Cryotherapy for Headache
Lawrence D. Robbins, M.D.*
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
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.
MATERIALS AND METHODS
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.
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
|Almost completely effective
|Question: Do you intend to use the cold pack in the
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,
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
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
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
Reprint requests to: Robbins Headache Clinic, 1535 Lake Cook Road, Northbrook,
Accepted for publication: May 11, 1989
*CHAMP Coldwrap, Carolon Company, Winston-Salem, North Carolina.
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COLD AS AN ADJUNCTIVE
THERAPY FOR HEADACHE
Seymour Diamond, MD
Frederick G. Freitag, DO
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
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."
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
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
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
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
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
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.
||Migraine Favorable response (% patients)
||Total responses (No.)
||Mixed Favorable response (% patients)
||Total responses (No.)
|Immediate decrease in pain
|Overall decrease in pain
|Intent to use in future
|*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
|| Medication alone
|| Medication plus cold gel pack
||Total responses (No.)
||Total responses (No.)
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Friday, January 27, 2006 THE WINDSOR STAR
Icy head may reduce
could inhibit cell death and avoid physical impairment
BY SUSAN RUTTAN
CANWEST NEWS SERVICE
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
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
“If it works, it's very very exciting,” Shuaib said of the
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
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
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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Prevent hair loss, inhibit stroke
paralysis, relieve migraine headaches, and sinus pain / pressure