One doesn’t start a blog and then not write posts. Unfortunately, that is what happened here. I was struck down in early September with the Queen Mother of all migraines. It lasted for seven weeks. I made it to classes. That’s about it. So, let’s talk about migraines because Complementary and Integrative Medicine (CIM) has a lot to say about them.
What is a migraine?
Classification of migraine in standard medicine includes the classic migraine with aura, the common migraine without an aura, menstrual migraines, hemiplegic migraines (one-sided temporal headaches, sometimes with balance problems, dizziness and vertigo), opthalmoplegic migraines (pain in the eye orbit, sometimes with double vision, droopy eyelid, or other visual disturbance), basilar artery migraine (intracranial and involving the main brain artery), benign exertional migraine, and status migrainous (severe prolonged migraines requiring hospitalization, and often preceded by anxiety and depression). Vestibular migraine is a newer classification that is still poorly understood, but involves vestibular symptoms such as vertigo, imbalance and head-movement intolerance, as well as photophobia and phonophobia, although patients with these migraine symptoms are not necessarily experiencing vestibular migraine, and there is no definitive test for vestibular migraine. This type of headache could involve neuro-anatomical pathway abnormalities and this new classification is used to justify new technologies with laser which are not yet evidence-based.
Chronic headache syndromes often involve a number of types of headache causes combined into a more complex syndrome. Headaches can be distinguished by classification of cause as vascular, inflammatory, lesion generated, degenerative, traumatic, endocrine, and autoimmune. This is why the migraine and cluster headache syndromes are so difficult to cure. Both extracranial and intracranial tissues may be involved, as is evident from the success with a small percentage of patients who receive Botox injections extracranially and experience symptom relief, as well as patients who obtain much relief from soft tissue therapies and myofascial release. Muscle tension, or traction, headaches can be a migraine trigger, or secondary to migraines. Common inflammatory headaches include sinus allergy headaches, as well as fibromyositis, a chronic inflammatory condition of the muscle and connective tissues. Lesions in temporomandibular joint syndrome (TMJ) or tumor growths, may produce pressure and irritation on facial nerves, increasing the potential of a migraine trigger or episode. (Migraine and Cluster Headaches)
This is a basic description of migraine, but it gets the ball rolling. What is important to note is that a migraine is not a “headache”. Per Dr. Peter Goadsby, professor of neurology and director of the NIHR Wellcome Trust at King’s Clinical Research Facility in London, “Migraine is an inherited episodic brain disease. It’s a serious problem that doesn’t shorten life, but ruins it.” There isn’t a sole cause for the disease either. Five people may have five different causes ranging from chronic muscular constriction around the occipital nerve originating from a whiplash injury to sinus allergy headaches causing chronic inflammation around the trigeminal nerve. Someone may have a mast cell disorder causing chronic meningeal inflammation resulting in intracranial headaches.
What are the traditional pharmaceutical migraine treatments available?
- Triptans are the go-to medication. When used at migraine-onset, they act as an abortive stopping a migraine even in the prodromal phase. They become much less effective if taken once a migraine has fully developed.
- Tricyclic antidepressants
- Anticonvulsant medications
- Beta-blockers and calcium channel blockers
- Muscle relaxers particularly for migraines exacerbated by tension headaches
- Occasional use of glucocorticoid drugs like methylprednisone
- Botox injected directly into muscle groups. This is effective only for extracranial headaches.
How effective are these pharmaceutical interventions?
I’ll use myself as an example because I have chronic migraine disease that occasionally remits for a month. I have been prescribed every medication on the aforementioned list except beta-blockers and botox. I also have a standing prescription for opiates and anti-emetics should nothing stop the progression of a migraine. This prevents a trip to the ER which has happened numerous times. During the last seven weeks, my neurologist prescribed a new round of steroids, a calcium channel blocker, and a new anticonvulsant in an attempt to arrest the migraine. It did not help. The headache stopped for a day and then returned the next day. It became the Every Other Day Migraine.
So, what gives? Are there other effective treatments for migraine that have shown to be effective?
Yes with the caveat that nothing improves overnight. It all depends upon what is causing your migraine in addition to what type of migraine you have, and this can be hard to parse out if you’ve had chronic migraines for years.
I know people with chronic migraines who have throbbing, dull pain that ceases to relent. They can function, but it wears them down and causes dysfunction over time simply because the pain is consistently present. It takes a toll. My pain, on the other hand, comes on fast and hard. It will become a 10 on the pain scale within an hour of onset and vomiting will co-occur if untreated which means I must carry triptans at all times, or I will be visiting my local ER. Why are there such different manifestations? Different causes.
So, put on your thinking caps, and let’s talk about what is happening in the body when a migraine occurs:
“Recent research has revealed the role of neurotransmitter and ion channel dysfunctions in the pathophysiology of migraine syndromes. For instance, fMRI and PNMRS brain studies show that migraine patients experience lowered magnesium levels in the brain (a common ion, or charged molecule) during the migraine attack, but not when the migraine was not occurring (Ramadan et al; Headache Jun 2005; Vol29(9): 590-3). This suggests a role of ion channel regulation dysfunction. Such studies have also found that glutamergic neurotransmitters (GABA regulation) were abnormal in key areas of the brain (anterior cingulate cortex and insula) during the interictal (time between migraine attacks) (Prescot et al; Molecular Pain 2009; 5:34). While the exact mechanisms of disease are still poorly understood, most experts now agree that hyperexcitability of neural membranes in the brain is central to the pathology, and that the main excitatory neurotransmitter in the brain, glutamate, is central to this dysfunction. An imbalance of glutamate receptor types, especially excess of NMDA glutamine receptors, may be central to the triggering of the neurovascular migraine chain of events. This may explain the apparent sensitivity of migraine patients to monosodium glutamate and the wide array of glutamate molecules now used in processed food to stimulate desire, or addiction, to the food.
Research has also revealed that the most common direct cause of migraine headache is temporal arteritis, which is inflammation of the small cerebral extracranial arteries under the temple, although the extent of this condition is usually mild and episodic, and a host of other contributing causes may participate, triggering the neuronal hyperexcitation and spreading cortical depression. These inflamed arteries are often running with superficial nerves, which are irritated, leading to the migraine episodes. The occipital nerve is another focus of research, and may be inflamed or compressed, often with myofascial contracture and syndrome underlying, triggering the blood vessel spasm. The prodrome, or aura, that precedes a classic migraine results from cranial vasoconstriction, and both temporal arteritis and occipital vasoconstriction, as well as myofascial contracture at the neck, base of the skull, and scalp, may contribute. This aura typically develops over 10-30 minutes and varies in intensity and manifestation, with the patient potentially experiencing light flashes, anxiety, numbness and tingling, dizziness, slight confusion, sensitivity to light and sound, nausea, and a throbbing headache in the classic syndrome.” (Migraine Headaches and the Importance of Knowing Which Type you have and Treating the Underlying Causes as well as the symptoms)
When I read something like this, I often wonder if there are other treatment approaches available other than more pills. In Traditional Chinese Medicine (TCM), there is the concept of the Origin and the Manifestation. We want to treat the manifestation particularly if the manifestation (or symptoms) are severe. More important, we always want to diagnose the Origin and treat it. In this way, the superficial signs of the pathology will decrease and homeostasis will return. According to this principle, the migraine is the manifestation of an underlying origin. What then is the origin, and how might we treat this?
“The German 3-year human clinical trial at Essen University proved that a simple uniform acupuncture treatment reduced frequency and intensity of migraine episodes as well as an intensive course of pharmaceuticals. The combination of magnesium and potassium aspartate, CoQ10, riboflavin B2, P5P (active metabolite of Vitamin B6), and inositol hexacotinate, an active metabolite of Vitamin B3 niacin, was also proven effective in Germany for a high percentage of migraine patients if taken for a prolonged period. Each year, more and more scientific proof of a holistic therapeutic protocol is emerging, allowing patients to successfully integrate TCM/CIM for better and safer results, and preventing the medication overuse syndromes of rebound migraine…While no direct therapy can easily correct this dysfunction, a combination of specific electroacupuncture stimulations and use of herbs with effects that calm neuroexcitotoxicity, such as Huperzine A and Vinpurazine, as well as a combination of L-Glutamine, inositol hexacotinate and P5P, may eventually correct these neurotransmitter dysfunctions. Studies of the brain with fMRI have demonstrated the remarkable specific effects of certain acupoints on these key areas of the brain, demonstrating for instance that stimulation of the P6 and GB34 points resulted in considerably lowered activity of the anterior cingulate cortex, and electroacupuncture at ST36 and SP6 significantly modulated activity in the insula (JNM 2012 July; 18(3): 305-316). Such research provides more specific treatment protocols to try in the course of treatment with acupuncture, herbal and nutrient medicine….In Germany, large trials in 2006 proved that acupuncture was a viable, and in fact superior, treatment for the migraine headache, performing at least as well as pharmaceutical therapies, with no adverse effects, and no risk of rebound headache syndrome (see the study link cited below). In 2013, a long-term randomized and controlled human clinical trial of 100 patients with chronic migraine syndromes was completed at the University of Padua, Italy, Department of Neurosciences, and here too, a course of simple standardized acupuncture treatment (20 sessions) outperformed pharmaceutical therapy in the long term. This study utilized what we know about acupuncture therapy for migraine syndromes, persisting with a longer course of therapy, and showing that outcomes may be better with pharmaceuticals in the short term, but at 6 months, the group receiving acupuncture consistently scored better on pain relief scales and subjective evaluation of pain intensity, and were able to reduce their use of triptan medications for migraine episodes significantly, compared to the standard protocol of daily use of a medication that included valproic acid (see study link below). In addition, the pharmaceutical course recorded adverse health effects, or side effects of medication, in nearly half of the participants, while no adverse effects of acupuncture therapy were noted. In fact, the side effects of acupuncture therapy is improved overall health and vitality. This human clinical trial clearly shows patients that a 10 week course of professional acupuncture therapy will result in an actual improvement in underlying health and causative factors, with lasting benefits. When combined with professional herbal and nutrient medicines, individualized for each patient, and taken in the proper step-by-step manner to correct the pathophysiological mechanisms responsible for these headaches, the results should be magnified greatly, insuring long-term reduction of debilitating migraine pain.” (Understanding the evidence for acupuncture and herbal nutrient medicine in the control and cure of migraine and cluster headaches)
“Since these landmark studies that provided sound evidence that acupuncture stimulation does work to decrease migraine pain and frequency, and can be effectively used in short repeated courses within a broader holistic protocol of herbal and nutrient medicine to achieve lasting benefits, the study of specific acupuncture treatments has accelerated to provide clinical guidelines. For instance, in 2014 experts at the Chengdu University of Traditional Chinese Medicine, in Chengdu, China, used randomized controlled PET-CT studies of the brain to determine the best treatment points and meridians, and types of stimulation, for migraine patients. This study showed that a combination of electroacupuncture and manual stimulation at Shaoyang (GB/SJ) meridian points, including SJ17, SJ8, and GB33 both decreased migraine pain and increased increased brain glucose metabolism in key areas associated with migraine pathology, such as the mid-frontal gyrus, postcentral gyrus, precuneus, parahippocampus, middle cingulate gyrus and cerebellum. Non-specific points used as a control did not produce this increase in brain function in these areas, but did provide some subjective pain decrease. Such studies will help guide professional acupuncturists in clinical practice (PMID: 25496446). Such treatment should be performed in short courses with frequent treatments, at least 2-3 times per week for a few weeks per course. The frequency of these courses over time is determined by the patient schedule, the severity of the symptoms, and the progress that is seen, but this allows for an inexpensive and easy treatment protocol within a broader and more holistic treatment plan, with herbal and nutrient medicine, avoidance of triggers of the migraine, and sensible alteration of medication protocols to prevent or decrease the potential for rebound migraine syndrome.” (Understanding the evidence for acupuncture and herbal nutrient medicine in the control and cure of migraine and cluster headaches)
What I want to point out here is that what appears to be effective is an integrative approach to treatment, and I emphasize this because there are many people in my program who are all or nothing in their healing paradigm. They vilify conventional medicine while putting all complementary medical protocols on a pedestal going so far as to judge people for taking prescription medications or vaccinating their children. This is unwise and unfair. Thus far, the studies that elucidate the most effective treatment for migraine disease involve an integration of both conventional and complementary treatment protocols using pharmaceutical, nutraceutical, and herbal supplementations along with acupuncture and other body work such as myofascial release, physical therapy, nutritional counseling, and long-term lifestyle changes to reduce stress. Chronic migraine disease involves the whole person.
I highly recommend these articles particularly if you are looking to heal from chronic migraines: