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Cryotherapy for Headache
Lawrence D. Robbins, M.D.*

45 patients wit migraine or migraine plus chronic daily headache evaluated the effectiveness of a cold wrap for headache relief. 35.5% judged it not effective, 29% judged it mildly effective, 26.5% found it moderately effective, and 9% judged it completely effective.. Previous studies on ice treatment for headache are viewed.
(Headache 29:598-600, 1989)

Ice treatment, or Cryotherapy, has its roots as far back as the ancient Greeks, with anesthesia being administered via cold therapy as early as the Middle Ages.(1) In 1849, James Arnott(2) published a paper on cold therapy, in which he used a mixture of salt and ice. Sir Samuel Wilks(3) suggested the use of a wet bandage around the head. Gowers(4) discussed local therapy to the head and neck.

Diamond and Freitag(5) published a study in 1984 in which they looked at the effect of cryotherapy on 90 outpatients with migraine, cluster, and mixed headaches. They used a reusable frozen gel pack. 52% of patients reported an immediate decrease in pain. 71% of all patients, and 80% of migraine patients, reported that the pack was effective. Overall decrease in pain was reported by 63% of patients. Of all the patients surveyed, 71% reported they would use the gel pack in the future. Lance (6) (1988) published results of a new device (Migra-lief Apparatus), which employs cold, pressure, and heat around the head. Severity of headache was reduced in 15 of 20 migraine patients, and in 6 of 7 tension headache patients.

In this paper, the results of a study on cold for headache are presented, and the pathophysiology of cryotherapy is reviewed.

45 patients, aged 16 to 54, agreed to participate in the study. They were all patients at the Robbins Headache Clinic. The patients had either the diagnosis or migraine plus chronic daily headache. Patients were given a CHAMP Cold-wrap* which consisted of a cold pack inside an elastic bandage. The cold pack was stored in the freezer and provided 20 to 30 minutes of cold therapy.

At the onset of the migraine, patients placed the cold pack around the head with the elastic bandage, using a moderate amount of pressure from the elastic wrap. They were asked to evaluate at least three migraine attacks in this manner, and they were allowed to use their usual migraine abortive medication. On subsequent visits to the Clinic, the patients were asked, "Is the cold pack and pressure not effective (0-15% relief), mildly effective (15-45% relief), moderately effective (45-75% relief), or almost completely effective (75-100% relief)?" In addition they were asked, "Would you use it in the future?" Results are seen in Table 1.

Table 1
Adjunctive Treatment with Cryotherapy for Migraine and Mixed Headaches: Results
Number of Patients = 45

Question: Is the cold pack, for the first 20-30 minutes of use:
  # of pt's Percentage of Total
Not effective
(0-15% relief
16 35.5%
Mildly effective
(15-45% relief)
13 29.0%
Moderately effective
(45-75% relief)
12 26.5%
Almost completely effective
(75-100% relief)
4 9.0%
Question: Do you intend to use the cold pack in the future?
Yes 26 58.0%
No 19 42.0%

When the 45 patients were asked to judge the effectiveness of the cold pack, 35.5% judged it not effective, 29% judged it mildly effective, 26.5% thought it was moderately effective, and 9% judged the cold wrap almost completely effective. 58% of the patients intended to use a cold wrap or cold pack in the future. It is unclear how much the wrapping of the elastic bandage around the head added to the effectiveness of the cold pack.

The major effect of ice is to decrease the amount of blood flow to the area. Abramson(&) noted that when a forearm is placed in a bath of 17°C for prolonged period of time, the blood flow drops from 2.6 milliliters per 100 milliliters limb volume to 0.7 milliliters. Although it is controversial(*), it is felt that vasodilation occurs after the constriction. There are three main thoughts as to why vasodilation does occur. It may occur because of a reactive hyperemia, or due to a local contractile mechanism failure, or from a decrease in response to constrictor hormones.(1) A further effect of cryotherapy is a reduction in metabolism. In one study, the oxygen uptake in the forearm was decreased from .199 milliliters per minute at 32°C to .071 milliliters per minute in a bath of 17°C.(7) Chemical reactions were decreased by approximately 50% when the temperature was reduced by 10°C.(9)

Local anesthesia is an important consideration in the use of cryotherapy. Lowering pain stimuli may be caused by a decrease in contraction. The "gate theory" postulates that the cold sensations overwhelm and block transmission of the pain stimuli into the cerebral cortex. (10). Ice reduced the release of histamines, vasoactive substances and enzymes that stimulate nerve endings. Conduction velocity of peripheral nerves is decreased as the temperature is lowered. (8) Certain nerve fibers are affected more by the cold, particularly the small myelinated fibers, and gamma fibers of the muscle spindle are affected prior to the alpha fibers of the muscle. (11-12) This may contribute to a decrease in spasm, maintaining the muscle in a more relaxed state. Sympathetic activity may have a role to play in the cryotherapy mechanism. (12) One further effect that cryotherapy may have is its influence on collagen. Cold will increase the stiffness of collagen, raising the resistance to stretching.(10, 14)

Hocutt (15) described four stages of cryotherapy. In the first stage, lasting 3 minutes, there is a feeling of cold. During the second stage, 2 to 7 minutes into therapy, there is a burning or aching feeling. In the third stage, local numbness begins (5 to 12 minutes into the cryotherapy treatment). Finally there is a deep dilation, but no increase in metabolism. This begins at the 12 to 15 mark of treatment. At least 12 minutes, therefore, of cryotherapy needs to be utilized.

Several studies have looked at cryotherapy in the postoperative setting. (16) Average amounts of narcotics given to patients with and without cryotherapy, after foot surgery, were assessed. The amounts of codeine, morphine, and meperidine were markedly decreased with cryotherapy.

Contraindications to cryotherapy are relatively scarce. Absolute contraindication may include Raynaud's phenomenon and cold hypersensitivity. A histamine release in these cases may possibly cause wheals, flushing of the face, or in extreme cases, syncope. Occasionally, cold exacerbates a headache, and, in rheumatoid conditions, ice may increase or precipitate cryoglobulinemia. Patients with paroxysmal cold hemoglobinuria need to avoid cryotherapy, as the free flow of hemoglobin produced may lead to renal dysfunction and hypertension.

It was believed in the past that headache was primarily of peripheral origin with nociceptors being activated in the periphery, much like the pain resulting from burning of the skin. (17,18) The central nervous system, without activation of peripheral receptors, is another source of the pain. Headaches may originate from either peripheral or central mechanisms. The vascular structures about the head are pain sensitive, primarily the proximal portion of the cerebral  arteries and the large veins and venous sinuses.(19) The trigeminal nerve provides the main innervation to the blood vessels. (20) Stretching and pulsating of the walls of the arteries, or muscle contraction, has been believed to affect peripheral nerve receptors in these tissues, with head pain being the result. However, it is most likely that muscle contraction and vasodilation, although certainly contributing factors in migraine, are secondary to the main central headache generating mechanism. It is very possible that cold to the area is helping this second source of pain, and pressure around the head may be constricting the arteries that are engorged. However, these are most likely secondary factors in pain relief. It is also possible that the placebo effect of the cold and pressure has played a role in certain of our patients.

1. McDonald DPM, Guthrie J, Douglas, Jr. DPM: Cryotherapy in the Postoperative Setting. The Journal of Foot Surgery 24:438-441, 1985.
2. Arnott J: Practical illustrations of the treatment of the principal varieties of headache by the local application of benumbing cold: with remarks on the remedial and anesthetic uses of congelation in diseases of the skin and surgical operations. London: J Churchill, 1849:3.
3. Wilks S: On sick-headache. Br Med J:8-9, 1872.
4. Gowers WR: A Manual of Diseases of the Nervous System. Philadelphia. Blakiston, 1893, Vol 2, p 862.
5. Diamond S, Freitag FG: Cold as an adjunctive therapy for headache. Postgraduate Medicine 79:305-309, 1986.
6. Lance JW: The Controlled Application of Cold and Heat by a New Device (Migra-lief Apparatus) in the Treatment of Headache. Headache 28:458-461, 1988.
7. Abramson DI: Physiologic basis for the use of physical agents in peripheral vascular disorders. Arch Phys Med Rehab 46:216-244, 1965.
8. Knight KL, Londeree BR: Comparison of blood flow to the ankle of uninjured subjects during therapeutic application of heat, cold, and exercise. Med Sci Sports Exercise 12:76-80, 1980.
9. Olson J, Stravind VD: A review of cryotherapy. Phys Ther 52:840-853, 1972.
10. McMaster WC: Cryotherapy. Physician Sports Med 10:112-119, 1982.
11. Stillwell K (ed) Handbook of Physical Medicine and Rehabilitation, 2nd ed., WB Saunders, Philadelphia, 1971, pp 268-272.
12. Till D: Cold Therapy. Physiotherapy 56:461-466, 1969.
13. Migleitta OE: Evaluation of cold in spascity. Am J Phys Med 41:148-151, 1962.
14. McMaster WC, Liddle S, Waugh TR: Laboratory evaluation of various cold therapy modalities. Am J Sports Med 6:291-294, 1978.
15. Hocutt JE, Jaffe R, Rylander CR, Beebe JB: Cryotherapy in ankle sprain. Am J Sports Med 10:316-319, 1982.
16. Schauber HJ: The local use of ice after orthopedic procedures. Am J Surg 72:711-714, 1946.
17. Raskin NH: Headache 2nd edition, New York, Churchill Livingstone, 1988.
18. Raskin NH, Hosobuchi Y, Lamb SA: Headache may arise from perturbation of brain. Headache 27:416-420, 1987.
19. Ray BS, Wolff HG: Experimental studies on headache. Pain-sensitive structures of the head and their significance in headache. Arch Surg 41:813-815, 1940.
20. Moskowitz MA, Beyerl BD, Henriskson GM: Approach to vascular head pain. In Diseases of the Nervous System, ed AK Asbury, GM McKhann, WI McDonals, WB Soudners, Philadelphia, 1986, pp 941-949.

*From the Department of Neurology, University of Illinois at Chicago
Reprint requests to: Robbins Headache Clinic, 1535 Lake Cook Road, Northbrook, IL 60062
Accepted for publication: May 11, 1989

*CHAMP Coldwrap, Carolon Company, Winston-Salem, North Carolina.

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Seymour Diamond, MD
Frederick G. Freitag, DO

Patients with acute headache are often so vexed by pain that they seek out numerous physicians and headache clinics in search of a cure. For some, drugs do not provide adequate relief and thus nondrug remedies are appealing. In the following article, Drs. Diamond and Freitag report the findings of a study conducted recently at the Diamond Headache Clinic, Chicago, of one nondrug regimen that may be worth considering in conjunction with standard medication.

Headache has been a common complaint of humanity for centuries. Writings of the ancient Greeks and Egyptians indicate that physicians of that time were concerned with this condition. In some cases, rather drastic measures, including bloodletting and craniotomy, were reportedly practiced in the treatment of acute headache. With the evolution of medical practice over the centuries, a variety of medicinal, surgical, and physical therapies have been used to treat headaches.

Today, patients frequently report during history taking that they have used physical therapy, such as application of heat or cold, to treat their headaches. However, scientific evaluation of the potential benefits of cold application in headache treatment has not yet been performed.

After a thorough search of the literature, one of us (S.D.) recently found a single reference to cold application in headache treatment, a treatise of clinical observations by James Arnott, MD, published in 1849. Arnott reported using cold "to such a degree as will immediately numb the part to which the mixture is applied, arrest the circulation of blood through it, and even congeal the fluids contained within it."1 He reviewed several cases of headache in which cold, or "congelation," therapy greatly improved the condition or at least relieved an acute attack. Arnott's patients had a variety of conditions, such as "nervous" headaches and hemicrania.

Arnott attributed the success of congelation therapy to its actions on the pathophysiology of the headache. He stated that "A morbid irritability or inflammatory condition of nerves and often of blood vessels, at a certain distance from the surface has to be removed. The severe cold penetrates to the depth required; it immediately benumbs the painful nerves; it permanently lessens their sensibility; it produces a lasting depression of the vascular system of the part. and probably otherwise modified the vital actions. By the time that this depressing or sedative influence, the morbid condition will be removed, or so much lessened as to require only a few repetitions of the same remedy to complete cure." 2

The cooling agent described in Arnott's book is significantly different from the cold compresses and ice packs currently in use. The mixture he used was prepared by dissolving salts in ice, which dropped the freezing point of the mixture to -17 to -23 °C (1.4 to -9.2°F). Extended application of cold to this degree could lead to freezing of skin structures, which generally occurs at -13°C (8.6°F). Damage may occur at -1°C (30.2°F). The potential for injury prohibits safe use of this type of concoction.

A commercial gel pack (Cold Comfort)* was used for application of cold in the study that we report here. The pack is self-contained, prepared for use by storing in a freezer, and is applied with a cover to protect the skin.

In a separate study, skin/gel pack and skin/ice bag interface temperatures were examined to determine the temperature curve of the gel pack compared to that of the ice cubes in a container similar to that of the gel pack.

The gel packs, which measure 4 1/2 x 10 1/4 in. and contain 300gm of gel, were obtained from a retail store. They were stored in a freezer at 23.3°C(-10°F) and slipped into spun, non-woven polypropylene protective covers before use. The plastic shells used in the manufacture of the gel packs were used as ice bags. They were filled with ice cubes from an ice machine (cubes measured 1/4 x 5/8 x 5/8 in.) and sealed with a flat, plastic ostomy bag clip; total weight of each bag was 300gm. No protective cover was used.

The gel packs and ice bags were placed on the left calf of the subjects while they were seated. Gel packs were affixed with tape and ice bags with elastic bands. Output from a thermistor located on the skin at the point of interface with the pack or bag was continuously recorded on a strip chart, and the data were converted to degrees Fahrenheit with a calibration curve.

The gel packs were used in seven trials and the ice bags in four, and average temperature-time curves were calculated. The ice bag's biomodal curve was due to melting and resettling of the cubes. Clearly, neither system posed a threat of freezing tissue. Because gel packs produce more rapid cooling of the skin, they probably are more efficacious for half-hour treatments.

The Study
In 1984, we studied the effectiveness of the gel pack as an adjunctive treatment in 90 patients with acute attacks of migraine, cluster, or mixed (migraine plus muscle contraction) headache. We compared treatment with standard abortive medication (eg., ergotamine oxygen muscle relaxants, analgesics) to that with such medication plus application of a gel pack to the area of pain. Since use of the gel pack was adjunctive, no attempt was made to include another physical treatment in a blind study.

Patients at the Diamond Headache Clinic, Chicago, were divided into three groups by headache type; each group consisted of 30 clinic outpatients with headache frequency of at least three times a month. Patients were permitted to continue using any prophylactic medication.

A crossover design was used. Patients in each group were randomly divided into two subsets of 15, and a series of four attacks was monitored. Group A used the gel pack and the standard abortive medication during the first two of the four attacks. For the last two attacks, these patients used only the standard abortive agent. Group B used the reverse sequence; the first two attacks were treated with medication alone the last two with medication and application of a gel pack.

A headache calendar was used to facilitate monitoring of the acute attacks. It included information on the date, time, and duration of the attack as well as they and amount of medication used and the duration of treatment with the gel pack. Headache severity was measured on a scale of 1 to 10 (1=no pain, 10=no relief).

Patients returned the calendar to the clinic after the fourth attack. At this time, an exit questionnaire was administered to evaluate the general benefit of therapy and to obtain information about the adjunctive treatment. The questionnaire particularly focused on the effectiveness of the gel pack; patients were asked about immediate and overall decrease of pain with gel pack and whether they intended to use it in the future.

Table 1 shows the results of questions pertaining to effectiveness of the gel pack; there was no significant difference in patient response by headache type. 71% of all patients and 80% of those with migraine headache considered the gel pack effective. Only 52% of all patients experienced immediate decrease pain; 63% had overall decrease in pain. 71% of all patients intended to use the gel pack in the future. Patients with migraine headache expressed greater overall satisfaction with the gel pack than did patients with mixed or cluster headache.

The relationships between headache duration, severity, or relief and treatment or headache type were examined. Simple correlations were calculated, and analysis of covariance was used for patients who complied with the protocol and for whom data were complete. mean scores are summarized in table 2. The correlation coefficient for duration and relief was 0.23; the coefficient for severity and relief was 0.3. These slight positive correlations indicate that as headache severity and duration increased, relief with the treatment protocol decreased.

Effectiveness was not significantly affected by timing of use of the gel pack (i.e.., use during first two attacks versus use during last two attacks). In addition, there was no significant difference in mean scores for headache relief between treatment including the gel pack and treatment not including it.

Use of gel packs is a safe method of applying cold in adjunctive treatment of acute headache. Interface temperature with such packs does not approach the range in which skin structures may be damaged. Gel packs reduce temperature more quickly than wet ice and therefore are more expedient. (A double-blind study cannot be easily performed with a physical modality such as cold.)

Our study consisted of patients at a headache clinic, many of whom have endured a long history of headache not readily responsive to therapy. These patients often do not show the excellent response to therapy that may be seen in the type of patients with headache that are usually encountered by primary care physicians. We suspect that cold application may be more effective in the later patients. Our results revealed that while improvement in headache pain for our patients was not statistically significant, most of them responded favorably to use of a gel pack for pain reduction. We conclude that cold application does not provide some symptomatic relief of headache and also offers some psychological alleviation of the pain.

We report the results of a study conducted recently at the Diamond Headache Clinic, Chicago, on the effectiveness of application of cold as an adjunctive therapy for acute headache. 90 clinic outpatients were divided evenly into three groups according to headache type - migraine, cluster, and mixed. They used the standard headache medication for two attacks and the standard medication plus application of cold with a reusable, frozen gel pack for two attacks. There was no significant difference in patient response to the gel pack by headache type. 71% of patients considered the pack effective; 52% reported an immediate decrease in pain, and 63% reported an overall decrease in pain. 71% of patients intended to use the gel pack in the future.

Use of such gel packs, which are available commercially, does not damage the skin. Our study indicates that cold application does provide some symptomatic relief of headache; it may also offer psychological alleviation of the pain. FGM

John Loperfido, PhD, of 3M Personal Care Products Division, St. Paul, Minnesota, assisted with the study reported here.

Address reprint requests to Seymour Diamond, MD, Diamond Headache Clinic, 5252 N. Western Ave. Chicago, IL 60625.

1. Arnott J. Practical illustrations of the treatment of the principal varieties of headache by the local application of benumbing cold: with remarks on the remedial and anesthetic uses of congelation in diseases of the skin and surgical operations. London: J. Churchill, 1849:3
2. Ibid. p 15


Table 1. Results of study of cold gel pack in adjunctive treatment of acute headache.
Benefit/future use Migraine Favorable response (% patients) Confidence interval* Total responses (No.) Mixed Favorable response (% patients) Confidence Interval* Total responses (No.)
Effective 80 65-94 30 62 44-80 29
Immediate decrease in pain 53 35-71 30 53 35-71 30
Overall decrease in pain 67 50-84 30 59 41-77 29
Intent to use in future 77 62-92 30 71 55-88 28
*95% confidence level for percent favorable response (lower confidence limit to upper confidence limit))


Table 2. Comparison of effectiveness of standard headache treatment with standard treatment plus use of cold gel pack, by headache type.
Characteristic Headache type Medication alone Medication plus cold gel pack
    Mean score Total responses (No.) Mean score Total responses (No.)
Relief* Migraine 2.9 56 3.5 60
  Mixed 2.6 52 2.7 54
  Cluster 3.2 54 2.9 54
  Overall 2.9 162 3.0 168
Severity† Migraine 6.5 60 7.1 60
  Mixed 6.3 54 6.1 54
  Cluster 6.2 56 6.5 56
  Overall 6.3 170 6.5 170
Duration (hr) Migraine 6.6 56 7.1 58
  Mixed 5.8 52 6.2 52
  Cluster 2.3 56 1.8 56
  Overall 4.9 164 5.0 166

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Friday, January 27, 2006 THE WINDSOR STAR

Icy head may reduce stroke
Cold could inhibit cell death and avoid physical impairment


When Randy Greene arrived at the emergency department last Oct. 2, paralyzed with a stroke, he got an unusual offer - spend the next 12 hours with an icy-cold helmet on his head.

He agreed. Today, Greene thinks the head hypothermia treatment helped him to overcome his paralysis and make a strong recovery.

Greene, 57, was part of a study at the University of Alberta Hospital that aims to help people survive a stroke without crippling after-effects.

"If it works," says the head of neurology for the Capital Health Region, Dr. Ashfaq Shuaib, "it could boost the number of people who make a full recovery from a stroke from the current 25 percent to, perhaps, 35 percent."

Shuaib is testing a combination treatment consisting of four drugs plus a head-cooling device, to try to slow the cell death that is triggered by an ischemic stroke. (Ischemic strokes are caused when a clot blocks blood flow to the brain. They make up four-fifths of all strokes.)

“As you cool the brain's temperature it slows the brain's metabolic activity,” Shuaib told reporters Thursday. “By doing that, it slows down the process that kills these cells.”

That slowing down of brain death will give the brain time to find an alternate blood supply through unblocked arteries, he said. It means patients may avoid the physical and speech impairments caused when parts of the brain die.

“If it works, it's very very exciting,” Shuaib said of the study.

However, he cautioned the study is far from complete yet. To date only three patients, including Greene, have had the full treatment and three others acted as a control group. Shuaib plans to do 37 patients on the combined treatment, plus 37 control patients.

Patients in the study start their therapy in the ambulance, with a paramedic administering the first drug, magnesium sulfate. In the ER, they get the cooling device wrapped around their heads and are given the other three drugs.

The cooling wrap works by circulating cold water inside small tubes in the wrap. It is normally used for migraine headaches or to help slow hair loss in chemotherapy patients, Shuaib said.

Made by the Cincinnati Sub-Zero company, it's not been used before for strokes, he said.

The experience of having one's head cooled to 34 C was painless but chilly, said Greene. “The staff just kept bringing nice warm blankets every half an hour.”

The important thing, he said, is that he went to hospital on a Sunday with his right leg paralyzed, and by Monday evening he could wiggle his toes. He's going back to work in March.

Shuaib said the drugs used are all familiar and relatively cheap.

What's new is the idea of putting them together in a drug cocktail, somewhat like the AIDS drug cocktail, that will protect the brain from cell death in a variety of ways.

The researchers hope the treatment will be effective as long as 10 hours after the stroke occurs.

Right now, the top treatment for strokes is a clot-busting drug, but it's not considered safe more than three hours after the stroke occurs because it may cause brain hemorrhage.

More trials coming
The study, called MINUTES or Multiple Interventions for Neuroprotection Utilizing Thermal Regulation in the Emergent Treatment of Stroke, has no big drug-company funding, he said.

“The industry does not fund these trials (of drug combinations),” he said. “They're all interested in their own drug.”

If the Edmonton trial goes well, a larger trial in other cities will be done, Shuaib said.

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