Migraine and Headaches: How to Deal with Them?

 

(This article is dedicated to my niece Lim Ming Nar in Singapore who has migraine). 

Headache is one of the most common complaints that brings a patient to see a doctor. Unfortunately, most doctors would not know how to treat a headache, especially a chronic persistent headache, other than prescribing paracetamol. If paracetamol does not work long term, they will switch to nonsteroidal anti-inflammatory drugs (NSAIDs) such as propionic acids (naproxen, ibuprofen, diclofenac, indomethacin), mefenamic acid (ponstan), COX-2 selective NSAIDs, example, celecoxib and rofecoxib. We shall briefly discuss this later.

Some more qualified and experienced clinicians may prescribe other pharmaceuticals such as ergot alkaloids, isometheptene, or even to the extent of giving intranasal lidocaine, triptans, valproate, magnesium, and even narcotics. In short, clinicians are mostly pharmaceutical-oriented trained, and they have no or little clue in other systems of medicine for which may be even better, resulting in better or more permanent cure especially in chronic diseases.  

If drugs prescribed do not work long-term for headaches, clinicians may investigate by taking medical history asking for frequency, severity, and location of the attack. If a diagnose is uncertain they may refer the case to a neurologist who may proceed with erythrocyte sedimentation rate (ESR), a blood test to detect inflammation, MRI or CT scan of the brain, digital subtraction angiography to produce a picture of blood vessels in the brain, or a spinal tap, to determine bleeding in the brain or the presence of bacterial or fungal infection.  Depending on the medical history of headaches, they may refer the case to other specialists such as to an orthopaedic surgeon if it involves the bones and cartilages, to an ENT surgeon if the headache was due to some sinuses in the nose or head areas, or to an oncologist if the pain was due to a malignancy.

 If a doctor thinks your migraine or tension headache was due to stress, he might refer you to a psychiatrist, and the psychiatrist, instead of prescribing stress management, may prescribe you antidepressants drugs. If you are referred to an orthopaedic surgeon he might suggest surgery for your spine, bones, joints and cartilages, or to a dentist, he would offer the removal of your teeth. If you were to be referred to a neurologist, he might give you neurobion, analgesics and pain killers. They would not go into the root causes of your headaches. Everything a doctor prescribes would either be a drug or involves a scalpel or pilers to pluck it out.  

Unfortunately, most clinicians have no clue how to deal with migraine or tension headache using other therapeutic modalities other than drug-based analgesic approaches. But first, let’s have a look at what actually causes a headache most people suffer from.

Among all the headaches, literally 90 % are either migraine, with or without aura; tension-type headache (TTH); or a mixture of the two. Thirty-six percent of adult women in Malysia and 6 % men suffer from migraine.¹   The causes of the other headaches are secondary to disorders of the tissues of the head and neck, including the cervical spine, sinuses, temporomandibular joints, dental structures and soft tissue trauma and post-trauma syndrome, primary tumours, infection, metastatic cancers constituting a very small fraction of all the possible causes.

“Red flag” symptoms of life-threatening disorders include early morning headaches that awaken the patient; visual dimming or double vision; headaches that are increasing in frequency or severity over weeks or months; headaches made significantly worse by postural changes; explosive onset of new, serve head pain; and headaches associated with mental status change, focal motor or sensory deficit, syncope, seizure, fever or stiff neck.

Headaches in the setting of systemic illness, loss of weight, human immunodeficiency virus (HIV), or known malignancy clearly requires thorough investigations. Findings on examination that prompt further diagnostic workup include focal neurological signs, evidence of head and neck trauma, temporal artery tenderness, papilledema, nuchal rigidity, fever, and physical evidence of, local or systemic infection or malignancy.

Clinical guidelines are available for pharmacological prevention.² However, the emphasis should be on non-drug approaches in prevention of treatment especially for migraine as this constitutes most of the causes of headaches. Non-pharmacological intervention includes behavioural, nutritional, and complementary therapies that are effective in the prevention and treatment of migraine and tension-type headache. Let us first have a look at the pathophysiology of migraine.

Pathophysiology:

 

Characteristics typical of migraine include subacute onset of throbbing head pain, either one side (unilateral) or on both sides (bilateral) associated with nausea or vomiting, fear or intolerance to light (photophobia) and sound (sonophobia). Headaches are heralded by visual or other non-pain premonitory symptoms (aura) in about 20 – 30 % of those with migraine. The duration usually last for more than 4 hours and can last for as long as 72 hours with fluctuating intensity. ³ The precipitating factors can include menus, certain foods, stress, or letdown following stress changes in the weather, infection, fatigue and bright sunlight or by flashing lights, loud  speakers and loud music, as well as cigarette  smoke inside a nightclub or similar places.

While the origin of migraine pain is not fully understood, recent evidence points to the role for potential vasodilators, such as substance P and calcitonin gene-related peptide (CGRP), released by peripheral nerve endings of cranial nerve V on the blood vessels in the scalp and meninges. ⁴

This leads to sterile inflammation and oedema of the blood vessels, with increased sensitivity to mechanical stimulation, resulting in pain. Glutamate (MSG – monosodium glutamate: food flavouring agent) nitric oxide and vanilloid receptors are also implicated in migraine. Translation of this information to therapy has been very active. For instance, CGRP receptor antagonists are already in phase clinical trials. ^5,6  In the periphery of the nerve, MSG  release  of serotonin by platelets in the early stages seems to increase pain and prolong the headache. Centrally, the presence of a “headache generator” in the midbrain and pons is supported by findings from positron emission tomography studies obtained during migraine attacks. Genetic influences are evident in a majority of patients with one or more family members experiencing migraine. Although the individual attacks of migraine are often stereotypic, variation is not uncommon and comorbid tension-type headaches (TTH) is frequent. This means, patients with migraine often suffer from TTH and other forms of headache. A careful recorded history of headache symptom characteristics helps establish criteria that lead to diagnosis and helps highlight distinction that guides specific therapies. The management of headaches should be integrative rather than depending on conventional allopathic approaches that relies heavily on pharmaceutical intervention to prevent or abort headache with analgesics, and antiemetics as described above. Although these measures by themselves are generally effective in the management of symptoms, they are often expensive, come with significant side effects, drug toxicities, and they do not address the underlying physical, psychological, and energetic issues that cause headache. Patients with headache currently use a variety of alternative complementary therapies when regular use of drugs have not solved their problems.⁷

We shall not go in chapters writing on the various other therapeutic options available to patients suffering from migraines and TTH as these would be very technical and lengthy. What we can do is highlight some of them in summary form without their technical details of how they work. These include lifestyle modification, sleep hygiene, exercise, stress management among others we will describe shortly.

 

Nutrition and Contraceptive Pills:

 

Nutrition, and nutritional supplements and or botanical medicine have been shown to be very effective in the management of migraines and TTH.  Elimination of food triggers such as red wine, dark beers, aged cheese, some nuts, onions, chocolates, aspartame, processed meat containing nitrates such as in sausages, luncheon meat, corned beef is one of the most powerful preventive strategies. 

So is the use of contraceptive pills that trigger a migraine attack. Surprisingly, caffeine in coffee taken during a migraine attack can reduce migraine in some patients, and its withdrawal can temporarily exacerbate migraine or TTHs possibly due to vasoconstrictive effects on the scalp and meningeal vessels. Caffeine excess with over 5 cups of coffee a day can cause chronic daily headaches especially taken with certain medication.  

Diets containing large amounts of proinflammatory omega-6 fatty acids are also likely to aggravate migraine and TTH. In a study of 65 adults with chronic daily headache of which 85 % had chronic migraine, there was a significant improvement in headache severity and frequency in those on high omega-3 and low omega-6 fatty acid diet compared to baseline and compared to those on low omega-6 fatty acids diet alone. ⁸ The dietary intervention lasted 12 weeks. Food was provided in a standardized and controlled intake, and all subjects received regular dietary counselling throughout the intervention. Fatty acid supplements were not given. Clinical benefits were most pronounced in the last 4 weeks of the intervention.  Most striking were the correlation between clinical improvement and levels of omega-3-derived anti-inflammatory lipid mediators. Biochemical endpoints correlated closely with clinical improvement in pain and psychological distress. ⁹

Obesity and metabolic syndrome have also been found to be associated with migraine and chronic headaches, perhaps related to the proinflammatory state associated with these conditions. ^{10 – 12} Inflammatory bowel disorders also have a higher incidence of migraine. ¹³ Treatment implications for migraine in these conditions, while not fully defined, favour integration of dietary choice with other forms of treatment.

Very, very briefly without going into very lengthy details, their dosages, and citations of studies done, it was found that magnesium, riboflavin (vitamin B2), coenzyme Q10, omega-3 fish oil significantly reduces the frequency and severity of migraine and TTH. ¹⁴

 

Lifestyle:

 

Effective management of migraine requires a careful assessment of lifestyle issues related to sleep, nutrition, exercise, stress management, and social relationship. Regular mealtimes, developing an exercise routine and correcting poor sleep can significantly reduce the frequency of migraine. ¹⁵ Adequate sleep and sleep hygiene are easy to follow, and this often leads to a decrease in the severity and frequency of migraine attacks.

 

Botanical Medicines:

Feverfew (Tanacetum parthenium leaf) has been found to be very effective in treating migraines. Johnson et al. reported a significant increase in migraine severity and frequency when feverfew was stopped in small group of migraine sufferers taking it for prevention.¹⁵ In one well-designed study, a 70 % reduction in in headache frequency and severity was shown in 270 patients with migraine. ¹⁶ Variations in the standardization of the dried leaves constituents cofound replication studies of this herb. A reproducibly manufactured extract of feverfew has shown preventive efficacy in a double-blind randomized controlled trial. ¹⁷ There are no head-to-head trials with other preventive medications. The mechanism of action using feverfew in migraine may be related to its inhibiting effects on platelet aggregation and inflammatory promoters, such as serotonin and prostaglandins, or possibly its effect in dampening vascular reactivity to amine regulators of blood flow. The oral administration of feverfew up to 125 mg / day of the dried leave standardized to a minimum of 0.2 % parthenolide. Beneficial effects may take weeks to develop.  Aphthous ulcers and gastrointestinal irritation develop in 5 % - 15 % of feverfew users. Abrupt cessation of feverfew sometimes results in agitation and increased headache, else feverfew is an effective alternative to drug-based treatment. It is not recommended during pregnancy due to prolongation of bleeding times.

 

Butterbur (Petasites hybridus Root)

 

In a large, three-arm, dose-finding RCT of a standardised extract of the root of this perennial shrub, it was found that migraine attack frequency was reduced by almost 50 %. Among those on the highest dose, 68 % had a 50 % or greater reduction in headache frequency. ¹⁸ This effect continued for at least 4 months. One smaller study showed similar results.¹⁹ and in another study in 108 children and adolescence with migraine also showed the same therapeutic results ²⁰ One study that compared butterbur root extract to both music therapy and placebo in the prevention of migraine in children had mixed findings with butterbur demonstrating efficacy compared to placebo in the long-term follow-up. ²¹ A systematic review of the published literature on the effectiveness of P. bybridus revealed that higher dose extracts (150 mg) were associated with a lower frequency of migraine attacks after 3 – 4 months compared to a lower dose and placebo .²² The extract is commonly standardized to 15 % of the marker molecule (petasins) and known carcinogen are removed. Drug-herb interactions have not been studied. The dose for butterbur is 50 mg three times a day for 1 month, 50 mg twice a day.

 

 

 Sleep Medicine:

 

Sleep management is the major therapeutic strategy in helping patients gain control over their headaches. Melatonin and valerian root can be used on a temporary basis to improve sleep. Melatonin is used in the management of migraine to improve sleep and circadian rhythms. Melatonin is recommended every night for 4 -6 weeks and then tapered off. During that period, a sleep hygiene program can be put in place to reduce the need for melatonin supplement. Melatonin has very few side effects such as fatigue, drowsiness, dizziness, abdominal cramps and irritability, but these are rare.  Leone and coworkers demonstrated that a daily intake of 10 mg of melatonin for 14 days significantly reduced cluster headache frequency. ¹⁶ Others have shown beneficial effects of melatonin in migraine and other types of headaches including migraine prevention in children. ^{23, 24, 25}

However, a crossover study comparing extended-release melatonin at a dose of 2 mg 1 hour before bedtime did not demonstrate improvement in migraine frequency compared to placebo. ²⁶ The dosage for melatonin is 2 - 12 mg, start at 2 mg and titrate up to 4 days as needed for sleep. Lower doses are needed if taken each evening for several weeks. Higher doses > 15 mg are needed to acutely sleep over several days such as in jet lag.  

Another natural botanical medicine for sleep is valerian (Valeriana officinalis Root). When taken at night for sleep, valerian rarely result in residue drowsiness on awakening. It is non-addictive and useful as an anxiolytic when given in the daytime up to 250 mg three times a day.  It does not impair psychomotor or cognitive performance. ²¹ The mechanism of action includes stimulation of the central nervous system gamma-aminobutyric acid (GABA) receptors along with enhanced release and inhibition of reuptake of GABA.

In clinical trials, including the use of for sleep and anxiety, it has been shown to be safe. ^{27, 28, 29, 30, 31, 32}  Gastrointestinal irritation is the most common side effect at 15 %.  The dosage for valerian is 100 -300 mg of the extract standardized to 0.8 % valerenate at bedtime or 250 mg every 6 hour for anxiety. The precaution is, it may aggravate nausea during migraine due to its unpleasant smell if not encapsulated. It may worsen TTH if taken for more than 3 months. It is contraindicated during pregnancy.

 

Pharmaceutical Approaches:

 

There is no inherent difficulty in integrating conventional drug -based with complementary approaches in the management of migraines and headaches.

We shall not go into the pharmacology of drug-based interventions as this makes this brief article far too lengthy. We shall drastically cut this down by mentioning preventive pharmaceutical therapies into categories, namely, preventive pharmaceutical therapies that includes the use of tricyclic antidepressants such as amitriptyline in doses up to 150 mg at bedtime, starting as low as 10 mg for prevention. Beta-blockers such as propranolol, nadolol, timolol, atenolol and metoprolol, and also calcium channel blockers along with anti-convulsant such as sodium valproate, gabapentin, topiramate, zonisamide and levetiracetam has also been prescribed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirins, naproxen, ketoprofen and tolfenamic acid and ketoprofen including even botulinum toxins in conventional medical treatment of migraines.

 

In abortive pharmaceutical therapies other drugs such as ergot alkaloids, isometheptene , intra nasal lidocaine and the triptans (5-hydroxytryptamine receptors 1B / ID agonists ) have also been used. We shall not go into all these drugs and their pharmacodynamics as this article on migraine and headaches is not on pharmacology.

 

We have not even touch on other non-drug therapies such as mind-body techniques, biofeedback, relaxation techniques, cognitive-behavioural therapy, hypnosis, mindfulness meditation, biomechanical and physical techniques, spinal manipulation in chiropractic and osteopathic manipulation approaches, bioenergetics such as acupuncture and homeopathic and Traditional Chinese Medicine in the effective management of migraines and tension headaches. To discuss and explain their dynamics and clinical efficacies will take an estimated another 30 - 40 pages to type. That attempt itself will give me an acute tension headache I wish to prevent and will not be able to solve unless I stop writing here to allow me to rest. 

I hope I have not given you a headache reading my blog articles. 

If not, thank you for reading and kindly write a comment in the comment column below each article. I will appreciate this very, very much.