Hi, Doctor Cobb here with you. Today we’re gonna do something a little different, a little lecture. Today we’re gonna talk about headaches. We just released our brain-based practitioner’s guide to headaches. This is part of our membership, but we just released the module itself for sale. So we’re getting a lot of movement professionals who are not a part of Z Health, but who are interested in what we do with regards to headaches.
So I want to do a quick little guided tour around migraine anatomy today. I know I spend a lot of time usually taking you through different exercises and exercise approaches, but a lot of this is theory based as well. Obviously we are deeply into research, so I want to discuss with you migraine. This has been driven by the fact that some really interesting new research came out four days ago showing some anatomical connections that we didn’t even know existed.
So we’re always learning more. So I just want to go through some basics with you because this will help explain of what we discuss in terms of things that we can do for migraine can potentially be effective based off the anatomy. So whenever we talk about migraine by itself, there are two major types. There are migraines with aura and without aura. If you’ve heard people say before I get the headache, I start feeling really weird, light.
I become really light sensitive, sound sensitive. I’ve had patients over the years who lost vision and one eye, all kind of crazy presentations that can be a prodrome to a migraine. So a couple different types. If you have them, you probably know what type you have. Migraines typically there are some characteristics we’re always looking at, typically unilateral, meaning one side of the head versus the other. It’s not always that way, but that is typical that we would see that and be looking for that in a history.
Migraines often feel like your head wants to explode, right? There’s a pulsating quality to it, so a throbbing quality. A lot of people with migraines cannot stand. They want to bend over or look down and it feels like their head is blowing up. So there is definitely this feeling associated with migraine of vascular sensation. And that’s because there is a lot of that going on. Typically migraines, as you know, moderate to severe intensity can be really intense for a lot of people.
They often are made worse by just things you would do through your normal day. So this kind of differentiates them to some degree from other types of headaches that, you know, reading, working on the computer, trying to drive the car. Walking outside without sunglasses, stuff that you would normally be able to do. All of that can massively aggravate the migraine and actually be incapacitating for some people often as well.
We’ll see people that have severe nausea, sometimes vomiting, photophobia, that’s light sensitivity and phonophobia, which is the sound sensitivity. So kind of the classic, you know, viewpoint of people with migraines are, you know, they’re gonna go into a dark, quiet room, pull the covers over their head, and just kind of wait for this thing to pass. Thankfully, there are a lot of interventions now available, different options depending on what kind of approach you wanna take, what healthcare provider you’re working with.
But what we’re gonna do is talk more about physical things that we can do from a rehab perspective or hopefully a prevention perspective by understanding more about the anatomy. Now, the main thing that I want you to hear as well is that migraines generally last anywhere from a few hours up to about three days. They can become longer than that. You can start to move into what they call kind of a static migraine, where now you’re 5678 days into this.
And that is potentially very problematic. There is some research that says if you are experiencing more than four migraine days per month, you are moving from an episodic migraine sufferer. Like, hey, I occasionally get migraines to someone who’s starting to deal with more chronicity by chronic migraine sufferer. And just like anything else, if you said, hey, I have a lot of back pain, and I asked you how often, and you said, probably two weeks out of every month, for me, as a practitioner, I would be worried that we’re altering your brain, we’re altering your nervous system to become more sensitive so that that can lead to more of a chronic pain presentation.
And that’s what we want to avoid. So anything that we can do to abort migraines early on, stop the pain, do some kind of rehab, we want to talk about. Now, in order to do that, we need to know some anatomy. So we’re talking about something called the trigeminal nerve. The trigeminal nerve is, it’s the largest cranial nerve now, a cranial nerve you can think about as the nerves that kind of work, like peripheral nerves in the rest of the body.
So most people have heard about carpal tunnel syndrome, right, where my hands getting numb and weak, and that’s normally from the median nerve, right? That comes from the neck, from. From the spinal cord, the neck, all the way down to the hand and wrist, the median nerve, just, they’re restricted to the head, so they are given a kind of different name and nomenclature in neurology. Now, the reason we’re going to talk more about the trigeminal nerve is that it is highly associated, and in fact, most people believe it is the cranial nerve that drives migraine presentations for most people.
So having said that, then we want to understand more about the anatomy. So it has tri in it. So that typically means three. So what we see initially are three primary branches. The names are ophthalmic, maxillary, and mandibular. You can see the little diagram there. We’re going to talk about each one of them in a little bit more depth, not because it’s just interesting information, but because this is anatomy that you can apply to hopefully do something to help yourself or, you know, your clients decrease the intensity of migraine.
So the ophthalmic branch, as you can see, this is the green branch. And what it does is it has a lot of different functions, but some of this is super important with regards to headache. So, number one, the ophthalmic branch is going to give sensory innervation for the skin of the upper part of the face and two thirds of the anterior scalp. So you can see that little map, right?
And basically what you’re going to see here for each of these zones is there’s a, there’s a map for each branch of the trigeminal nerve. And within that branch, it does some different stuff. So the ophthalmic branch, if I touch my forehead or I put an ice cube on my forehead or I put some electrical stimulation on my forehead, as long as it stays within that zone, it’s going to be stimulating the ophthalmic branch, which means the sensation being created here is going to use that particular branch of the trigeminal nerve to send that information down into the brainstem for processing.
And that’s going to be really important as we go forward as well. So in addition to the sensory innervation, it also gives somatic sensation from the eyes. So when your eyes are dry and a little gritty, et cetera, that information is being conveyed to your brain and brainstem via the ophthalmic branch. It provides superficial and autonomic sensory innervation to the ciliary body, lacrimal gland, etcetera. So this means that this portion of the trigeminal nerve is involved with your eyes, with your tear ducts, with your tear covering of your eyes, with your ability to change focus to some degree.
The ciliary body. So there’s a lot of stuff about the visual system and the eye anatomy itself that is innervated via the ophthalmic branch of the trigeminal nerve. So it makes sense then, as we go a little bit further, that migraines often have visual issues associated with them. Now, the other thing about this ophthalmic branch is this. It is the predominant pathway for what is called nociception, from structures inside the head, intracranial structures, including the meninges.
The meninges are the covering that we’re gonna talk a little bit more about later and maybe some other blogs, but the meninges are a big player in migraine. Now. The ophthalmic branch is the predominant pathway by which nociception and nociception is. These are little receptors found throughout the body that we call threat receptors. Ultimately, if enough nociceptors are triggered, once that information gets to the brain, the brain will go, hey, there’s a problem there, and it will often interpret that as pain.
So a lot of people confuse this. We don’t have pain sensors in the periphery. We don’t have pain sensors inside the skull. We have nociceptors. And when that nociception goes to the brain, the brain then makes a decision, if it’s dangerous enough, we will then begin to experience pain. This, again, for migraine, is hyper important because those coverings of the brain, the meninges, as well as the fluid, cerebrospinal fluid, that will develop some proteins during migraines that are inflammatory.
All of that is going to be sending sensation to the breast of the brain and the brainstem via this ophthalmic branch. So that should mean to you that the ophthalmic branch may be a pretty important target to work with if people have migraine. Next we have the maxillary branch, and as you can see, that’s going to go along the cheekbones. This one gives sensory innervation for the skin that you see covered there.
It also is really important because it provides sensory information for the upper teeth and gums, the palate, through the top of the roof of your mouth, mucous membranes, your sinuses, your nasal cavity. And we will talk about that going forward, that this can be a big player as well in migraine. So, again, it’s providing sensory information. It’s making your brain and brainstem aware of what’s going on with your teeth and the top of your mouth.
It then has some what are called post ganglionic parasympathetic fibers that reach the lacrimal glands. We’re not gonna get into that right now. It’s a little complex for this little YouTube blog. It also does, however, go inside the skull to reach some of the dura. So we have both ophthalmic and maxillary branches that are communicating with the dura. Now, the largest of the three branches is called the mandibular branch.
And you can see that it’s like a chin strap comes all the way down the outside of the jaw, all the way down to the point, gets some of the lower lip. So it gives a huge amount of sensory input to the brain. So we’ve got the cheek, posterior part of the temporal region. You got earlobe stuff inside your ear, the external ear canal, lower lip and chin.
So all the sensation from here is going to be transferred via the mandibular branch to the brain. It also carries information from the tongue, cheek, the floor of the mouth, or oral cavity, and lower gums and teeth. So whenever we talk about your teeth and gums, we have the maxillary zone or maxillary branch. For the upper, we have the mandibular branch for the lower. Now, this one’s also important because it’s involved in motor innervation for chewing and biting.
So the trigeminal nerve doesn’t just take in information, it also sends commands out to musculature. And typically, we say the trigeminal nerve innervates the muscles of mastication, which is biting. Right. You’re chewing muscles. So people that have, you know, temporomandibular joint disorders, often we’re looking at trigeminal dysfunction there as well. And it should make sense to you then, that there’s a lot of headaches associated with that particular condition.
And also, once again, has a branch that innervates the meninges. So the trigeminal nerve, it’s doing all kind of stuff in the front of the head, the eyes, the sinus cavities, inside the mouth, the teeth, and it’s also sending some branches up into the covering of the brain. Next we want to look at. All right, well, if the trigeminal nerve is doing all this stuff in the head, where does that information go in the brain?
And again, this is why this is so important to us from a migraine management perspective, because information from those different branches is going to go to different areas of the brain stem. Now, if you’re not familiar with the brain stem, we talk. There’s typically three components. There’s a top, a middle, and a bottom. The top is called the midbrain, or mesencephalon. The middle is called the pons, and the bottom is called the medulla.
And underneath the medulla is the spinal cord. So it’s all. It’s kind of this older brain region that does so much, and it’s highly involved in movement and pain and all kind of things. Now, whenever we look at that, that brainstem area, where they’re gonna look at groupings of what are called nuclei. So this is gonna be a spot where a lot of nerve fibers are gonna go in, and that nuclei is gonna be responsible for receiving information and sending information onto other areas of the brain.
So whenever we look at the trigeminal nerve, we have three different nuclei that are really important. Number one, we have a nuclei in that top part. Okay? The mesencephalon is called, as you can see, the mesencephalic nucleus. We then have what’s called the motor nucleus. Remember we talked about innervating the muscles, mastication, making muscles move? So we have a motor nucleus. We have a primary sensory nucleus. So all that stuff we’re talking about, right?
I’ve got ice on my forehead, or I’ve got, you know, some kind of vibration tool I’m using on the outside of my jaw or in my teeth, that information is going to be going typically to that sensory nucleus. And then finally we have what’s called the spinal nucleus. The spinal nucleus is going to be involved in a lot of the nociceptive. Remember, that could eventually be interpreted as pain processing.
So if we go a little bit more deeply in each one, obviously, the mesencephalic nucleus is in the midbrain or mesencephalon. So whenever we look at mesophalic nucleus, what it basically does is it receives signals from jaw and eye muscles and periodontal ligaments. So we talk about this midbrain nucleus as being a kind of proprioceptive nucleus, where it’s telling us where our jaw is, what’s happening with our teeth, as well as kind of integrating what’s going on with our eye movements and our jaw movements.
So it’s making things aware, making your brain aware of where those things are in space. The motor nucleus is going to make the muscles work, is coming out of the pons. It’s going to send motor signals, like I said, primarily to the muscles of mastication or chewing, a few other things. We then have the primary sensory nucleus once, which is also in the pons, which is that second part of the brainstem.
It’s going to receive information, and this is important about fine touch and vibration. So if I take a q tip and I stroke my forehead, or I take, like I said, a little vibration unit and I put it on the skin, or I use a tens type unit, a little electrical stem unit, and all I can feel is a light tingle, all of those types of fine sensations are going to go to this nucleus, this primary sensory nucleus located in the midbrain.
That is then going to contrast to the spinal nucleus, the spinal nucleus, which is in the bottom portion, so it’s in what’s called the medulla, and then in the upper portion of the spinal cord, right underneath it. This particular nuclei receives signals for crude touch, deep touch, temperature, and then nociception. So if someone’s doing a really deep massage over your jaw, that’s uncomfortable or you know something, maybe you’re starting to try to do some kind of therapy on your own, and you use a vibration tool, and you, instead of using a soft tip, use a firm tip, and you put it right on your skull, and it starts pounding away, and it’s going to trigger off some of these nociceptive signals.
And those nociceptive signals are going to go down to that nucleus and potentially eventually be interpreted as pain and precipitate migraine. So that’s the basic anatomy here. Now, there are really practical elements to all of this. Before I go on about some of, you know, ways to think about it, I just want to show you a couple more things. So this is a little diagram of the spinal trigeminal nucleus.
The reason that this is, we’re talked about a lot in migraine research is, again, this is the one that’s at the bottom of the brain stem and going into the spinal cord. What we know at this point is it’s divided up into some different divisions as well. So, basically, the way, you know, neurology works is we show you a nerve, and then it goes to this nucleus, and then within that nucleus, we divide it up into different parts.
Because it’s so complex, we need to know what each little part does. Most of this, you don’t really, really need to understand any of the names. All I want you to look at is the job. So we have, first of all, it’s called the pars oralis. It’s primarily going to be tasked with receiving touch or tactile information from the mandibular branch. All right? Remember the mandible coming all the way down around the jaw, like the chin strap?
We then have a middle pars called the interpolaris it primarily is going to receive touch or tactile information from the maxillary branch. So that’s v two, and then we have the bottom one, the pars caudalis. It starts in the medulla, goes down into the upper cervical spine, and it primarily receives nociception threat signals from the ophthalmic branch. So we go through all this anatomy to say, hey, at the end of the day, it’s probably this bottom part of the spinal nucleus of the trigeminal nerve in the bottom of the medulla, the top of the cervical spine, that is primarily going to be receiving threat signals from the ophthalmic branch.
And why that’s really, really important is this particular study which clearly states it’s generally recognized that the development of migraine headache depends on activation of nociceptive afferent signals. All right, so basically that’s information going to the brainstem, nociceptive afferent fibers of the ophthalmic division of the trigeminal nerve. So this is all the stuff we were just covering. This is going to convey pain information from the intracranial structures like the meninges, the dura mater and large vessels.
And this is going to go to the trigeminal nucleus and then ultimately down into what’s called the trigeminal cervical complex, which is why headaches then evolve into lots of neck and shoulder pain and a lot of other stuff. So we know that there’s this pathway involved. We know that we have to at some point figure out what to do about that. I don’t want you to lose sight if you’re a movement professional, however, of the fact that it’s not always just the ophthalmic branch.
We have two other branches of the trigeminal nerve that are also involved. So we know experimentally that if we have people clench their teeth or we give them some kind of apparatus to put in their mouth, that changes their bite function, that can induce headache. So tension type headaches. So tension headaches, and it can also induce migraine in some people. Now, what’s interesting is we can alter your bite, we can change how your mouth is working, how your teeth are interrelating to one another, or just have you clench.
Even if you don’t have headaches normally, if we have you do that enough and long enough, you’ll also get attention type headache. It’s just much more frequent and much faster in people that regularly have headaches. Now, most neurons within the spinal trigeminal nucleus, we’ve been talking about, they exhibit what’s called an extensive convergence. Now, what that means is a lot of different signals from a lot of different nerves from, and different receptors from all over the head and neck are going to converge into that particular nucleus.
And so we see this convergence of these incoming signals. Those are called afferent inputs. Those come from the facial skin, they come from the tooth, the tooth pulp. You know, if you think about stuff that your dentist has told you about your teeth, the oral mucosa. So throughout the oral cavity and muscles of the cranium, there’s even more stuff that feeds in there as well. But basically what we’re seeing is that this is like a repository spot for information from a ton of different tissues, which makes it a prime target for us in terms of how can we change its functioning if we’re trying to help people manage migraines?
And that’s all going to come back to a really, really powerful theory about pain control. This has been replaced to some degree. It still works. It was just expanded upon. But many years ago, these two gentlemen named Mel, Zach and Wall realized that if you smash your thumb with a hammer, most people don’t just sit and stare at it. They grab it, they start rubbing it, they blow on it.
So basically what they’re saying is that most people instinctively try to use a counter stimulus to decrease pain. And that’s what this diagram is showing you. So at the top of the diagram, you see in red, it says pain, and then going across, it says a delta or c fibers. And then in the yellow box, it says normal sensation. And that’s going to be stuff like vibration, light, touch, those are probably the two that you would most typically see.
There’s some other things we could include in there, but because of the way these fibers work, often if we give a lot of normal sensation, what that normal sensation will do is it will actually trigger activity in what is called an inhibitory interneuron. So you see that these two, the path from the red box, the path from the yellow box, are actually joining in the middle, and that’s the normal sensation is interacting with this nociceptive signal or this pain signal, and if we have enough of it, it will actually turn it off.
So that’s basically what this last statement is saying, that jaw movements and externally applied pressure to the palate. So just having people, like, put their thumbs in their mouth and push up on the roof of their mouth, those have been found to increase the threshold and tolerance of pain via the trigeminal nerve. So we have a lot of experiential evidence. We have a lot of research evidence that says, hey, if we want to help people who have migraines, we need to take a close look at the different branches of the trigeminal nerve.
We need to recognize that the trigeminal nerve is going to pick up information about jaw movements. Right. We said we have this mesocephalic nucleus. It’s going to tell us about where jaw is in space, what my teeth are doing. So there are exercises available where we work on jaw motion, forward and back jaw motion, side to side, opening the jaw. We can then come inside the mouth, if you are licensed to do that.
If not, people can do it themselves. You can get little therapy devices where you can just work on individual vibration of each tooth. As long as it’s non painful, you can, you know, obviously talk with your dental professionals about all this. The main thing here is that we’re going to think about the jaw, the teeth, the bottom teeth, the upper teeth. We’re going to think about our eyes and making sure that we are utilizing, you know, dry eye treatments if we need them.
We’re blinking a lot. We’re getting away from screens, because every single irritant to your jaw, to your teeth, to your sinuses, to your eyes, to the skin of your face, to the muscles of your jaw, any irritant, any threat, has the potential to get down into those nuclei and participate as a potential migraine trigger. But more importantly, every one of those sensations as well is an opportunity for us to provide ongoing increases in normal sensation that should trigger inhibitory interneuronal activity that would, over time, help reduce pain.
Now, that was a long lecture on some neuroanatomy. This is what we do in our more advanced courses, obviously, because we’re brain based professionals. Everything we’re talking about, obviously, we would back up with movement practices, with different interventions. But I want you to understand, this is something I’ve been talking a lot about in our courses and some of our writing. One of my overseeing doctors when I was a young intern used to tell us all the time, everything we do is applied anatomy.
And that has stuck with me. So for my entire life, everything I’ve tried to explain and teach is based off what do we know about the functional anatomy of this area and how can we alter it? Because ultimately, whenever we can change some of those signals that are going to the brain, we have a good opportunity to make a big change for our clients. I hope you guys enjoyed this.
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