1. American College of Osteopathic Pediatricians
An Osteopathic Module for the Pediatric Migraine Patient Rachael Zanotti-Morocco, DO
American College of Osteopathic Pediatricians

2. Background
AT Still, DO was known to cure a migraine with a swing. Migraines are common in the pediatric population. Migraines affect 4% of children in the US. 50% of children that present to their primary doctor with the complaint of headache are diagnosed with migraine. The male to female ratio in children is 1:1. Migraines are characterized by throbbing pain, nausea, vomiting, photophobia, phonophobia, irritability, paresthesias, and tightness of neck and scalp muscles. Migraine attacks can last as long as 1-3 days and can be quite disabling. Migraines in children are often of shorter duration than adults and can be characterized by less pronounced symptoms such as cyclic vomiting, abdominal pain and vertigo.

3. Background
Migraines are caused by disordered neurogenic control of the craniocervical circulation especially the trigeminal vascular system. The cerebral blood vessels are affected by trigeminal, vagal and upper cervical neurons that converge in the trigeminal nucleus in the brainstem. The current theory is that some trigger (different in each patient) causes enhanced neuronal firing that sends a wave of depolarization to these pain sensitive blood vessels resulting in an inflammatory reaction causing vasodilatation and irritation to surrounding nerves. This results in pain.

4. Background
During the acute phase of migraine, active OMT techniques can increase blood flow to the head resulting in an exacerbation of symptoms. Therefore, at that time gentle techniques such as cervical/thoracic myofascial release and sub occipital release should be performed. 75% of patients with migraine complain of back or neck pain during, or immediately before a migraine. In these patients, special attention should be given to the muscles of the neck, scalp and upper thoracics. Children with migraines have been found to have paraspinal muscle spasm at the level of T4, along with neck muscle spasms. In the times that a patient is not having a migraine, more direct techniques can be used such as cervical HVLA which can prevent further migraines from occurring. For some patients, one of the triggers of migraine is musculoskeletal pain and by eliminating this trigger, these migraines can be avoided.

5. Cervical Kneading

6. How It Is Done: 1)Patient is supine.
2)Physician stands at head of patient on opposite side to be treated
3)Place one hand on the patient’s forehead.
4) With the other hand grasp the posterior cervical muscles and stretch.

7. Demonstrate the procedure on patient in front of director

8. Sub Occipital Tension Release

9. How It Is Done: 1)Patient is supine with physician at head of bed.
2)Place index and middle fingers in the occipital sulcus on both sides.
3)Apply linear traction until a release is felt, about 1 minute are as long as needed to feel the release.

10. Demonstrate the procedure on patient in front of director

11. Cervical HVLA

12. How It Is Done:
1) Patient is supine with physician sitting at the head of patient.
2)Place 2nd metacarpophalangeal joint along the posteriorly rotated articular pillar.
3)Side bend away and rotate towards the point of somatic dysfunction.
4)Apply rapid rotary thrust and then recheck to see if dysfunction is improved.

13. Demonstrate the procedure on patient in front of director

14. Innervation Table Organ/System Parasympathetic Sympathetic
Ant. Chapman's
Post. Chapman's
EENT
Cr Nerves (III, VII, IX, X)
T1-T4
T1-4, 2nd ICS
Suboccipital
Heart
Vagus (CN X)
T1-4 on L, T2-3
T3 sp process
Respiratory
T2-T7
3rd & 4th ICS
T3-5 sp process
Esophagus
T2-T8
---
Foregut
T5-T9 (Greater Splanchnic)
Stomach
5th-6th ICS on L
T6-7 on L
Liver
Rib 5 on R
T5-6
Gallbladder
Rib 6 on R T6
Spleen
Rib 7 on L T7
Pancreas
T5-T9 (Greater Splanchnic), T9-T12 (Lesser Splanchnic)
Rib 7 on R
Midgut
Thoracic Splanchnics (Lesser)
Small Intestine
T9-T11 (Lesser Splanchnic)
Ribs 9-11
T8-10
Appendix
 T12
Tip of 12th Rib
T11-12 on R
Hindgut
Pelvic Splanchnics (S2-4)
Lumbar (Least) Splanchnics
Ascending Colon
 Vagus (CN X)
T9-T11 (Lesser Splanchnic)
R hip
T10-11
Transverse Colon
Near Knees
Descending Colon
Pelvic Splanchnic (S2-4)
Least Splanchnic
L hip
T12-L2
Colon & Rectum
Pelvic Splanchnics (S2-4)
T8-L2

15. Print out the answer sheet to use with the following questions.

16. Circle the correct answer and review with director:
Question1: A, B, C, D, E.
Question2: A, B, C, D, E.
Question3: A, B, C, D, E.

17. Question 1
A 12 year old presents with headaches that have been defined as migraines. You may perform the following OMT.
a. Galbreath maneuvre
b. Occipital release
c. Sinus efflurage
d. Triple release
e. Temporal release

18. Question 2 Dr Still once used this to treat his own migraine:
a. a pulley system
b. a mule
c. a swing
d. a tractor
e. a tree limb

19. Question 3
Migraines are typically caused by problems with which nerve:
a. vagus nerve
b. trigeminal nerve
c. occipital nerve
d. phrenic nerve
e. accessory nerve

20. Certificate of Completion
I, _________________________, successfully completed the Pediatric OMT Module on __ __ 20__
Signatures:
Pediatric Resident ____________________
Pediatric Residency Director____________
( Please print and give to program director.)

21. Congratulations