APPLYING OF LOW LEVEL LASER THERAPY (LLLT) FOR PAIN MANAGEMENT IN MIGRAINE

Abstract

Key words: Low-level laser, Pain, Migraine, Drug consumption.
Background & Aim:
The effects of laser therapy on pain attenuation were established in numerous meta analysis studies. The aim of this study was the measurement of LLLT effects on pain reduction in migraine.
Method: In a randomized double blind study 30 patients were divided in two groups (n = 15). each group was treated by LLLT for 10 sessions every other days .Case group was treated with laser set in turn on situation ( P =100 w wl =890 nm f = 3000 Hz ∆t = 200 ns D = 3 j/cm2 ) and control group was treated with laser set in turn off situation . None of the patients knew about the laser situation. All the patients were allowed to consume acetaminophen and ergotamine –compound if they needed. Pain number =PN (according to visual Analog scale = VAS) and the amount of drug consumption were measured at the beginning , at the end of treatment and 6 months later by a neurologist who was blind about the groups.
Results: At the end of treatment, PN and amount of drug consumption decreased dramatically in laser group compare to control. In addition, PN in case group was lower than control group 6 months later.

Conclusion: LLLT can be applied for pain attenuation and reduction in drug consumption successfully in migraine. We propose a controlled studies with bigger number of cases for better evaluation of LLLT effects on migraine.

Full text

Iranian Medical Laser Association (IMLA)

Introduction:
Migraine is called "benign" by physicians
simply because there is no direct threat to
life. This does not mean, It is also regularly
exhausting, frustrating, and life -robbing. It
is characterized by severe head-pain,
accompanied by nausea and weakness. The
pain is so intense that it has been said to be
worse than child-birth, and it has been
described by sufferers as a kind of "death."

Migraine Headache
Up to 90% of the general population
reported experiencing headaches at
some point in their lives. At any given
point in time, up to 10% of the general
population seeks medical treatment for
the relief of disabling headaches,
Headache in migraine has a complex
phenomenon.

Pathophysiology of Migraine: I
The pathophysiology of migraine is still
unclear. The last century has brought the
shift from the vascular theory (that cranial
vessels are the prime movers of the disorder)
to a more integrated neurovascular theory,
which takes the view that vascular change is
secondary to neural activation. The initiation
of migraine attack involves primary CNS
dysfunction with subsequent activation of
the trigeminovascular system. In this
complex reaction a variety of biochemical
factors take place.

Pathophysiology of Migraine: II
" In summary, the pain-control system of the
body appears to malfunction. This system
works with "endorphins," naturally
produced chemical opiates , strong sedatives
and pain-killers. The headache of migraine is
really the end-point of a cascade of
biochemical events which have various
effects on the body. Endogenous substances
(serotonin, peptides, nitric oxide [NO], etc.)
play a key role in this sequence.

Low level Laser Therapy has
been used for pain reduction
and wound healing since 40
years ago.

Meta-analysis Articles:
Beckerman H, de Bie RA The efficacy of laser therapy for
musculoskeletal and skin disorders: a criteria-based meta-analysis of
randomized clinical trials. Department of Rehabilitation Medicine, Free
University Hospital, Amsterdam, Netherlands. : Phys Ther. 1992
Jul;72(7):483-91.
Brosseau L, Welch V, Wells G Low level laser therapy for osteoarthritis
and rheumatoid arthritis: a metaanalysis. Physiotherapy Program,
School of Rehabilitation Sciences, Faculty of Health Sciences,
University of Ottawa, Ontario, Canada. J Rheumatol. 2000
Aug;27(8):1961-9.
Woodruff LD, Bounkeo JM The efficacy of laser therapy in wound
repair: a meta-analysis of the literature. Department of Physical
Therapy, North Georgia College and State University, Dahlonega,
Georgia, USA. Photomed Laser Surg. 2004 Jun;22(3):241-7
Enwemeka CS, Parker JC The efficacy of low-power lasers in tissue
repair and pain control: a meta-analysis study. School of Health
Professions, Behavioral and Life Sciences, New York Institute of
Technology, Old Westbury, NY 11568-8000, USA: Photomed Laser
Surg. 2004 Aug;22(4):323-9
Brosseau L, Robinson V Low level laser therapy (Classes I, II and III)
for treating rheumatoid arthritis. University of Ottawa, School of
Rehabilitation Sciences, Faculty of Health Sciences, 451 Smyth Road,
Ottawa, Ontario, Canada K1H-8M5 Cochrane Database Syst Rev. 2005
Oct 19;(4):CD002049

Wong E et al. Efficacy of low power laser therapy in pain relief
of migraine headache. Proc Ninth congress soc Laser surgery
and Medicine, Anaheim, California, USA,2-6 NOV. 1991
Costantini D, et al.: Treatment of cranio-facial pain by
electroacupuncture and laser irradiation . 1: Ann Ital
Chir.;68(4):505-9. 1997 Jul-Aug
Guseinov TIu.[Interdisciplinary physio-reflexotherapy in the
treatment of headache]. 1: Zh Nevrol Psikhiatr Im S S
Korsakova;99(9):23-7.1999
Wong F. :Laser treatment for headache of neurogenic and
neuromuscular origin. Laser in surgery and medicine. Suppl
12 : 13 , 2000
Allais G,et al.: Non-pharmacological approaches to chronic
headaches: transcutaneous electrical nerve stimulation, laser
therapy and acupuncture in transformed migraine treatment.
1: Neurol Sci. 24 Suppl 2:S138-42; May 2003
Ebneshahidi NS, Heshmatipour M,etal The effects of laser
acupuncture on chronic tension headache-a randomized
controlled trial. 1: Acupunct Med. 23(1):13-8 . Mar 2005
Literature Review:

The effects of LLLT on pain managing:
1) Increase the level of beta- endorphin in CSF.
2) Increase urinary excretion of glucococrticoid, which is inhibitor of
beta-endorphin synthesis.
3) Increased pain threshold through a complex electrolytic block
mechanism of nerve fibres. The permeability of the membrane of the
nerve cells for Na/K is decreased, causing hypo polarization.
4) Increased urinary excretion of serotonin, affecting negatively
neurotransmission .
5) Decrease chemical substance like histamine, a power -ful
inflammatory and algesic agent, and acetylcholine, another algesic agent
that is blocked through an increase in acetylcholinerase activity.
6) Decrease synthesis of bradykinin a potent analgesic agent that
normally irradiates nociceptors and cause pain.
7) Alters the noradrenalin/adrenalin activity.
8) Increase ATP production.
9) Improve local micro circulation, so the O2 supply to the hypoxic cells
in the trigger points area is increased . The asphyxia of the tissue is
reduced to a minimum and removal of collected waste products takes
place at the same time.
10) Increased lymphatic flow, thus reducing oedema. Laser in dentistry
&medicine
11) Acts on the prostaglandin (PG) synthesis, increasing the change of
PGG2 and PGH2 into PG12 (also called prostacyclin)

The aim of the study :
(Randomized double blind case control study)
Evaluation the effect of low level
laser therapy (LLLT) on pain
managing in migraine.

Method of Study :(I-Groups )
30 patients with common migraine (without aura) who consumed
pain killers more than 3 days /week were divided in 2 groups and
they were blind about the groups allocation.
Case group or
Laser ON group
(case group) n=15
Female n=11
Male n= 4
Age 35.27
Sessions:10 sessions,
Every other day
Control group or
Laser OFF group
(Control group) n= 15
Female n = 10
Male n = 5
Age 35.67
Sessions:10 sessions,
Every other day

Method of Study (II- Laser set)
Laser set
Parameters:
Mode Pulse
λ 890 nm
Peak
Power 100 w
ΔT=Pulse
Duration 200 ns
Area
1Cm²
Frequency 3000 Hz
Dose 3 J/Cm² on Trigger and
Tender points
6 J/Cm² on Spinal
Processes of Cervical
Vertebras
Sessions 10 = (3 times/week)

Technique of Radiation:

Method of Study (III)
Patients were examined at the beginning and
the end of 10th session by a neurologist who
was blind about the groups’ allocation:
Pain was estimated subjectively with visual
analogue scale (VAS)
The number of days which patients had
headache per week (headache days)
Amount of medicine consumption
(Acetaminophen and Ergotamine
compound )
6 months follow up

Results:
The results were analyzed by
SPSS program.

Laser
ON
Before
Laser
ON
(After)
Laser ON
6 Mo.
Later
Laser
OFF
(Before)
Laser
OFF
(After)
Laser
OFF
6 Mo.
Later
Age 35.27 - - 35.67 - -
Gender F/11,
M/4 - - F/10 ,
M/5 - -
Pain number 10 2.27 3.94 10 6.53 6.87
Headache
days/ week 4.73 0.67 1.82 5.07 4.27 5.38
Acetaminophen
mg/week 3500.00 433.33 1450.00 4080.00 3170.00 3900
Ergotamine
mg/week
5.600 0.333 1.20 7.833
6.2 7.20

pain number/off
8.07.06.05.04.03.02.01.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.06
Mean = 6.5
N = 15.00
pain number/on
8.07.06.05.04.03.02.01.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.16
Mean = 2.3
N = 15.00
The pain number after treatment
Case group = Laser ON
Mean =2.27 Control group= Laser OFF
Mean =6.53
p=0.0001

The number of headache
days / Week before treatment
pain number /days/week/before laser/off
9.78.26.85.33.92.41.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.53
Mean = 5.1
N = 15.00
pain number /days/week/before laser/on
9.78.26.85.33.92.41.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.44
Mean = 4.7
N = 15.00
Headache days/week Before
treatment (Laser OFF) Mean=5.07
Headache days/week Before
treatment (Laser ON) Mean= 4.73
Sig=0.544

The number of headache days /
Week After treatment
pain number/days/week/after laser/off
6.05.04.03.02.01.00.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.10
Mean = 4.3
N = 15.00
pain number/days/week/after laser/on
6.005.004.003.002.001.000.00
10
8
6
4
2
0
Std. Dev = .62
Mean = .67
N = 15.00
Pain - days/week After
treatment (Laser ON) Mean=0.67
Pain - days/week After
treatment (Laser OFF) Mean=4.27
Sig=0.000

Acetaminophen Consumption
( mg/week) Before Treatment
acetaminophen/mg.week/before/off
6000.05000.04000.03000.02000.01000.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1460.04
Mean = 4080.0
N = 15.00
acetaminophen/mg.week/before/on
6000.05000.04000.03000.02000.01000.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1511.39
Mean = 3500.0
N = 15.00
Acetaminophen (mg/week)
Before Treatment (laser ON) Mean =3500 mg/week
Acetaminophen (mg/week)
Before Treatment (laser OFF) Mean=4080 mg/week
Sig=0.294

acetaminophen/mg.week/after/off
6000.05000.04000.03000.02000.01000.00.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1459.23
Mean = 2990.0
N = 15.00
acetaminophen/mg.week/after/on
6000.05000.04000.03000.02000.01000.00.0
10
8
6
4
2
0
Std. Dev = 222.97
Mean = 440.0
N = 15.00
Acetaminophen (mg/week)
After Treatment (laser ON) Mean=433.33
Acetaminophen (mg/week)
After Treatment (laser OFF) Mean=3170
Acetaminophen Consumption
( mg/week) After Treatment
Sig=0.0001

Ergotamine (mg/week)
Before Treatment
eryotamin/mg.week/before/off
12.010.08.06.04.02.00.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 2.37
Mean = 7.6
N = 15.00
eryotamin/mg.week/before/on
12.010.08.06.04.02.00.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 2.67
Mean = 5.6
N = 15.00
Ergotamine (mg/week)
Before treatment (laser ON)
Mean=5.6
Ergotamine (mg/week) Before
treatment (laser OFF)
Mean=7.8
SIg=0.029

Ergotamine (mg/week)
After Treatment
eryotamin/mg.week/after/off
12.010.08.06.04.02.00.0
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 2.81
Mean = 6.2
N = 15.00
eryotamin/mg.week/after/on
12.010.08.06.04.02.00.0
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.05
Mean = .3
N = 15.00
Ergotamine (mg/week) After
treatment (laser OFF)
Mean=6.20
Ergotamine (mg/week) After
treatment (laser ON)
Mean=0.333
Sig=0.0001

Pain Number 6 Mo. Later
pain number/ 6 month later/off
8.66.74.82.91.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.41
Mean = 6.9
N = 15.00
pain number/ 6 month later/on
8.66.74.82.91.0
10
9
8
7
6
5
4
3
2
1
0
Std. Dev = 1.53
Mean = 3.9
N = 15.00
Case Group, Mean=3.93 Control Group, Mean=6.87
Sig=0.0001

Laser ON
(Before)
Laser
ON
(After)
Laser
ON
6 Mo.
Later
Laser
OFF
(Before)
Laser OFF
(After)
Laser
OFF
6 Mo.
Later
Age 35.27 - - 35.67 - -
Gender F/11, M/4 - - F/10 ,
M/5 - -
Pain
number 10 2.27 3.94 10 6.53 6.87
Headache
days/
week
4.73 0.67 1.82 5.07 4.27 5.38
Acetamin
ophen
mg/week
3500.00 433.33 1450.00 4080.00 3170.00 3900
Ergotami
ne
mg/week
5.600 0.333 1.20 7.833
6.2 7.20

Side Effects:
No side effects were
reported.

Conclusions:
LLLT is a side effect free and safe
method for pain managing, and our
study showed the following results :
Reduction in pain number.
Reduction in the number of headache
days.
Drug consumption was reduced
effectively.
Its effects stayed for a long time.

Future Plan
We are going to plan another
clinical trial with the big number of
patients to more evaluation the
effect of laser therapy on migraine .