest that there is a big highlighted usefulness for spinal adjustments in managing tension headaches extending beyond just the improvement in frequency or intensity. And they also reinforce those guideline recommendations. Remember this was a multi year follow up. So this was not just one incident, one medication for one week, one week of adjustments and then test it the next week and see this was over a multi year period. So the benefit of what we can do again extends far beyond just the care that we provide. I think there's a lot of different reasons for that. Now chiropractors, of course we are non pharmacologic providers, we don't prescribe butalbital and we're not faced with the, as they describe here, pressure, quote unquote to prescribe medication. That's a really interesting word choice. They don't get into what they mean by that pressure, but, but it is highlighted there. Additionally, they highlight the fact that there are recent systemic reviews, systematic reviews, excuse me, suggesting that SMT may reduce the pain intensity of tension type headaches and both the reduction in intensity and frequency had a statistically significant decrease. Now medication overuse headache is a chronic disabling headache that adversely affects quality of life, work, income and can this, this is rich and can actually be more impactful than the headache itself. So again, I've said it before on this podcast, I'll say it again, I've said it multiple times today. This is a big deal and this needs to get out there in your community. Their conclusion was, quote, our findings reveal a significant reduction in likelihood of both butalbital prescription and tentatively medication overuse headache through two years follow up among adults with tension type headache receiving spinal manipulative therapy compared to matched controls. These findings reinforce clinical practice guidelines already recommending spinal manipulation for tension type headaches. End quote. Already recommending further reinforcement and a great study. Now there were some things in this, I'm not familiar with that medication but it was really interesting to see how often that is still being prescribed a barbiturate and kind of the opioid, greater opioid family there being prescribed 15% of the time when people go into a clinic looking for help, they walk out with a script that has high harms, low efficacy and a high risk of addiction issues and just perpetuating the actual problem that they're there for in the first place. So if you take care of people with headaches if you'd like to take care of people with headaches, then utilizing this research as what you can be talking about on your social videos, your social posts in office, maybe even a workshop could be based off of the tenants of this study. Absolutely critically important. And again, I'll go to the place of relationship building and communication. Relationship building with other healthcare providers. Absolute requirement in my opinion. Absolute requirement. If you consider yourself a great chiropractor in your community, you cannot live on an island. You have to get out there and build relationships. Yes, you will generate referrals. That's what we do with MD connection at the evidence based chiropractor. But if not, just if not for the benefit of your business, for the benefit of the health of your community, you can't be the best kept secret in town. And that's where it extends over also to Patient Pilot by the smart chiropractor. Getting this information out there. You have patients that come into you for an array of different conditions. Some of them might be, let's say, a low back issue. They don't know you take care of headaches and they might have somebody at home, a loved one that is struggling with medications and tension type headaches that doesn't know as much as you're like, duh. I can tell you most often when people come in for one thing and one thing only, they're myopic in that realm. So unless you're consistently communicating with them, weekly emails, teaching and inviting, asking for referral, giving them the opportunity, the invitation for referrals to come back in if they've fallen out of care, and highlighting the different things you can take care of, you're just missing a massive opportunity not only to reactivate patients, but have more referrals coming in as well. That's what Patient Pilot's all about. Of course you can check that out@the smartchiropractor.com but I thought this was a fantastic study. Great way to kick off the new year, highlighting the benefits of what we do, the low harms and just the challenges that people are dealing with when they're looking for answers to what they probably consider to be simple questions. I have a headache but my neck hurts. Can you help me, doc? And if they're walking out with a butalbital prescription, the answer might be not today, but if they're coming into your practice, the answer can be yes today. And yes, let's look forward to not only getting you back to where you were, but far better. And that's what we see in that two year follow up. If you have not left a rating or review to this podcast, I would love it if you would take a moment and do so. Scroll on down, tap how many stars, leave a line of text. If you have any questions, you can always hit me up. Jeff the evidencebasedchiropractor.com and I'll wrap up by talking about Turncloud EHR. They have stripped away everything that's not essential and they have an intuitive application where no one needs a user manual. You can learn more@TurnCloud.com it's practical, yet elegant, and TurnCloud's design was to help you find the most efficient path in a day of life in your practice. That means it's dynamic, it's simple and easy to use, and it has what you need and nothing that you don't. Check it out. Connect with their team@TurnCloud.com, have a fantastic week in practice and I will talk to you soon.

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