The Practice Gap
The Practice Gap
# 35 Headaches: Patient Communication, Research, Medication Overuse, Skepticism and Assessment Hacks with Aleksander Chaibi, PhD, DC, PT
Why you should listen to this episode:
You will get tips on where to start when assessing a headache patient, and how to communicate with your headache patients for the best results.
You will also get to know more about medication overuse headaches, and how to talk with the patient's primary care physician about it.
Our special guest, Aleksander Chaibi, is a distinguished chiropractor and senior researcher. Alexander takes us through his journey from earning a PhD at the University of Oslo to his current role, offering crucial insights into the diagnosis and treatment of headache disorders. You'll learn how to differentiate between various headache types, including migraines, tension-type headaches, and cervicogenic headaches, through strategic questioning and patient history. Alexander's unique diagnostic approach is designed to rule out serious conditions and confirm diagnoses effectively, ensuring precise patient communication.
In an engaging discussion, Aleksander sheds light on a multifaceted treatment strategy for chronic primary headaches, combining physical manipulation, neurological assessments, cognitive therapy, exercise, and stress reduction. We address common misconceptions about chiropractic care, particularly concerns about neck manipulation, and emphasize the importance of patient involvement and confidence throughout their treatment journey. Tune in for practical headache management strategies, from staying active to celebrating progress. This episode is your go-to guide for understanding and managing chronic headaches with expertise and empathy.
Link in this episode:
https://jamanetwork.com/journals/jamaneurology/fullarticle/2766518
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Kind regards,
Elisabeth Aas-Jakobsen, DC, MSc
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Hi and welcome to the Practice Gap, the podcast for closing the gap between the practice you have and the one that you want. I'm Elisabeth, a chiropractor, a business owner, coach and entrepreneur, on a mission to help you move from frustration and overwhelm to clarity, focus and joy in practice. Aleksander Chaibi, and welcome back to the studio thank you very much we are now going to dive deeper into both communication and research and a lot of other things let's start by could tell the audience a little bit about your research?
Aleksander Chaibi:Okay, my PhD, which I did at the medical faculty at the University of Oslo, was on headache disorders, primarily migraine, but I did also research on tension-type headache and cervicogenic headache, Delivered a thesis in 2016. I defended the thesis in 2017, I think. After that, I've been in research as a senior researcher affiliated with the hospital. I did my PhD at the Akershus University Hospital and then I moved over to the medical faculty University of Oslo, where I'm a senior researcher and supervisor for a place.
Elisabeth Aas-Jakobsen:Let's just stop here a second here. So you are, you're running a clinic with 20 people and then you are like how much do you work with research? What the percent? You're weak I also think I believe you have some kids also.
Aleksander Chaibi:yeah, I do two, two, one and a half years between them. You need to be strict on time, otherwise you don't have any chance at all. But I do work reduced at the clinic. How?
Elisabeth Aas-Jakobsen:many percent.
Aleksander Chaibi:Maybe around 20-22 hours with patients.
Elisabeth Aas-Jakobsen:Which is about 50% of the week with patients. Yeah, and then how much on the administration of the clinic?
Aleksander Chaibi:yeah, that's a little bit as well. And then and then I do research every week. Yeah, at least two days a week. I do a little bit, but it goes a little bit up and down, because sometimes it's really hectic with deadlines etc, etc. And then you need to work a little bit more, like during my PhD. I did work a lot of weekends, really many weekends. Otherwise I didn't have a chance and with small kids at the time, I also had to drive up to the hospital to work there. I could not sit at home.
Elisabeth Aas-Jakobsen:What made you choose to do a PhD?
Aleksander Chaibi:I don't know. I think the reason why is that I've always fancied research that contributes. It needs to have a meaning, a clinical implication, otherwise I find it often a little bit boring and meaningless. Doing a PhD you really go into depth of the topic. I didn't know at the time that the methodological quality of the papers that was published had shortcomings and I thought and believed I still believe that we could close those shortcomings and improve chiropractic research, and that was the main target.
Elisabeth Aas-Jakobsen:How has doing research on that level that you have changed the way you practice?
Aleksander Chaibi:it's definitely changed my communications towards the patient.
Elisabeth Aas-Jakobsen:It could you give us some examples?
Aleksander Chaibi:for example, I I can talk with more authority and credibility because I've actually read the paper and I can also. The thing is it's not with me, but in general, the better you know something, the easier you can explain it, and that has probably helped me a lot. And knowing a topic or subject really good, I have a tendency to simplify.
Elisabeth Aas-Jakobsen:Okay, so if I'm a patient, come to you, alexander. I've had headaches all my life. I've tried everything. I don't know what to do. Can you help me?
Aleksander Chaibi:Yes, the first thing I would do then is just ask them some general questions, so it takes about two minutes, then I can start closing in the questions that are really important for diagnosing because, there is 300 headache diagnosis.
Aleksander Chaibi:So I need to just exclude all the serious secondary. And you do that easily by asking them do you have a day without headache? If they do, there's no tumor, because that comes, presses on the meningi and it just progress. There's no bleeding, because that's the same. The bleeding just expands and then presses on the meningi and then it causes headache and there's no meningitis I think the english word is because they are not able to communicate and they have fever spiking 40, so that's 250 plus out okay, good.
Elisabeth Aas-Jakobsen:So all of you just remember to ask do you have any days without?
Aleksander Chaibi:headaches crystal, clear days crystal clear, yeah and follow up that question with from you wake up until you go to sleep. There's not 0.2 on a 0 to 10 scale. Pain scale, uh, headache there's nothing your head is perfectly clear. That's a crystal clear headache so a follow-up?
Elisabeth Aas-Jakobsen:okay. So I just asked you do you have any days without any headaches whatsoever? So from the day you wake 8 o'clock and go to bed at 10. There's not even a little tiny bit of something reminding you of a headache. Okay then, 250 diagnoses out the window. Yes, Perfect, thank you.
Aleksander Chaibi:Then we need to ask them a little bit if they've had a diagnosis and if that was done by the physician or a neurologist, because there's a more diagnostic certainty with a neurologist with experience in headache.
Elisabeth Aas-Jakobsen:So if then I said well, I have a lot of my headache comes with stress and I think I have a migraine, because my dad has a migraine and I've read a little bit about it on the internet. It looks like that.
Aleksander Chaibi:And I've read a little bit about it on the internet. It looks like that yeah, then I would say I know from research, if the patients say they have migraine, they are 95% correct, so I know that then. So all right, let's have migraine on the diagnose list until proven otherwise. Then I will ask them if they've tried specific migraine medication. If they say yes and they have responded, then that diagnosis is set. But we're not finished there, because some people or patients have multiple headache diagnosis, so we need to address all of them, because there's different approach for different headache. And then I'll just continue until I have one, two, three or even four headache diagnosis and then I go into medication use because there might be some improvement there and it might be something they haven't tried which could help, or sometimes the the headache diagnosis is wrong and we need to contact the physician to to address the diagnosis and maybe change it and change the prophylactic strategy.
Elisabeth Aas-Jakobsen:So you figured out to have some kind of migraine and also a stress headache. So now you are going to explain to me how you can help. Why should I get treatment by you?
Aleksander Chaibi:Yeah, if you have stress headache, which we call tension type headache, I tell the patient that tension type headache is like a puzzle. There's a lot of pieces and one piece is the work environment, one is the family, one is children, one is all the money we lost on stocks, the other one is bad hair day, and the list goes on. Everything from A to Z. And sometimes the puzzles are put upside down and because if we look at the definition now I'm talking to you as a patient- yeah, I'm the patient here.
Aleksander Chaibi:If we look at the definition for tension type headache, here's the definition it's a neurological disorder with central and peripheral mechanisms involved. And and to translate that for you, that's like when you gamble. In Norway we have tippigupong and that's a football game. It's either home victory, draw or away victory, and if you pay enough you can put a cross on all of them. So that's definitely a win on that game and it's 12 games and we call that helgradering. So you cover yourself on all the results. Because if you define tension type headache as a central and or peripheral mechanism involved, you basically are saying that we don't have a clue. So if we don't have a clue, it's not life-threatening. We know that.
Aleksander Chaibi:It's one medication for chronic tension type headache you can take every single day. But for all headache diagnosis they are designed for other disorders. This one is designed for depression, but you dose it a little bit lower. So if that's been tried, which it often hasn't been, so that's a strategy you can use. You need to go about on a really multi-model approach and try to address the different components. But again, you need to build up the credibility for the patient so they can explore different strategies, maybe cognitive strategies alone or with a psychologist. They need to change their exercise routines because every change is good for the body, so I don't really care what they do. I want them to change anyway okay.
Elisabeth Aas-Jakobsen:So if I exercise I twice, twice a week at the gym, I lift some weight yeah so then you just want me to then I'll first ask you a little bit how much, on a scale from zero to ten, do you enjoy lifting weights?
Aleksander Chaibi:if you say ten, I will never remove it okay if you say two two.
Aleksander Chaibi:Then I'll say I don't want you to lift weights for the next 12 months. I want you to get on the bike and ride as fast as you can up to the highest point in your area, and then I want you to ride really quickly down at least once a week. I want you to beat your time on the downhill every time with 0.1 or one second doesn't matter for me. So it's up to you how slow you go the first time, but you need to beat it every time. The reason why I do that is because I want to stimulate. I want to stimulate the patient's achievements and by doing so you release all the fantastic hormones.
Elisabeth Aas-Jakobsen:So so by learning a new, new skill exercising you both get rewards of the exercise itself and also to manage something new yeah, exactly, and you need to push that all the way.
Aleksander Chaibi:So balance and coordination is really quick to improve. So that's a strategy to use. But I always try to facilitate risk reward thing in order to facilitate serotonin and endorphin hormone thing, which is documented to change with, for example, manipulation.
Elisabeth Aas-Jakobsen:How about if I say that I I am at 10. I love weightlifting. What would you tell me then?
Aleksander Chaibi:Then I would say, excellent, just stick to weightlifting. But I want you to change some of the strategy. Within weightlifting, you can work on endurance, max strength or hybrid. You can work on speed and you can do weightlifting by implementing coordination and balance, for example, implementing a coordination and balance, for example. So then I just changed their routine with what they do, but I want still want to add a aerobic exercise as well, so you're so now I'm going to change how I work out.
Elisabeth Aas-Jakobsen:But you also said a little bit that manipulation could help, or treatment. Could you yeah?
Aleksander Chaibi:we don't really know, but the paper is published on on chronic primary headaches.
Elisabeth Aas-Jakobsen:So now I'm the patient, now you're patient, yeah, so um how can you help me doctor?
Aleksander Chaibi:yeah, we can address the physical thing. But, as I said to you, the tension type headache is like a puzzle. We have this medication that you haven't tried. That's an option we can look at if you don't respond, because nobody wants to stay put on medication for the rest of their life or a longer period. So that could be a backup plan and then we can address the function.
Aleksander Chaibi:We'll do some neurological tests etc just to I don't know comfort the patient, because it's really really seldom that you pick up a glossopharyngeal tumor really seldom that you pick up a glossopharyngeal tumor and then I tell the patients that I need you to be on board here. I need us to start start with blank paper, because they've read so much, they've heard so much and they are getting conflicting evidence from everywhere. So now we need to like and sometimes I even tell the patient I need you. If it's really complicated, I needed to just roll up your sleeve and say fuck the health care. This is what I'm gonna fix this. I'm gonna fix this myself, because sometimes you need really to push them just to, just to stimulate and and and work on a confidence level, because all research says that exercise helps tension type headache. So why on earth are they getting so tense?
Elisabeth Aas-Jakobsen:and that's not as straightforward as you want, it's a million reasons so then, we've gotten to the point that you actually, in addition to all these things, I'm going to do occasion, I'm going to do cognizant therapy, I'm exercising and reducing stress in my life, and you have gotten to the point that you found that you also want to treat my neck. Yeah, and I say, what do you say that treatment? How can that treatment help me as a patient?
Aleksander Chaibi:yeah, if let's say I've done the assessment, I found some restrictions in in your neck and maybe mid-back and maybe here and there, and I said, all right, we have some findings. That's good because then, we have something to work on if your body was perfectly fine. I would scratch my head and I wonder what to do. Yeah, so that's good. Okay, so I think we're gonna start off with treating your lower neck today, and then I'll see a panic attack in your face.
Elisabeth Aas-Jakobsen:I'm super scared and I don't want you to. Really I'm scared of somebody touching my neck okay.
Aleksander Chaibi:Have you had any experience with this before?
Elisabeth Aas-Jakobsen:uh, no, but I did watch youtube yeah, all right, I get.
Aleksander Chaibi:I get goosebumps from youtube as well. That's not how it should be done. It's crazy and should be prosecuted. So that's not what we do here. But we need to improve the function and then I'll show again on the patient. So you see, if I move your neck to the right, for example, you feel a hard, stiff feeling at the end and the softer one on the other side. That's a restriction. So if we can release that, so the softness is on both sides, that'd be perfectly fine okay, so if I'm soft here, so what I feel, then it's stuck.
Aleksander Chaibi:That's the movement of the so basically, I'm gonna place my index finger on your lower neck, I'm gonna make have your head rest on my chest and I'm gonna make a small push in and just to help you a little bit, I'm going to do everything on until the small push and I'm going to move away, get in front of you and ask you how that feel okay so that then you get a get a feeling of what's going on.
Aleksander Chaibi:So I'm never going to surprise you on anything, but have you had any experience? If you had an experience, like a bad experience, somebody who pushed really hard or did something without your- consent, because we, well, I, I don't.
Elisabeth Aas-Jakobsen:But of course I have patients who come in and say like he was just jumping on me and there was so much noise and I was super scared and I just don't want you to touch my neck. Yeah, I understand that's perfectly fine.
Aleksander Chaibi:I don't want you to touch my neck. Yeah, I understand, that's perfectly fine, I don't have to do it, but then I think the treatment will take much longer. In terms of safety, it's actually much safer to get a neck manipulation by a chiropractor than walking from here to the underground. And now I can lean on my research. But not everyone can. But if I was not a researcher, researcher I would say there's actually been a lot of research on safety, on spinal manipulative therapy. We've done all the orthopedic and neurological tests. It's all clear. Uh, you, you're not in the age group and um, but it's all up to you.
Elisabeth Aas-Jakobsen:I cannot force you, I can only help well, thank you, I think I'll go for that. So how many times do I have to come back, doc?
Aleksander Chaibi:well, that's a good question that we need to. We need again at the puzzle. It depends a little bit on your response and how much you work with yourself, because the responsibility is on you, it's not on me.
Elisabeth Aas-Jakobsen:I'm more a consultant so I have to start with myself again again.
Aleksander Chaibi:But now we're gonna shake it up a little bit and centrifuge you okay, and we're gonna celebrate the all the victories. So if you get another day without headache, I want you to crack a bottle of champagne and enjoy the glass and take it, really just celebrate. But when you have a setback with stronger headache, I want you to try to just ignore it. But another thing that in terms of your question, how many times? Because my previous mentor, he also always said that pain is not a good parameter for for monitoring effect or anything, because pain is the last symptom that comes in in the injured tissue area. But luckily it's the especially luckily for chiropractors, because we have a really low number to treat to get relief of pain. Pain is the first thing that removes, but that's not synonymous with stability or improved function or improved quality of life. Then you need to address the puzzle as well.
Aleksander Chaibi:But spinal manipulation is a really valuable and strong tool to get through because it's so visible, it's so invasive for the patient that you get a really kickstart. But it has a huge effect on the neurological system. It has a huge impact on the cortex. We know that from research. So, yes, it has a huge impact. Impact on the on the cortex. We know that from research. So yes, it has its place. But in complicated, chronic cases you need to address a lot of other stuff what are?
Elisabeth Aas-Jakobsen:when you meet physiotherapists or medical doctors in the research field and at the hospital, what are they when you're telling them you're a chiropractor? When they're skeptic, what are some reactions you get?
Aleksander Chaibi:It could be like pseudoscience bone crackers, killers, everything. There's everything, from A to Z. How?
Elisabeth Aas-Jakobsen:do you meet it? How do you meet like?
Aleksander Chaibi:I was a little bit more provocative before, I think, than I am now, but like my the neurologist I do research with, still he always says that it's so much easier to criticize than to produce. Just Always know that, alex, and I lean myself a little bit on that. Because people criticize they probably never produced anything. Because if they have produced a solid, randomized, controlled placebo, controlled clinical trial, they know and don't want to mess with another person who's done the same because it's so hard.
Aleksander Chaibi:But you can start off by saying do you know what a chiropractor is? Do you know that it's a profession that involves diagnosis, intervention and follow up and communication with other healthcare professionals? Do you know that they have a five year university degree in Norway? Do you know that they are licensed therapists who are able to give sick leave, refer to radiology, including MRI and CT scan, or refer to hospital for operation? Do you know all this? No, I don't. Normally, they say, because many people that criticize they just automatically.
Aleksander Chaibi:I don't know why put chiropractors and manipulation synonymous. It's basically like if I was blind and deaf and the only thing I did was crack and go on to the next one. I did not assess, I did not talk to the patient, I did not give exercise, I did not call the patient and ask how they felt, I did not refer for imaging, I did not write a notice to the medical doctor to communicate what findings were and what we are planning to do, and that I'm going to give them a follow-up notice on the improvement or the process. It's just insane to listen to, but you cannot explain the whole process every time, so I tend to lean on, just ignore them. They never produced a single thing. I tend to lean on, just ignore them. They never produced a single thing.
Aleksander Chaibi:But sometimes I've been in situations where patients have been taking too much medication because medication overuse. Headache that's a secondary headache that's really rising on the global burden of disease and I'm having so and you should always expect medication overuse when there's chronic headache. That means 15 days. There's chronic headache, that means 15 days or more with headache. Just expect medication overuse until proven otherwise.
Elisabeth Aas-Jakobsen:So, if a patient comes in and says I have at least 15 days, 15 plus. Then in addition to the headache, you also have an overuse medication.
Aleksander Chaibi:You just need to ask them. You need to really stare them straight in the eyes and ask them. You need to be honest now, because if you're not and you have medication overuse, you're basically treatment resistant. Nobody can help you, not even my magic hands, that's what I say.
Elisabeth Aas-Jakobsen:Here's a small medication question. How is opioid use? Do you have a lot of patients who are on OxyContin?
Aleksander Chaibi:I have some, but maybe a handful. They are all overusing, but it's not as common in Norway as it is in, for example, other countries. But in terms of just to conclude on the other one, in terms of communication with medical doctors, because when I report back that the patient has clearly a medication overuse that is overshadowing all the primary headaches migraine or tension type I have experienced a few times that the medical doctor has called me and really yelled at me and asked me who, who I am and how can I go about and interfere with this and this, and then I challenged the physician softly to begin with and then, if he doesn't respond, then I challenge a little bit harder how does it?
Elisabeth Aas-Jakobsen:how okay, so I'm the doctor I called you. It's like how you can't tell me what to do with my patients, and then where do you start?
Aleksander Chaibi:Yeah, I'll start with. The patient has a headache, as you know. It's not your fault that the patient has taken too much medication, but the headache frequency has just exaggerated up to daily now and there's a really linear correlation with migraine medication or paracetamol, ibuprofen. So the diagnosis medication overuse is pretty certain, and the patient has seeked other therapists as well, without relieving getting any relief from the symptoms, and the best treatment is no treatment.
Elisabeth Aas-Jakobsen:What do they say?
Aleksander Chaibi:They say you cannot interfere. And then I go. Just for your information, I have a PhD on migraine. I do research with the leader of the medication overuse classification the guys who set the diagnostic criteria that you use for migraine attention type. I know what I'm talking about. The patient needs to detox for two months. It's your responsibility to guide. Otherwise we need to send it to a neurologist. And then what the medical doctor does this is a little bit cocky, okay, but sometimes I need to push a little bit. But I tend to have a softer approach, okay, because I know that they don't like interference. But if your argumentation is good and a little bit softer and a little bit humility, that helps as well. I've learned that from Anders. You need to be a little bit more gentle in your approach.
Elisabeth Aas-Jakobsen:And Anders. He's a beloved Norwegian chiropractor and medical doctor.
Aleksander Chaibi:He's a good consultant in terms of communicating to the medical professions.
Elisabeth Aas-Jakobsen:But how about me, or us, the audience, who doesn't have a PhD in what can we say?
Aleksander Chaibi:You can write that all right. I have this common patient of ours. Her headache has exaggerated during the past 12 years. She says that she takes sumatriptan nearly daily and has done so for six months. I suspect that the patient has developed medication overuse, in addition to the migraine and tension type that you already diagnosed. According to the International Headed Classification Society, you could consider a detox for two months because the response is really good 50 to 70 percent and you can refer to the Akershus University Hospital study that was done on the medical doctor, like primary care physician offices.
Elisabeth Aas-Jakobsen:Is there a link I can put in the notes for this program?
Aleksander Chaibi:Yeah, we can find that and put it in. It's just, it's Aspen Sakser, kristoffersen's PhD. He did that on detox in the medical offices and got 50 to 70 percent. It's it's. You get gain about 20 percent extra effect if you abruptly detox but, you can also have gradual reduction of medication, but um abrupt is better perfect.
Elisabeth Aas-Jakobsen:thank you so much, alex. To sum up a little I don't know if I can do this summary the big things when you have headache patients do the big ask if they have any daily totally without headaches. And then all this, a lot of things are out the window. And then big take-home message is if you have headaches with tension and migraine, it's usually chronic, it's usually part of the puzzle. And then we have the nicely beautiful picture of the puzzle upside down where you don't really know where the part is.
Elisabeth Aas-Jakobsen:And get your patients to switch your exercise routine. Keep doing what they love and just change it and if they don't like it, do have them to do something else to both create the happiness of managing new results and also, if we're going to treat you and work on this together, just get rid of all the things, all your common beliefs, and let's do it together. Start anew, celebrate wins like a day without the headache with champagne, and then, if you have a bad, if it doesn't have it like, if you have an extra day, just forget about it and move on and we can do this together. And then, if you are coming when, if you treat patients with headaches, get up to date with the research and be aware of of the medication use. Be humble when you speak with others and be sure, when you are met with skepticism, to ask if they know what a chiropractor is and if they know that they have all this education and knowledge. Does that that sound?
Aleksander Chaibi:That sounds really good, and always make sure to tell the patient that we have the same goal. Yes, perfect.
Elisabeth Aas-Jakobsen:Thank you, alexander, for all your wonderful advice, and it was lovely to have you here.
Aleksander Chaibi:Thank you so much.