Articles

Migraine

Introduction

What should I know about Migraines?

As anyone who has experienced one knows, there is absolutely nothing like a migraine headache. A migraine headache can be debilitating for hours and sometimes for days. The migraine headache is considered a vascular headache, although the precise mechanism and cause remain unknown. There are several known triggers, some of which include food allergies, blood sugar disturbances, stress load, mechanical injury, and hormonal fluctuations. Treating a migraine means working with these triggers.

Migraine may be classified as migraine without aura, formerly called common migraine, or migraine with aura, formerly known as classic migraine. The differences are based upon the presence or absence of neurologic symptoms prior to the onset of headache. The aura may consist of flashing lights, or zigzag lines, or may manifest as blind spots in the vision. Some people even experience speech difficulty, tingling in the face or hands, confusion, or weakness of an arm or leg. The majority of people suffering from classic migraine have an aura that develops 10-30 minutes prior to development of the actual headache. According to recent studies, the aura is believed to be the response to a trigger that creates a neuronal depression. This may result in as much as a 25-35 percent reduction in cerebral blood flow, and is certainly enough to cause the symptoms associated with the aura.

Auras are experienced by approximately 10 percent of those who have migraines. (1) The International Headache Society has developed a classification system of migraine headaches that includes six subdivisions under the heading migraine with aura. These range from a migraine with an aura that lasts for less than one hour to one that lasts for up to one week. The common migraine, or migraine without aura, occurs in approximately 85 percent of those affected.

Statistic

World Health Organization, 2004.

  • Worldwide, migraine alone is 19th among all causes of years lived with disability (YLDs).
  • 8% of men and 18% of women experience migraine each year.

American Council for Headache Education, 1999.

    25-30 million Americans get migraines. 6% of men get migraines. 18% women suffer migraines at one time in their lifetime. 3 out of 4 migraine suffers are women.

National Headache Foundation, 1999.

    Migraines have increased 50% in the last 20 years.

Signs and Symptoms

[span class=alert]The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.[/span]

Migraines frequently occur in the early morning hours. Approximately 60 percent of people who have migraines experience symptoms, which may occur for hours or days before the onset of headache. (2) Early symptoms may vary widely among those suffering from migraine, yet are usually consistent in an individual. They can present as psychologic symptoms such as irritability, anxiety, depression, fatigue, drowsiness or euphoria; or neurologic symptoms such as increased sensitivity to light, sounds, and smells. Symptoms such as diarrhea, constipation, excessive urination, stiff neck, thirst, yawning, or food cravings may also occur.

Peak intensity of migraine pain typically occurs within an hour of onset. Pain is usually on one side, but can occur anywhere on the face or head, most often in the temple. (3) Typical migraine headaches are of moderate to severe intensity and are often described as pounding, pulsating, or throbbing. Activities of daily living are often affected as physical activity may worsen headache pain. Patients often seek a quiet, dark place to rest. Headaches may last from 4 to 72 hours and patients typically suffer from post-headache exhaustion, scalp tenderness, and recurrence of headache with sudden head movements.

Prodrome (before the attack)

  • Irritability, anxiety, depression, fatigue, drowsiness, or euphoria
  • Diarrhea, constipation, increased urination, or stiff neck
  • Increased thirst, yawning, or food cravings
  • Sensitivity to light or sound

Migraine Attack

  • Peaks within an hour of beginning
  • Pain is usually on one side of the head
  • May occur anywhere on the face or head but is usually in the temple
  • May be described as throbbing, pulsating, or pounding
  • Physical activity often causes pain to be worse
  • Additional complaints include nausea, vomiting, diarrhea, or loss of appetite
  • Sensitivity to light or sound
  • Headaches may last from 4 to 72 hours

Postdrome (after the attack)

  • Exhaustion
  • Scalp tenderness
  • Recurrence of headache with sudden head movements

Treatment Options

Conventional

Management of migraine headaches should begin with identification and removal, if possible, of factors that consistently provoke migraine attacks. Some of these triggers may include environmental factors such as cigarette smoke, loud noise, and bright or flickering lights; psychological factors including stress, anxiety, or depression; dietary factors such as alcohol, chocolate, caffeine, or tyramine containing foods, food additives, or citrus fruit; or life-style factors such as inadequate or excessive sleep, fasting or dieting, fatigue, skipping meals, or strenuous exercise.

A higher incidence of migraine is also seen during menstruation, while generally a decrease is seen during pregnancy. A number of medications have been associated with drug-induced migraine. Some of these are cimetidine, cocaine, ethinyl estradiol, fluoxetine, histamine, hormone replacement therapy, indomethacin, mestranol, nicotine, nifedipine, nitroglycerin, oral contraceptives, and reserpine.

The use of medications in management of migraine may be targeted in two ways, either to alter the attack once it is underway (abortive therapy) or prevention of the attack altogether. Abortive therapy must begin at the onset of the attack to achieve its full potential. Once an attack is fully developed, treatment is much less likely to be effective.

Simple analgesics, such as aspirin and acetaminophen, should be used in individuals with infrequent and mild forms of migraine. Aspirin is considered the drug of choice in these people, unless contraindicated or not tolerated. There are also combination medications, with additives such as caffeine, for increased GI absorption, bultalbital, to aid in sleep, and other narcotics for additional pain relief. These should be used with caution since rebound headache may occur when the effects wear off, leading to additional medication consumption.

Nonsteroidal anti-inflammatory drugs (NSAID's) have been used with some success in treating migraine headaches. Inhibition of prostaglandin synthesis by NSAID's may prevent neurogenic inflammation in the trigeminovascular system and alleviate migraine pain. (4) Those with a rapid onset of action such as ibuprofen or naproxen may be superior to those with a slower onset of action. Migraines that occur before, during, or after menstruation may respond well to NSAID therapy. The injectable drug, ketorolac, has been used in patients unable to tolerate oral therapy due to nausea and vomiting, and in patients with drug-seeking behaviors.

Ergotamine has been used for years as a treatment for migraine, and as theories of the pathophysiology of migraine have changed, so have proposed mechanisms of action for ergotamine and its derivatives. Currently, it is believed that antimigraine action occurs as a result of stimulation of presynaptic 5HT1 receptors. Ergotamine is available as an oral tablet, a sublingual tablet, and a suppository. (5)

Nutritional Suplementation


Magnesium

Magnesium’s role in the pathogenesis of migraine headaches has been clearly established in numerous clinical and experimental studies. However, the precise role of how and why low levels of magnesium increase the risk of migraines remains to be discovered.

Examples of studies reporting on the relationship between magnesium and migraine headaches include the following: Patients with migraines have low brain magnesium levels (6) and in a study of 3,000 women, 80 percent responded well to magnesium supplementation. (7) Magnesium was also found to be effective in the prophylaxis of menstrual migraines. In a double-blind trial, women taking 360 mg/day of magnesium for two months reported a reduction in the number of days with headaches in addition to overall improvement in premenstrual complaints. (8) In addition to reducing the incidence of menstrual migraines, the authors of this study suggest that low levels of magnesium could actually act as a trigger to induce migraine headaches.


Vitamin B2

High-dose riboflavin therapy has proven to be remarkably effective in the treatment of migraine headaches. (9) In an open study, 55 patients took 400 mg of vitamin B2 daily for three months. Riboflavin was far superior to placebo in reducing the frequency of migraine attacks and the number of days with headache. The number of patients who improved by at least 50% (responders) was 59% for riboflavin compared to 15% for the placebo patients. At this high dosage level, only two patients reported minor side effects of diarrhea and excess urination. (10)


Vitamin D, Calcium

Two studies report that a combination of vitamin D and calcium were effective in reducing the frequency and duration of migraine attacks. One was a case study of two postmenopausal women who developed frequent and excruciating migraine headaches (one following estrogen replacement therapy and the other following a stroke). These women were treated with a combination of vitamin D and calcium. This therapeutic supplementation resulted in a dramatic reduction in the frequency and duration of their migraine headaches. (11)

The second study is a report of two premenopausal women with a history of premenstrual syndrome coupled with menstrually-related migraines. Each woman was treated with a combination of vitamin D and elemental calcium for late phase symptoms of PMS. Both cited a major reduction in their headache attacks as well as premenstrual symptomatology within 2 months of therapy. (12) The results of these two small case studies that vitamin D and calcium therapy should receive consideration as a possible treatment of migraine headaches.


Omega-3, Omega-6

In an open-label uncontrolled study, 129 migraine patients completed a 6-month trial in which they were administered a combination of gamma-linolenic and alpha-linolenic acids. 86% of the patients experienced reduction in severity, frequency, and duration of their migraine attacks, 22% became completely free of migraines, and more than 90% reported a reduction in nausea and vomiting. Most of the participants reduced their self-medication to simple analgesics, while only 14% of patients experienced no improvement. (13)

Herbal Suplementation


Feverfew

Feverfew has gained immense popularity because of its effectiveness in relieving migraine headaches. (14) , (15) It can take time for this herb to work, so staying on it for a minimum of a month is recommended for proper activity. It is also used for inflammatory conditions such as rheumatoid arthritis, (16) relaxing smooth muscle in the uterus, (17) inhibiting platelet aggregation and blood clotting, (18) , (19) and fever. (20)


Turmeric

In Ayurvedic medicine (traditional Indian medicine), turmeric rhizome has been used for centuries internally as a tonic for the stomach and liver and as a blood purifier, and externally in the treatment and prevention of skin diseases and in arthritic complaints. (21) The laboratory and clinical research indicates that turmeric and its phenolics have unique antioxidant and anti-inflammatory properties. (22) The anti-inflammatory strength of turmeric is comparable to steroidal drugs such as indomethacin. (23) Turmeric has been reported to be anti-rheumatic, anti-inflammatory, and antioxidant. (24) Many of these pharmacological factors contribute to the supportive use of turmeric in migraine headaches. (25)


Kava

Decreasing and managing stress may also play a key role in relieving and preventing migraine headaches. The herb kava has been used for centuries by South Pacific natives. The root is used in the preparation of a recreational beverage known by a variety of local names (kava, yaqona, awa) and occupies a prominent position in the social, ceremonial, and daily life of Pacific island peoples as coffee or tea does in the Western cultures. In European phytomedicine, kava has long been used as a safe, effective treatment for mild anxiety states, nervous tension, muscular tension, and mild insomnia. (26) , (27)


Evening Primrose

Evening primrose oil (EPO) is rich in gamma-linolenic acid which is an omega-6 fatty acid. (28) , (29) Omega-6 fatty acids reportedly reduce the arachidonic acid cascade and decrease inflammation through inhibiting the formation of inflammatory mediators in this process. Fatty acids are an important part of normal homeostasis. The human body can produce all but two fatty acids - omega-3 and omega-6 fatty acids. Both must be obtained through the diet or by the use of supplements. Obtaining a balance of these two fatty acids is essential. Essential fatty acids are needed for building cell membranes and are precursors for production of hormones and prostaglandins. Modern diets tend to be lacking in quality sources of fatty acids.


Gymnema

In the instance where migraines may be related to sugar metabolism, the herb Gymnema may be useful. Gymnema is a rain forest vine found in Central and Southern India which has a long tradition in the treatment and management of diabetes. The Indian name is Gurmar, which means “sugar destroyer." Its use has been documented in Ayurvedic medical texts for over 2000 years in the treatment of “sweet" urine. Gymnema is gaining popularity with clinicians utilizing natural therapy protocols in the management of diabetes, hyperinsulinemia, and impaired glucose tolerance. The leaves of gymnema are thought to increase insulin secretion, and several studies report control of hyperglycemia in moderately diabetic laboratory animals. (30) , (31)

References

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  3. View Abstract: Silberstein SD, Lipton RB. Overview of diagnosis and treatment of migraine. Neurology. 1994;44(suppl 7):s6-s16.
  4. Welch KM. Drug therapy of migraine. N Engl J Med. 1993;329:1476-1483.
  5. View Abstract: Mathew NT. Dosing and administration of ergotamine tartrate and dihydroergotamine. Headache. 1997;37(suppl 1):26-32.
  6. View Abstract: Ramadan NM, et al. Low Brain Magnesium in Migraine. Headache. Oct1989;29(9):590-93.
  7. Weaver K. Magnesium and Its Role in Vascular Reactivity and Coagulation. Contemp Nutr. 1987;12(3):1.
  8. View Abstract: Facchinetti F, et al. Magnesium prophylaxis of menstrual migraine: effects on intracellular magnesium. Headache. May1991;31(5):298-301.
  9. View Abstract: Boehnke C. High-dose riboflavin treatment is efficacious in migraine prophylaxis: an open study in a tertiary care centre. Eur J Neurol. 2004 Jul;11(7):475-7.
  10. View Abstract: Schoenen J, et al. Effectiveness of high-dose riboflavin in migraine prophylaxis. A randomized controlled trial. Neurology. Feb1998;50(2):466-70.
  11. View Abstract: Thys-Jacobs S. Alleviation of migraines with therapeutic vitamin D and calcium. Headache. Nov1994;34(10):590-2.
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  14. View Abstract: Johnson ES, et al. Efficacy of Feverfew as Prophylactic Treatment of Migraine. British Medical Journal. 1985;291:569-73.
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  21. View Abstract: Ammon HP, et al. Pharmacology of Curcuma longa. Planta Med. Feb1991;57(1):1-7.
  22. View Abstract: Sreejayan. Nitric oxide scavenging by curcuminoids. J Pharm Pharmacol. Jan1997;49(1):105-7.
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