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Thinking outside the box: food allergy and migraine headache -- a case study.

History

An 11-year-old white female presented with a history of migraine headaches since the age of five. The headaches occurred weekly, were unilateral-right involving the eye, frontal, temporal, and occipital regions and had a lancing quality. Aura preceded the headache, and visual disturbances and nausea were always experienced. She had missed at least one day of school per week since kindergarten due to the incapacitating pain. The headaches began at varying times of the day and appeared to have no relationship to meals. Patient drank approximately three glasses of water per day regularly. She had no headache at time of presentation. Social history revealed an apparently happy, well liked young lady from an affluent upper middle class family who was active in school activities and on the A-honor roll.

The patient had no history of trauma, previous fractures, or surgeries. She had previously undergone multiple evaluations by a family allopathic physician, pediatrician, psychiatrist, ophthalmologist, and a neurologist. Prior diagnostic testing including CBC with differential, comprehensive metabolic panel, glucose tolerance test, lipid panel, thyroid screen, MRI, CAT scan, EEG, and ECG were unremarkable. Ophthalmoscopic evaluation established a need for corrective lenses at age six. The patient was initially diagnosed with depression and tension headaches and underwent brief counseling. She was later diagnosed with migraine headaches and prescribed amitriptyline, 20mg BID and Maxalt, prn. Amitriptyline is an antidepressant not recommended for children under age 12. Maxalt is an analgesic not recommended for children under age 18. She had taken these prescriptions without change in frequency or severity of headaches for the past five years. She had no prior experience with chiropractic.

Objective Findings

She was 58 inches tall and weighed 87 pounds with a blood pressure of 104/66. Her pulse was 82 bpm and regular, and her temperature was 98.7 degrees. She appeared healthy and well groomed and was cooperative and intelligent. She wears corrective lenses, not contacts. Her skin was pink, warm, and slightly moist. Facial expressions were appropriate, and she smiled frequently. Facial palpation was non-tender, and her sinuses illuminated well. Canker sores were noted on the inside of her lower lip, gum line, and right buccal mucosa. Cranial nerve function was normal. Pupils were equally reactive to light and accommodation. Cervical, thoracic and lumbar range of motion were within normal limits globally with mild, localized tenderness and joint lock noted at Occ-C1, C2-3, T3-4, T7 and L2. Mild suboccipital tension was noted on the right. Foraminal compression and distraction were negative. Romberg and Soto-Hall tests were also negative. DTR and dermatomes +II bilateral upper and lower extremities. Pulses were inta ct and equal bilaterally in carotid, radial, femoral and dorsal pedis arteries. Her chest clear with no murmurs noted. She had a trim abdomen with no tenderness or masses evident. Bladder and bowel function were normal with 1-2 bowel movements per day.

My assessment was migraine headaches, suboccipital myofascitis, spinal biomechanical dysfunction, herpes simplex. The initial treatment started with CMT-diversified technique twice/week for two weeks, and I also recommended increasing water consumption to six 8-oz glasses/day minimum.

After the first two weeks of treatment, her spinal dysfunction and MPS stabilized; however, her headaches were unchanged. With the chronic nature and continued severity of the patient's disability, it was my opinion that something else must be the cause of her migraine headaches. It was time to "think outside the box." I recalled what Dr. Michael Cessna, DC DABCI taught during the diplomate lecture series, "If a patient is not responding to treatment or if they have bizarre symptoms; and diagnostics are non-conclusive of cause, THINK FOOD ALLERGY!" The direction of evaluation was changed.

I discussed food hypersensitivities with the patient and her family. I explained that food allergies are more commonly delayed hypersensitivities and that what one eats may not produce symptoms for up to three days. Due to this delayed onset of symptoms, it is difficult to identify offending foods by history or dietary diary and that blood testing is necessary to accurately assess food allergies. With continued consumption of an offending food, chronic illness can result. Upon query, it was determined that the patient, though young, had a very diverse diet encompassing 91 out of a list of 100 foods. Food allergy testing was ordered.

A blood sample was acquired in office, prepped, and sent to Sage Systems, Inc. for evaluation of 100 foods for delayed hypersensitivity utilizing their multi-pathway method. Results were received within 10 days. Positive reactive foods were scored >10%, Equivocal reactions 9-10% and non-reactive foods <9%. Results are as follows:
Positive Reactive Foods


   Banana                 11%
   Beef                   11%
   Brewer's yeast         24%
   Cabbage                11%
   Coconut                11%
   Coffee                 14%
   Corn                   14%
   Cow's milk             16%
   Egg                    12%
   Honeydew               11%
   Lemon                  12%
   Pinto bean             12%
   Shrimp                 11%
   String beam            11%
   Sugar cane             13%
   Tomato                 12%
   Trout                  17%
   Watermelon             17%
   Wheat                  11%

Equivocal Reactive Foods

   Almond                  9%
   Apple                  10%
   Apricot                10%
   Cauliflower             9%
   Cherry                  9%
   Cocoa                   9%
   Cola                    9%
   Cottonseed              9%
   Crab                    9%
   Cranberry               9%
   Grapefruit             10%
   Green pea               9%
   Lobster                10%
   Millet                 10%
   Pear                    9%
   Safflower               9%
   Salmon                 10%
   Snapper                 9%
   Spinach                 9%
   Strawberry              9%
   Sweet potato           10%
   Tumeric                10%
   White potato           10%


With offending foods identified, the patient started the elimination phase of a rotation diet, avoiding of all reactive and equivocal foods. The patient and family were provided guidelines and preparatory suggestions for this -phase. It took approximately three weeks for the family to identify all sources of these foods at home, school, and elsewhere. A red sticker was placed on foods to be avoided and a green sticker placed on allowed foods at their home. Instructions were provided for rotating allowed foods over a four-day period so as to reduce possible allergy development of non-reactive foods.

The elimination phase lasted six weeks. Four days into the elimination phase, symptoms increased dramatically, and the patient was "sick" with headache, nausea, and photophobia for three days. This is not an uncommon part of withdraw reactions. However, after day 10 she was free of symptoms and was so for the duration of the six-week period of elimination. She had her first month of perfect attendance at school.

Week seven brought the beginning of the challenge phase. In this phase foods are added back to the diet one at a time, per four-day period. A single reactive food is eaten in two meals over a 24-hour period and then removed again from the diet. The patient makes note of any symptomatic reactions over the following 3-4 days, then repeats the process with another reactive food until all foods are challenged. With only two foods challenged per week, this process takes time. I find, however, that this allows for a less intense reaction to challenged foods that are still provocative. At the time of this article, the patient has challenged 24 foods and found that milk, corn, apple, lobster and brewer's yeast produce a mild headache if consumed. These foods, and others to be challenged later that produce symptoms, will not be returned to her diet. The headaches the patient experienced during the challenge phase were non-migrainous and still allowed her to attend school. She is hoping for a perfect attendance certifi cate at school next year.

Discussion

Headache is a common complaint and can occur for many different reasons -- muscle tension, depression, stress, spinal dysfunction, trauma, tumor, and vascular etiology, to name a few. However, as one can see, food allergies can also initiate migraine headaches. Edward Brown, DC DABCI, Chair of the Department of Diagnosis and Clinical Applications at Parker College of Chiropractic, cites a double-blind clinical trial that found 93% of children with severe frequent migraine headaches showed significant reduction of symptoms when their allergic foods were removed from their diet. Healthy food truly can make you sick.

In the case of my patient, the young lady's diagnostic evaluation was thorough and essentially normal, with life-threatening conditions appropriately ruled out prior to presentation. But please take note of one thing that caught my eye while preparing this study: All the physicians "thought inside their own box." The psychiatrist diagnosed her with depression, the neurologist diagnosed her with migraine headache, and the chiropractor (me) diagnosed her with spinal biomechanical dysfunction. Notice also that all "treated within their box" via counseling, antidepressant/analgesic medication, and chiropractic manipulation, respectively. All treatment was appropriate, but how long do you continue the same treatment if the condition is not improving? When do you examine further? Two weeks of spinal manipulation may seem brief, but I am so glad that I did not keep doing the same thing over and over again for six years expecting a different result. This patient's migraine headaches and disability were caused by some thing other than subluxation; they were being caused by food allergies.

Doctors, for those of you who have patients who are not improving, have chronic conditions, or are just seeing you too often because they simply do not feel "well," consider food allergy testing. Sometimes we need to just "THINK OUTSIDE THE BOX." After all, an apple a day ... may be keeping your patient ill.

REFERENCES

(1.) Physicians' Desk Reference. 51st edition. Medical Economics Company, Inc.; 2945-2947.

(2.) Drugs and Herbs. MSN. April 13, 2002. http://content.health.msn.com/drug_article/article/4046.2068?bn=Maxal t

(3.) Cessna RM. The Diagnosis and Management of Internal Disorders. Lecture notes, Module VII, Session 21-22.

(4.) Sage Systems Inc. 318 N Nova Road, Ormond Beach, FL 32174-5126.

(5.) CMDT. 34th edition. Tierney, McPhee and Papadakis.; 827-830.

(6.) Brown E. "Clinical Ecology." The Original Internist, 2002; 9 (1):29-31.

About the Author

Harold M Chalker, DC DABCI is a Magna Cum Laude graduate of Cleveland Chiropractic College, Kansas City. He earned his Diplomate from the American Board of Chiropractic Internists in 1996. He is in private practice in Meade, Kansas and is currently on the Allied Health Staff of Meade District Hospital. Dr. Chalker was a winner of the 1998 Regional Community Health Service Award from "Prevention Magazine" and the Alliance for Chiropractic Progress.
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Author:Chalker, H.M.
Publication:Original Internist
Geographic Code:1USA
Date:Jun 1, 2002
Words:1671
Previous Article:Delayed food allergy (Type II).
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