So let's bring this all together to develop a individualized treatment plan for a patient. So I'm going to present Pamela again and up in the right corner right here you see this picture and this is actually a picture. Of a patient of mine that had, was their headache, their diagram, their body diagram of their headache. You can see they had this very unique pattern of this tightness in their neck, pain in their neck, and then it builds up into the temporal area. And this of course is the classic picture for the trigger point for the upper fold of the trapezius. And of course when I saw that pattern I knew immediately what I was dealing with with the patient. But once again we've talked about her as we've worked through her. She does, is doing some clenching and has some masticatory. In cervical myofascial pain, and once again she has these migraines. I did have her see one of the dentists that I work with as her headaches transformed into a more chronic headache and she was clenching, and she had a disc displacement on the right. And some of the factors, additional factors that were identified including that she was chewing gum on a daily basis, she was occasionally clinching her teeth, and actually grinding her teeth at times. And the big stress for her was that she was a working mom, busy mom, of, with two kids. And was struggling with a little bit of stress. Kind of fitting it all in in her life. So how do we come about the management of this in these more complex cases. I think it's important to establish a good working relationship with a provider who enjoys treating people with headaches. That has, that reads the literature. And can put together a comprehensive plan that covers multi-systems and that's one of the components of what Dr. Frickten is talking about is this human systems approach to management, management and preventing of chronic pain. We want to work out identifying triggers. I don't tend to tell people to avoid triggers. Anything that you tend to avoid, neurophysiologically will make you more sensitive. And so I talk about people managing their triggers. So, we go back to the person that, that her migraine was somewhat triggered or related to the. Having a candy bar at two in the afternoon. I would tell her that, you know, when you're under a lot of stress, not getting a good sleep, that is probably not the best time to be eating chocolate, if you're sensitive to it. And it's probably not the best time to go home and have a glass of red wine, which is a classic migraine trigger, to help recover from the stress of the day. It might be worthwhile to go to the gym or the spa and relax, stretch out, recover, address your muscle issues, get your energy back. And then you may be able to enjoy white wine or something else at night but you really want to manage those triggers and how they play out in your life. So that you don't become more sensitive to them over time. With that said, there are people that are very sensitive to certain triggers that can never really drink red wine without actually experiencing a headache. And that needs to be factor, factored into your management. But important behavioral strategies is always getting enough sleep, getting some exercise, eating meals on time. Even if it's a small meal. And addressing issues of stress management and lifestyle. Then we talk about pharmacologic interventions. One of the things that's very important about managing headaches is one's self care. So I'm just going to go over self care just very quickly. A typical pattern I might, self care pattern I might do with an individual patient. And I talked about doing a little bit of self care in the morning. In the evening. What you do in the morning sets the tone for your day. What you do at night sets the tone for your sleep. And then taking little mini breaks throughout the day. So what would be a typical self-care pattern or program for a patient? We might teach a patient to learn how to stretch out their scalp, if their scalp is particularly. Tight. We teach them to stretch out their squinting muscles, relax their jaw, and then a program of stretching out their neck, and shoulder girdle. Your shoulder girdle should stay down, if I come to the side here, if I. How a neutral position and then slump. I tip my hat I tighten up my upper cervical spine, my shoulder girdle gets tight and that's a big pattern for headache and so we work on adjusting our posture, doing a chin tuck and in general you can basically just assess yourself. You do a chin tuck, where do I get tight? 25%, 50, 75, 100. And if you get tight at any one of those points, 25%, 50%, 75%, then you, will, loosen it up. Get your range of motion back. If you spend a lot of time sitting at a computer. I particularly have trifocals here. The only posture I can really sit in using my glasses with a computer is like this. And that's why I get everything in focus, and so I have to, I spend more time like this or adjusting my computer so I can be up right. So I manage some of the muscle dysfunction by changing my work environment. And you need to step away from the computer periodically. Stretch out your neck, your shoulder girdle, stabilize. So that you address all of those pericranial muscles that get tight with daily life and the stresses and strains of. Life. Keeping a headache diary is very important. it, it just gives data for what's really going on in life. This is a diary that I use in clinic for people that have episodic headaches and it, it starts with. The day when it came on, when it ended, how bad it was, what you took for it. And then it has both kind of physical and emotional factors in foods. And you can see there's a list here of the different triggers that are associated with migraine headaches. And so I'm able to identify. Factors that contribute. I but two years ago I saw a person that was having daily headaches. She ended up keeping a diary, she discovered that she, I didn't know this at the time talking to her after I saw here, but she was eating five bananas a day. As soon as she stopped eating five bananas a day, her daily headaches went away. And so these food triggers or food sensitivities are very important in some people. And the only way to really figure them out is to keep a diary. And I recommend that on anybody with headaches. So in management of the more complex people what are the principles? Proper diagnosis. Always start with the proper diagnosis. Rule out any organic disease if we need to. You start managing contributing factors. We come up with a pattern of medication management that keeps them below. The level that will lead to medication overuse headache. We address muscle factors either TMD or neck problems. We come up with a pharmacological plan that addresses both acute and preventive medications and then we address mind body issues and self care with the more complex cases that. That need it or people who just want to go that way. [BLANK_AUDIO].
