Post-traumatic Headaches: A Form of Neuropathic Pain | E4

This episode explores the connections between post-traumatic headaches and neuropathic pain, providing insights into the neurological underpinnings that affect pain perception and treatment efficacy. We emphasize individualized approaches to treatment and highlight the importance of understanding the brain's role in experiencing and managing pain.

• Understanding persistent post-traumatic headaches
• Exploring neuropathic pain in relation to concussions
• The brain's role in interpreting pain signals
• Hallmarks of neuropathic pain: allodynia and hyperalgesia
• Importance of individualized treatment approaches
• Effects of acupuncture and cognitive therapies on recovery
• Neuroplasticity and its impact on pain perception
• Encouragement for patience and continued treatment for chronic pain
• Insights from case studies on acupuncture effectiveness
• The evolving landscape of pain management strategies and research advancements

Research Study Referenced in this Podcast:
Leung, A. (2020). Addressing chronic persistent headaches after MTBI as a neuropathic pain state. J Headache Pain, 21(1), 77. doi:10.1186/s10194-020-01133-2

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Chapters

• 0:00 Post-Traumatic Headaches
• 5:21 Neuropathic Pain
• 14:30 Neuropathic Pain and Concussion Recovery
• 23:26 Therapies for Neuropathic Pain and Concussion
• 31:32 Acupuncture, Neuroplasticity and Chronic Pain
• 41:22 Functional Approach to Post-Traumatic Headaches

Transcript

Ayla Wolf: 0:00

If people that have these persistent post traumatic headaches aren't responding to kind of migraine medications or migraine treatments, why is that? What makes these different? And they were saying that because this resembles neuropathic pain so closely, it's likely that there is this neuropathic pain component, which again, makes perfect sense when you realize that a concussion is causing all kinds of dysregulation and dysfunction within the brain and central nervous system that is, in a sense, affecting all of these specific areas of the brain that are associated with neuropathic pain and a loss of the inhibition of pain.

Sophia Bouwens: 0:44

Welcome to the life after impact podcast where we do a deep dive into all things concussion and brain injury related. We talk about all of the different symptoms that can follow a brain injury, different testing methods, conventional and functional, different types of specialists out there and different therapies available. I'm Sophia balance, and I'm here with Dr Ayla Wolf, and we will be your guides to living your best life after impact.

Ayla Wolf: 1:15

Welcome back, Sophia.

Sophia Bouwens: 1:16

Well, thank you, Ayla. How are you?

Ayla Wolf: 1:18

I'm great. I'm excited to provide another episode where hopefully we can give people some further insights into how they can find a path through dealing with one of the most complicated symptoms following a concussion, which are sometimes very stubborn post traumatic headaches.

Sophia Bouwens: 1:37

If people have been following us through our first few episodes, they know by now that there's a lot of nuances and a lot of different ways they can present, and also a lot of similarities and overlap between them. Today we're talking about neuropathic pain. Our last podcast, we talked about a number of different presentations, including tension headache, cervical genic headache. And then we did a full episode on migraine, and migraine like headaches, but this one is interesting, talking about neuropathic pain in relation to post traumatic headache.

Ayla Wolf: 2:13

And I think going back to we've been talking about a lot of the research on this, and researchers have been trying to get to the bottom of why are post traumatic headaches more complicated to treat, and this one particular paper really approached it from this perspective of saying, Okay, we know that even though post traumatic headaches often look like migraines, they're migraine like in their presentation, they don't respond well to a lot of migraine medications. And so what is it that makes them different? And the paper really highlighted the fact that they are looking at Post Traumatic headaches more as a neuropathic pain state. And if people aren't familiar with what neuropathic pain is, that's kind of, I think, what we'll talk about first, and then we'll get into some of these hallmarks of neuropathic pain and how that relates back to these post traumatic headaches.

Sophia Bouwens: 3:10

Yeah, this paper was interesting to me to see all of the overlap between neuropathic pain state and post traumatic headache. Do you have the definition for neuropathic pain,

Ayla Wolf: 3:22

I do, and it's actually kind of vague in the sense that it's literally saying that neuropathic pain is a disorder or dysfunction of the somatosensory system. And what they mean by that is that we've got an area of our brain called the parietal lobe that has a map of our entire body in it. And so we have the what's called the s1 area and the s2 area for short, and this area of the parietal lobe has this somatosensory cortex, right? It's this part of the brain that contains a map of our feet and our legs and our knees and our hips and our torso and our shoulders and elbows and face and the

Sophia Bouwens: 4:04

homunculus, a picture you might have seen or reference, where everything is like proportional to what our brain feels from it is a funny little thing to look up.

Ayla Wolf: 4:14

exactly so like the face and the tongue and the hands have a lot of real Estate,

Sophia Bouwens: 4:21

and the genitals

Ayla Wolf: 4:22

of course, yes, in our in our brain. And one of the ways that I like to explain that to people is, if you've got a tarantula, for example, if that tarantula is on your palm, on your hand, you're going to be able to feel all eight legs, right?

Sophia Bouwens: 4:40

Yeah, I can feel it just thinking about it.

Ayla Wolf: 4:42

Yeah I know I hate spiders, but if the tarantula is on your low back, you're less likely to feel eight individual legs. You're more likely to just feel one big lump of something crawling on your back. Probably

Sophia Bouwens: 4:55

Okay, everyone who's still listening, hopefully you didn't turn off because of the arachnophobia.

Ayla Wolf: 5:00

exactly, the point being is that our low back has very little real estate in this homunculus in this meta sensory cortex of our brain, which is also why low back pain is kind of the number one pain that humans complain of is we don't have a whole lot of brain integration into our low back. And that sets people up for a lot of injuries and problems for sure. And so this idea of neuropathic pain is that there are different areas of the brain that are responsible for interpreting pain, and then, in a sense, kind of having a perception of that pain. And so a somatosensory dysfunction in the brain, means that all of these pain sensations that were originally going to that part of the brain, it's almost like they're being perseverated on long after the injury has healed. And I've certainly had patients that said, you know, I got hit on the back right side of my head, and now here I am, four years later, and that part of my head, even though the actual there's no physical damage or trauma that's there, they still feel pain in that area. And so it's almost like the pain neuro matrix in the brain has gotten stuck on this pain signal long after the injury has occurred, and long after there's you know, any tissue damage has healed

Sophia Bouwens: 6:23

right, almost a protective mechanism of like, We don't ever want something that to happen again. We'll be really aware of anything back there, or something just got turned on and never got turned off after that initial injury.

Ayla Wolf: 6:37

Yeah, and then that part of the brain that's picking up on that pain is then communicating to other parts of the brain, such as the insular cortex, which also has a map of kind of our internal gut and our digestive system, as well as our external body parts too. And then there's a part of the brain called the anterior cingulate cortex, and this is where we actually have the emotion of suffering, and I think that's really important to kind of tease out this idea that you can have two people with the same, let's just say, low back pain, for example, and they can have very different experiences of that low back pain, absolutely. And one person can just be like, Yes, I have this low back pain, and I go and I do these things to try to help manage it. Somebody else could say this low back pain is just absolutely preventing me from focusing on anything else, and I'm have this extreme suffering over the fact that I have this pain. And so you can have two people with very different perceptions on what that pain means to them and what that means in their lives.

Sophia Bouwens: 7:40

That meaning and that perception, like I said before, Perception is everything. It's so much of the picture.

Ayla Wolf: 7:47

and to think that somebody can have a dysregulation in this anterior cingulate cortex that would then lead them to get stuck in a state of suffering, that's a that's a real phenomena that can occur for some people.

Sophia Bouwens: 8:02

like that loop gets stuck on that sensitivity and that suffering.

Ayla Wolf: 9:09

Yeah, and so I think that you know really neuropathic pain is the important thing to realize is that it's happening in the brain. It's happening in the central nervous system, and the central nervous system is perseverating on a pain signal long after it really needs to

Sophia Bouwens: 9:26

One area you didn't mention is the prefrontal cortex. And that paper really dove into that too, just how that also is responsible for almost turning off or inhibiting some of those signals from having meaning, or some of that perception of what that meaning is coming from those other areas, right? So we don't have as much inhibition or stopping of those alarm systems. I can't shut that off.

Ayla Wolf: 9:54

Yeah, that's a great way of explaining it. And somebody else had said that the prefrontal cortex basically just tells all these other areas of the brain "shhh". We just quiet down, be quiet, right? And what the research has also shown is that when you have a concussion, in many, many cases, blood flow to that prefrontal cortex goes down, and so you can have a Hypo metabolism, or less activity and less blood flow to the part of the brain that is responsible for shushing all the other parts of the brain that are perceiving pain

Sophia Bouwens: 10:29

and sensitivity in another area that's telling you you're suffering a lot from this pain, and that a mapping disconnect there that tells it that this pain is really big, versus a really healthy somatosensory cortex, which might interpret it as smaller or larger, given where it is, right?

Ayla Wolf: 10:49

that idea of mapping is huge, and it opens up people to a whole world of therapy which we should get into after we kind of go over these hallmark symptoms of neuropathic pain. I think that that concept. Of remapping we should come back to definitely.

Sophia Bouwens: 11:06

I think one of the things about the neuropathic pain that really woke me up to this overlay is that a lot of the symptoms of this neuropathic pain are really similar to concussion.

Ayla Wolf: 11:20

One of the clinical hallmarks of neuropathic pain is that you've got persistent pain after tissue healing, so after kind of the injury has occurred. And so in the case of a concussion, what they're saying is that this can manifest as persistent head pain long after the injury. And I've certainly seen that with many of my patients, that they can point to specific areas on their scalp or their head where they say they've got persistent pain long after the concussion occurred,

Sophia Bouwens: 11:54

and then maybe the area is more sensitive to something that shouldn't be painful, right? So we have this, what's called aladyna, or hypersensitivity to pain, which is very common in neuropathic pain, a hallmark sign of that and having that on like the scalp or in the body as a whole, but specifically, usually in the area of injury, with concussion.

Ayla Wolf: 12:15

I've had people say that it's even painful to brush their hair or to wash their hair, because even that light touch sensation on their scalp, they're perceived as painful. I had one patient where if I just touched her forehead, she would say that it was like a six out of 10 pain. So her brain was even confusing light touch with a very painful stimulus.

Sophia Bouwens: 12:38

Extreme exacerbation of pain with something that's not painful, is an important hallmark of neuropathic pain. And

Ayla Wolf: 12:47

And then there's hyperalgesia, which is an enhanced pain perception. So something that might normally be painful, like you, you know, bang your elbow on the door frame, which would, you know, anybody would say, ouch. It can be perceived as extremely painful. So you can have these heightened sensations of pain with something that maybe you know otherwise would have been just kind of a milder pain sensation.

Sophia Bouwens: 13:11

And with that might come like a bigger emotional response to that too, like if it hurts more or perceived to be hurting more, the response in the system is higher, right? So the emotional suffering you might feel with this light bang on your elbow, on the door frame, might set you off in a different way, more emotional too.

Ayla Wolf: 13:33

And I think that speaks to that autonomic dysregulation that is also kind of a hallmark of neuropathic pain. Is you can have this dysregulation of autonomic function, where if you do have elevated sympathetic activity, then you can also have this heightened pain response as well.

Sophia Bouwens: 13:50

kind of stuck in that fight or flight mode with that sympathetic activity that isn't able to kind of calmly assess that this was actually not a big deal. I just bumped my elbow. It's fine, because you have this hyper sensitive system to that which sets you in a stressed out state even more, leading to things like anxiety or a lot of irritability, things that can come with concussion to begin with, because you already don't have that frontal lobe working the same way right to turn it off.

Ayla Wolf: 14:19

Such a vicious cycle, and then you can have altered motor or sensory functions, such as things like Tinnitus can be a problem as well. You know the auditory cortex. We've got our primary auditory cortex, which takes in sound, and then we have these Association cortexes that take sound and then mix it with other sensory input. And so it's in these kind of association areas where you're now combining the sound input with other sensory inputs that can actually be more dysfunctional in certain cases of tinnitus, where it's almost like the brain is perseverating on this sound long after it needs to so

Sophia Bouwens: 15:03

tinnitus, being that ringing sound in the ears, this high pitched tone,

Ayla Wolf: 15:08

and then the light sensitivity and the sound sensitivity that people have can also be kind of this altered sensory function. And then even balance problems I have had patients tell me that if there's a loud sound all of a sudden, it'll affect their balance, for example.

Sophia Bouwens: 15:26

So it's interesting, I'm convinced now this neuropathic pain, with persistent pain hypersensitivity, especially to touch or to other sensory stimulus like sound, enhanced emotional responses, different motor and sensory functions, an enhanced, stressed out state, or sympathetic state, and some mood dysfunction that can come from kind of running all of those things at once. Those are all hallmarks of neuropathic pain. But that sounds really similar to what I see in concussion patients too.

Ayla Wolf: 15:57

and that was the big picture of this paper, and what they're trying to get at is saying - okay, if people that have these persistent post traumatic headaches aren't responding to kind of migraine medications or migraine treatments, why is that? What makes these different? And they were saying that it the because this resembles neuropathic pain so closely, it's likely that there is this neuropathic pain component, which again, makes perfect sense when you realize that a concussion is causing all kinds of dysregulation and dysfunction within the brain and central nervous system that is, in a sense, affecting all of these specific areas of the brain that are associated with neuropathic pain and a loss of the inhibition of pain,

Sophia Bouwens: 16:46

right? So maybe the area is healed up right, like you hit your elbow and now it's totally fine and better, but the brain is still on fire about the painful sensation that came from there, so it's kind of hyper aware, which leads you to think like, well, this is all in the central nervous system. Then it's all the relaying of that information that's coming from the nerves causing neuropathic pain. So how might you work with someone that's having this neuropathic pain state? Right?

Ayla Wolf: 17:18

Part of it comes back to that somatosensory cortex and that parietal lobe, where we've got a map of all of our body parts, so to speak. And I think one of the important things here is to recognize that the brain is very plastic, and so parts of our mapping system can become blurred. And I see that really commonly in let's say somebody has a shoulder injury, and then all of a sudden the pain just gets worse and worse, and now it's not just the shoulder, it's the neck and the upper back and the shoulder, and the pain radiates all the way down into the lower part of the arm too. And once you start treating that patient, all of a sudden their pain becomes more localized, and they're no longer complaining about pain in their neck, back and entire arm and shoulder. But rather, now they can point to one specific spot and say, Here, this is now the spot that still hurts. And to me, that's always been a sign of we're heading in the right direction in the healing process. And so even when we're talking about a concussion and head pain, we have to, you know, look at this concept of mapping in the body and recognizing that it we should. We should test all the body parts and we could. We should test these people's mapping to see how intact is, their parietal map, they're homunculus, and if we can clean that up, if they do have kind of errors in their mapping, that can go a long way towards actually improving their relationship to pain and their sensation of pain and where that pain is.

Sophia Bouwens: 18:58

For sure, because the perception get more accurate. Instead of the brain thinking that your whole left side was hurting. It gets more accurate in perceiving it's just this little point in the shoulder.

Ayla Wolf: 19:10

Yeah, and not to go off on too much of a tangent, but I had two injuries that were three weeks apart, and one injury I landed with my arm outstretched when I was wakeboarding, and I stretched out my brachial plexus, the nerves kind of right by my left collarbone going into the arm. And then three weeks later, I got caught in a head and arm choke in a jiu jitsu competition. And

Sophia Bouwens: 19:37

Ninja you are,

Ayla Wolf: 19:38

my sternum COVID killer joint got damaged on the same side, and it was really more of a compression injury that was the exact opposite mechanism, because I was basically being choked out with my own arm, which is never fun, and no so I had basically because of my concussions that had happened around the same time, I did not have the ability to inhibit pain, and I developed really excruciating left arm pain, and it really was a neuropathic pain, in the sense that it was burning, it was tingling. Some days, heat would feel good. Other days, heat would make it worse. Some days, ice would help. Other days, ice wouldn't help. It wasn't really responding to a lot of things, and what I had completely failed to recognize in that moment was that, because of my concussions, my ability to inhibit pain was affected, and it wasn't until I could heal from the brain injury and actually do neurological rehab to fix my brain that that was Actually the solution to fixing my shoulder pain, right?

Sophia Bouwens: 20:44

We don't we think it's not in the shoulder, it's in the nervous system or the brain, right? So that perception needs to to come off the table. Sometimes there's so much emphasis like, oh, it's your shoulders. It hurts. We're just going to focus on the shoulder. But if it's not the shoulder, actually, that's the you. Problem, it's the perception of the shoulder, the emotional reaction to the shoulder, the memory of pain there, that keeps these systems going. You have to work a little differently, because every you can treat the shoulder all you want, but the pain is not going to change. And with head injury, we get so many complexities that you take for granted when you haven't injured your head, makes it harder, so having guidance or insight into helping that component is really key.

Ayla Wolf: 21:30

And I think that after my experience, that really clued me into the fact that, you know, when I'm working with patients, a lot of times, let's say somebody was in a car accident and they have a concussion, well, they also likely have whiplash. They've got trauma to their neck. The seat belt often causes trauma to the shoulder and the torso. So people can have like, rib cage pain and shoulder pain, pain in their torso and their chest. And then, you know, I've had people that have also injured their knee in the process of their car getting smashed, and so now you've got people that have the concussion, all of the symptoms from that they've got, then all the soft tissue injuries from the damage to the neck and from the seat belt and then other physical injuries. And one of the reasons why the whiplash and the neck injury are hard to treat and the shoulder is hard to treat and the knee is hard to treat is because the brain is injured and the ability to inhibit pain has been injured. And so again, the path forward is not just trying to treat these other injuries in isolation, but to actually improve the prefrontal cortex right improve the functioning of these parts of the brain that are responsible for inhibiting pain as part of the treatment.

Sophia Bouwens: 22:45

The whole world could use better prefrontal cortex function, right? So what are some things that you find really helpful for improving prefrontal cortex activation or function?

Ayla Wolf: 22:57

There's a couple of things, and I like to distinguish between your passive therapies and your active therapies, right? So active therapies involving the prefrontal cortex, you know, could be a lot of cognitive type challenges and actually trying to exercise certain types of cognitive functions. So one of the tests, or, sorry, one of the kind of therapies that is really hard is called a dual N back challenge. Dual N back, yeah, so, and the letter N stands for number, and so if you're doing a one back, basically, if I were like, laying cards down on the table, and I laid down an ace and then a jack, you would have to try to remember the ACE under the jack, and then I lay down a 10, and you'd have to remember the jack under the 10, right? So that would be a one back. But then if we were doing a two back, if I lay down the 10, you gotta remember the ace from two cards before. And so that would be just a normal end back challenge. A dual end back is where there's two different sets of data. So now, like one of the apps that I use is called the end back challenge, and it's literally a grid, and so a box will light up in the grid, and then they say a letter, and then a different box lights up, and then they say another letter, and you have to tell the app whether or not the Box was in the same location, and whether the letter was the same. And so you're having to remember two sets of data, lead the alphabet and then the location of these boxes. And so things like that, that challenge, that prefrontal cortex, are very, you know, helpful in the long term. And it's really funny, because the app actually, like, after you do it a couple times, it sends out a little newsletter that talks about the research behind it, and it also says, you know, unlike some other brain training games, this one's not fun, it's really hard, it's really hard, it's not fun, and it's actually quite therapeutic, but it's not necessarily enjoyable, like some of the other things out there

Sophia Bouwens: 25:05

I could see how it'd be good for that prefrontal cortex, who we think about as mainly inhibiting information, right? So you're gonna get all this information thrown at you, and you have to stop paying attention to the stuff that's not important and keep in your mind what was important, which is, with this app, it sounds like it's changing often, right? So you have to ignore the unnecessary data and remember the necessary parts while paying attention to two different data sets what's going on. Yeah, that sounds really challenging. And for someone with that concussion or a headache and concussion, it sounds even more challenging.

Ayla Wolf: 25:45

And then there's other things out there too. Like, you know, I can have letters on the wall, for example, just like the alphabet spread out on the wall. And then I'll give somebody a word, and they have to find the letters to spell out the word, but they have to point so if the letter is on. The right side, they have to point with their left hand. And if the letter is on the left side of their body, they have to point with the right hand. And so you're engaging their visual system to search for letters. You're engaging bilateral stimulation by using cross body pointing. And then you can even make it harder by, say, have someone balance on one foot, or have actually distracting music playing in the background while they're trying to do the task. And so you can run people through these kind of complicated cognitive tasks to help engage that part of the brain. And then also, you know the where, where these kind of passive therapies come into play, acupuncture, certain acupuncture points have been shown very effectively to help with improving blood flow to that prefrontal cortex and the frontal lobe. And so using therapies that help to improve blood flow to that part of the brain can also help so that you can do that therapy, or whether it's hyperbaric oxygen therapy, you know, whatever the tool is to kind of drive more blood flow, oxygen activation to that part of the brain, and then pairing that with an actual cognitive task, and you start to basically wake up these parts of the brain

Sophia Bouwens: 27:15

make a difference, which is important, and when you're waking them up, I find with neuropathic pain, oftentimes people are very sensitive At the beginning of treatments, and I know that they're improving when their perception of stimulus gets more accurate, and things are not nearly as sensitive over time, right? So the brain changes in its way of perceiving things, which is, I think, a key here.

Ayla Wolf: 27:39

And meeting people with where they're at is so important. There are some people that really can't even they're not going to benefit from immediately jumping into therapies that they can't perform, right? And so for some people, you have to they come up with therapies that they can do while they're still laying down or seated. Or for some people that are very sensitive to screens and light, you know, they might need to do therapies that don't need any technology to start, right? And so it's like you're taking away all the technology, and you're doing these things low tech in a way that doesn't require people to be in front of a screen. And so, you know, everybody's different in terms of the amount of stimulus that they can handle. And so the idea is not, you know, just assuming that everybody can do the same therapy, you've really got to be able to gage where people are at and then meet them there and work with each person at that individual level,

Sophia Bouwens: 28:34

for sure. And that's why individualized approaches are always so much more effective, I find, than protocols or everyone one size fits all kind of thing. Because if that were the case, it would be easier as a provider, because I wouldn't have to do much thinking, right? Just, Oh, you have this. I'm going to just give you this protocol. But if you really want to progress, you have to work within your means. I think that's especially important after a head injury.

Ayla Wolf: 29:00

And that's also why, again, kind of this splitting things up into whether they're an active or a passive therapy. I'm very excited about transcranial magnetic stimulation because that has the you have the ability to focus the TMS therapy on the prefrontal cortex, and so that is a therapy that people can go and receive transcranial magnetic stimulation, and it helps to improve the functioning of the prefrontal cortex, and in doing so, it can help with neuropathic pain, it can help with post traumatic headaches, it can help with depression, it can help with these cognitive symptoms. And so I'm super excited about TMS as a growing therapy, and even in some insurance companies are starting to pay for it. And so I think more and more the research that is so positive that's coming out on it is also, I think, spreading quickly, and a lot of hospitals and clinics are recognizing that this is actually a very promising thing for some of these very difficult to treat cases of neuropathic pain, depression, post traumatic headaches and chronic pain.

Sophia Bouwens: 30:10

So thinking of neuropathic pain and modalities you can use to treat it, I find acupuncture is one of the most effective for neuropathic pain. Why do you think that might be from your perspective neuro ninja that you are? Can you break it down in a way that is understandable or relatable to patients who might feel like I already hurt enough I do not want to get a bunch of needles put in me. How is that going to help my nervous system be better at not being in pain?

Ayla Wolf: 30:42

Yeah, there was a study that I loved that looked at the use of acupuncture over time. So it was looking at the consecutive effects of acupuncture on the brain. So they were doing functional MRI imaging, and what they were showing is that acupuncture modulates the activity in. In a lot of the same areas of the brain that are involved in that pain neuro matrix, including the somatosensory cortex and the insular cortex, the prefrontal cortex, the anterior cingulate gyrus. And so what they were recognizing is that the reason acupuncture is effective for treating chronic pain and neuropathic pain is because it is actually modulating parts of the brain that are involved in in pain perception. And the way I like to think of it is, if you have this pain neural matrix, this conglomerate of different areas of the brain that are all perseverating on a pain signal. It's almost like you've got one one conversation happening that we could just call like we're Heavy Metal, right? So the pain neural matrix is playing heavy metal music, and that is what the brain is paying attention to, over and over and over again all day long. And then as you get acupuncture, the cumulative effect of acupuncture is almost like turning a different radio station on, and so now all of a sudden, classical music is playing, and now you're giving the brain the ability to listen to the classical music instead of the heavy metal music, you're giving it a different signal to tune into that can actually dampen down the heavy metal that we're equating to As a pain perception, right? And so that's how I look at it in my in my mind, after reading the research and seeing how doing acupuncture, like I said, is changing and modulating the conversation happening in the brain in these exact same areas.

Sophia Bouwens: 32:38

So it could be very helpful for that type of pain which is perceived by the central nervous system, if it's changing the way that those structures are listening to pain, right? Yeah.

Ayla Wolf: 32:51

And I think the other important piece of that is that when things have been chronic for a long time, you're talking about changing neuroplasticity, and that takes time. And there was a really great case study that was published that I think, you know, would have been relevant to our previous episode. But let's talk about it here. It was a woman who had had migraines for 35 years, and she was on lots and lots of medications for the migraine, pain, for depression, for anxiety. Then she developed gastritis from all the medications. Then she had all this abdominal pain and symptoms. They diagnosed her with medication overuse, headaches, and they took her off of all these pain meds in hopes that she would get better. And after a year of getting detoxed off of all these medications, she was still having headaches every single day. And so then they said, well, let's do acupuncture. And they did 48 acupuncture sessions. It's a lot, it's a lot. It was twice a week for six months. But here's the kicker, after four weeks, so after a total of eight treatments, absolutely nothing had changed. She was still having headaches 30 days a month, but after 12 weeks of therapy, she was down to eight headache days a month, and after the six months, she was down to one headache day a month. Wow. Now so many people, if they were coming in for acupuncture twice a week after four weeks, if they had had no improvement, they probably would have quit, right? It was, this isn't working for me, so if they had just stuck with it like she could have quit, right? She could just say this isn't working, but she stuck with it and had a complete resolution of her headaches after six months. And I think what people don't realize is that when you've had chronic pain and it's been there for so long, it takes time to change that neuroplasticity. A lot of the problems that that I face are people coming in with the expectation that, okay, I'm finally brave enough to try this, but man, if it doesn't work within three treatments, I'm done, right, you're fired!

Sophia Bouwens: 35:04

I always bring it back to the parallel between acupuncture dosing and exercise, right? If you're training for a marathon, no one would think I'll go to the gym once and I'll be ready or go to the gym three times and I'll be ready to go unless you're already in great shape. But that being said, if you're coming in for pain, even like a neuropathic pain, and you're not better in one to three treatments or after, what was it? A month of treatment, twice a week, and you're still feeling like this is still going on. It's really hard to keep sticking with it, unless you understand that each treatment is like a workout and it builds on the last and it's making changes is just slower depending on your condition going into it, your train faster or how frequently you train, that's going to make a difference too. What you're doing outside of the gym to help eat right? Will make a difference for how you recover or gain strength,

Ayla Wolf: 35:58

right, whether we're sleeping or not, your stress levels.

Sophia Bouwens: 36:01

And with acupuncture, the same thing goes right, and sometimes it's that the treatment isn't right for you. You could try something else, but not to give up on it if, right away, it doesn't make a huge difference, because that dose, given the nature of your condition and the nature of your body going into it, is going to need to be different, because that neuroplastic change, or that physiological change in the system takes time.

Ayla Wolf: 36:27

and there have been situations, too, where I've had somebody who had really severe post traumatic stress disorder, and then they had a concussion, and the PTSD symptoms got so much worse after the concussion, and when they would come in to see me, they their nervous system was so dysregulated from the PTSD symptoms that they weren't even really responding to my acupuncture treatments very well. And I've now started to recognize that if anxiety is so off the charts high that people can't even shift into a parasympathetic state that sometimes they really need to make the the mental health symptoms their number one priority, and actually start seeking out things like EMDR therapy and other types of things that can help them to get out of that extreme kind of sympathetic state before they're even real there, before their Nervous System is even going to be in a place where it can receive something like acupuncture as a therapy, because

Sophia Bouwens: 37:29

it's hard to change a system if it's in constant stress.

Ayla Wolf: 37:34

And what's interesting is that acupuncture, in some cases, can really shift people into that parasympathetic state really strongly. It can help with anxiety. But then I think when there are cases where, in some situations, people just are in a state where they are not responding and the acupuncture is not doing that for them, we have to recognize that and say, Okay, what therapy is going to actually get them out of this extreme sympathetic state, if it's not acupuncture, what is it definitely and so that's important to recognize as well. And I think that, you know, again, going back to this idea of, you know, chronic pain and expectations, like you said, you know, sleep is so important, and so if people aren't sleeping, then that's also another barrier. And so we have to look at it from all these different angles.

Sophia Bouwens: 38:23

So there's a lot of complexity, but I love Chinese medicine because it pulls together all of these things. And I think this conversation, and our previous conversations, just really dive into making sure the diagnosis is right, or the driving factors are what you're really paying attention to. If the driving factor is migraine, then you need to work at it from one angle. If it's cervicogenic, it needs to be coming from a different angle. If it's neuropathic, we might need to work more internally, or like, with the function and the cognition in the central nervous system or the relaying of information.

Ayla Wolf: 38:57

And then bring in some of those, like remapping therapies, you know, whether that's Feldenkrais or, you know, some of these, like wonderful movement therapies that really help to kind of remap the brain and the body and create a better connection there. One of the reasons why I find a very comprehensive neurological exam to be helpful is because you can start to pull out different biomarkers. So let's say you're looking at someone's pupillary light reflex, and you see some abnormalities with the way that the pupil is constricting or dilating, that gives you window into the autonomic nervous system. Or you're doing a sensory test, and the pinwheel is sharper on one or two branches of the trigeminal nerve. Or you start to look at someone's motor output, and you see these differences between, say, the right hand and the left hand. By doing a very comprehensive functional exam, you start to see these kind of errors in the system. And when you start to treat people, even if they don't necessarily have this immediate, huge shift in their symptoms, with the head pain, for example, if you are at least seeing improvements in their neurological output, you know that their brain is healing and that there, there is something beneficial happening. It just hasn't yet translated into that inhibition of pain. But I think for some patients, if they are coming in and they're doing therapies and they're wondering, I'm not even sure, if this is doing anything because I still have my headache. If you can at least point to the fact that these other things are improving, it does serve as a kind of guiding light to say, hey, you know, your brain is healing. Things are shifting. We're having less errors in your system. Eventually this is going to translate. It just isn't quite yet. You know, I think that the default is to just give people medications, right? And a lot of those medications, like gabapentin, for example, are things that just kind of globally inhibit the brain. And I really feel like when it comes to concussions and concussion recovery, you don't want to globally inhibit the brain. That's not kind of what we're trying. Do. We're trying to get the communication and then the function better, instead of inhibiting everything.

Sophia Bouwens: 41:07

Absolutely so medications might turn the alarm off, but they're not going to put out the fire. So finding how to go into the system and help talk to the system to strengthen it in the right ways is important.

Ayla Wolf: 41:22

Highlighting this idea that post traumatic headaches should not just blanketly be diagnosed as migraines, that if there is a neuropathic pain component, a lot of times, the medication route is not giving people the relief that they were hoping for, and that we need to look at it from more of this functional perspective of increasing function, blood flow, neurological activity within the prefrontal cortex and the areas of the brain responsible for inhibiting pain, helping to remap the body in the somatosensory cortex, to bring more integrity to that part of The brain, and then doing therapies that help support neuroplasticity and kind of change the conversation in the brain so that it's not perseverating on pain over and over and over again, absolutely.

Sophia Bouwens: 42:12

And that makes me think of our research study where we just did one treatment style for all different types of post traumatic headache, and we saw some great changes, but there's a lot of complexities in that too, and an interesting discussion to be had around our interpretation of that or where we might go next.

Ayla Wolf: 42:34

So coming up in our next podcast, we'll dive into our research on post traumatic headaches using acupuncture, the outcomes of that study, and then kind of what we're hoping to see in the future with future studies down the pipeline,

Sophia Bouwens: 42:47

stay tuned.

Ayla Wolf: 42:53

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