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Migraine headache.

The following article is an abridged version of the "Migraine Headache" chapter that appears in Disease Prevention and Treatment, 5th ed., an integrative-health textbook published by Life Extension.

Migraine headaches are recurrent, painful headaches often accompanied by nausea, light sensitivity, and/or sound sensitivity. A migraine is often one-sided and pulsating, and may occur with or without an aura (Cutrer 2012; Rakel 2011; Ferri 2012; NINDS 2012; Goldman 2011).

Avoidance of migraine triggers such as intense emotional stress, poor sleep habits, food allergies or intolerances, and unbalanced hormone levels may reduce the frequency and severity of attacks (Gaby 1998; Alpay 2010; Shugart 2012; Mayo Clinic 2011; Dzugan 2006). Several safe and effective natural treatment approaches are available to prevent migraines and reduce their frequency and intensity (Schiapparelli 2010).

What Is a Migraine Headache?

Migraine headache is often described as an intense throbbing or pounding head pain (Rizzoli 2012; NINDS 2012), is often made worse by physical activity (Walling 2012), and may interfere with a person's ability to function normally. Although migraine duration varies from patient to patient, a typical attack lasts for several hours but can last up to several days (Walling 2012).

Symptoms that precede a migraine headache by a few hours to a few days are called a prodrome. Prodrome can include appetite changes, loss of balance, mood changes, tiredness, neck stiffness, and changes in alertness (Rossi 2005).

Approximately 25% of migraine sufferers experience a premigraine phenomenon called aura, characterized by mostly visual, but also other sensory and/or movement symptoms (Cutrer 2012; Digre 2011 c).

What Causes Migraine?

Migraine headaches are believed to result from complex dysfunction within the central nervous system (Charles 2009). Several factors may contribute:

Serotonin. The neurotransmitter serotonin is believed to play a role in migraine attacks, as migraine patients tend to have low levels of serotonin in their brains (Panconesi 2008). Also, tricyclic antidepressants, which increase serotonin signaling, reduce the frequency of migraine attacks (Cutrer 2012).

The role of hormones. Migraine disproportionately affects women-70% of all migraine patients are female--suggesting a potential hormonal link (Dhillon 2011).

Although many hormonal events in a woman's life may influence the occurrence of migraine (Sacco 2012), menstruation appears to be the most important: 70% of female patients who experience migraine report some type of menstrual link (Calhoun 2012). A phenomenon called "estrogen withdrawal," which occurs in the late luteal phase of the menstrual cycle and is characterized by an abrupt decline in estrogen levels, is likely an important migraine trigger in some women (MacGregor 2009; Lay 2009).

Among women with menstrual-related migraines, hormone therapy that minimizes monthly declines in estrogen concentration may be effective in preventing migraine attacks (Calhoun 2009). Studies suggest that non-oral routes of estrogen therapy, such as in a cream applied to the skin, are more likely to improve migraine than oral estrogens (MacGregor 2009).

The Neurohormonal and Metabolic Dysbalance Hypothesis of Migraine

Some researchers suspect that an important cause of migraine is an imbalance between estrogen and progesterone levels, rather than simply the absolute amount of these hormones. Indeed, in preliminary reports, therapies aimed at improving the ratio of estrogens to progesterone have successfully relieved severe menstrual migraine (Holdaway 1991).

One link between hormonal imbalance and migraine may be the opposing roles of estrogen and progesterone within the brain. While estrogen stimulates neural excitability, progesterone exhibits inhibitory actions in central neurons (Finocchi 2011). Tailored hormonal replacement therapy (HRT) aimed at minimizing estrogen/progesterone imbalance and stabilizing estrogen levels may be effective for preventing migraines among pre- and postmenopausal women (Nappi 2009; Shuster 2011; Schurks 2010; Calhoun 2012).

Other sex hormones such as testosterone, dehydroepiandrosterone (DHEA), and pregnenolone may also play a role in migraines (Dzugan 2006).

Although well-controlled clinical trials designed to test this hypothesis have not yet been performed, several case reports have demonstrated positive outcomes using this novel approach (Dzugan 2006).

Women with migraines who have not received relief from other treatments may want to consider comprehensive hormone testing and restoration of hormonal balance using bioidentical hormone replacement therapy.

Diagnosis

History and physical examination are used to diagnose migraine headaches (Cutrer 2012; Katsarava 2012).

Some less common but potentially serious disorders can cause migrainelike symptoms, including subarachnoid hemorrhage, intracranial mass lesions, and cerebral vasculitis. Migraine headache is often misdiagnosed as sinus headache or tension-type headache (NHF 2012; Merck Manual 2012; Kwiatkowski 2009; Bope 2011; Ferri 2012).

Tests such as computerized tomography (CT), magnetic resonance imaging (MRI), and a spinal tap (lumbar puncture) to test cerebrospinal fluid may be used to help rule out other possible causes of headache (Mayo Clinic 2012; Kwiatkowski 2009).

Conventional Treatment

Most migraine treatment plans involve both acute and preventive strategies (Braun 2010).

Acute Treatment

The goal of acute treatment is to relieve the intensity and/or duration of an imminent or ongoing migraine (Hershey 2011). First-tier options for acute migraine management may include nonsteroidal anti-inflammatory drugs (NSAIDs) and/or mild analgesics (e.g., acetaminophen or aspirin) (Hershey 2011; Bajwa 2012). Caffeine, due to its vasoconstrictive properties, is sometimes combined with aspirin and/or acetaminophen as well (Aukerman 2002). The triptan drugs (e.g., sumatriptan, rizatriptan, eletriptan, and almotriptan), which are used for more severe migraines, promote vasoconstriction and block pain pathways by activating certain serotonin receptors in cranial blood vessels (Bajwa 2012).

Although the triptans are arguably the most effective treatment for acute relief of a migraine headache, they have a number of side effects (Cady 2011). For example, triptans should be avoided in patients who are at risk for cardiovascular events and stroke (i.e., patients with heart disease). Furthermore, triptans require careful monitoring because they are known to interact with a large number of other commonly used medications (Bajwa 2012).

Other drugs that may be used to treat migraine include ergot alkaloids, which cause blood vessel constriction, opioids, and, less commonly, corticosteroids.

Medicating as early as possible during a migraine attack increases the chances of successfully aborting an attack or reducing its intensity (Aukerman 2002).

Preventive Treatment

The main goals of preventive therapy are to reduce migraine frequency, severity, and duration, as well as to improve response to acute treatment(s). Preventive treatment options include headache trigger avoidance, daily medication, physical therapy, and/or behavioral therapy (Braun 2010).

Drugs used to prevent migraines include blood pressure medications (e.g., beta blockers, calcium channel blockers, ACE inhibitors, and angiotensin receptor blockers), tricyclic antidepressants (e.g., amitriptyline [Elavil]), and anticonvulsants (e.g., valproate [Depakote], gabapentin [Neurontin], and topiramate [Topamax]). These drugs should be started at low doses and given adequate time to reach peak effectiveness. Therefore, depending upon the chosen medication, a proper drug trial could take anywhere from 4 weeks to 3 months to produce the desired effect (Bajwa 2010).

Unfortunately, too much migraine prevention medication over too long a period can lead to "medication overuse headache," which can become a chronic, self-perpetuating condition called "chronic daily headache." This is characterized by daily headaches, and patients often inadvertently perpetuate it by continuing to medicate their headaches. To prevent medication overuse headache, migraine patients should (on average) limit use of NSAIDs to 15 or fewer days a month and limit triptan or over-the-counter combination analgesic use to 9 or fewer days a month (Garza 2012; Young 2001).

Lifestyle Considerations

Many migraine patients will not experience significant symptom relief from drug treatment alone, until healthful lifestyle modifications are made (Sun-Edelstein 2009a). The following lifestyle interventions may prevent migraines (Chaibi 2011b; Gallagher 2012; Linde 2009; Honaker 2008, Hauge 2011):

* avoidance of caffeine, nicotine, red wine, and other migraine triggers

* stress reduction

* improving sleep hygiene

* massage therapy

* chiropractic manipulation

* acupuncture

* sufficient exercise

* frequent stretching

Dietary Interventions

One out of every 4 migraine patients report that certain foods can trigger an attack (Mueller 2007). Furthermore, the avoidance of food allergies and/or sensitivities may reduce or eliminate migraine symptoms for some patients (Ross 2011; Gaby 1998).

Common migraine triggers in food include (Mueller 2007):

* monosodium glutamate (MSG), a commonly used flavor-enhancer found in some soups and Chinese food

* nitrites, preservatives found in processed meats such as hot dogs

* tyramines, natural compounds found in wines and aged foods (e.g., cheeses)

* phenylethylamine, a stimulant compound found in chocolate, garlic, nuts, raw onions, and seeds.

Other potential dietary triggers include cow's milk, wheat, eggs, alcohol, artificial sweeteners, citrus fruits, pickled products, and vinegar (Mueller 2007; Ross 2011).

Many experts recommend the use of simple and inexpensive food diaries to identify dietary migraine triggers (Sun-Edelstein 2009a). Trials have demonstrated that food allergy elimination based on testing for immunoglobulin G (IgG) food antibodies successfully reduces migraine symptoms (Arroyave Hernandez 2007; Alpay 2010).

Additionally, not eating for over 4 hours has been linked to an increased risk of migraine attack (Gallagher 2012; Fukui 2008).

Integrative Interventions

Natural therapies (e.g., dietary supplements) are well tolerated, and many have been shown to reduce migraine symptoms (O'Brien 2010; Schiapparelli 2010).

Butterbur root: Butterbur (Petasites hybridus) extracts possess analgesic, anti-inflammatory, antispasmodic properties (Pothmann 2005; Oelkers-Ax 2008). Butterbur root extract (standardized to 15% petasins) has been shown to be both safe and effective for the prevention of migraines (Diener 2004; Lipton 2004; Pothmann 2005). In one study, researchers divided 245 patients into three groups that received 75 mg of butterbur extract twice a day, 50 mg of butterbur extract twice a day, or placebo. At the end of a 4-month treatment period, those taking the 75 mg dosage experienced a 48% reduction, on average, in the frequency of migraine attacks (Lipton 2004). The American Academy of Neurology (AAN) and the American Headache Society (AHS) have recommended butterbur extract as an effective treatment for migraine (Holland 2012).

Coenzyme Q10: Coenzyme Q10 (CoQ10) is a potent antioxidant (Ross 2007) and an important component of cellular energy production. Its anti-inflammatory effects and ability to improve mitochondrial function may account for its efficacy in prevention of migraines (Slater 2011). CoQ10 at a dose of 100 to 300 mg daily has been shown to prevent and reduce the frequency of migraine attacks among adults (Schiapparelli 2010; Slater 2011).

Riboflavin: Riboflavin (i.e., vitamin B2) contributes to cell growth, enzyme function, and energy production (AMR 2008). High-quality research indicates that riboflavin is effective for the prevention of migraine among both children and adults (Condo 2009; Boehnke 2004), and may decrease the need for conventional rescue medications (Boehnke 2004). It is believed that riboflavin's beneficial effects are due to its ability to enhance mitochondrial energy production (Brenner 2010). Riboflavin is especially effective among migraine patients with mitochondrial genetic abnormalities (DiLorenzo 2009).

One study involving 23 participants showed that supplementation with 400 mg riboflavin daily reduced headache frequency by an impressive 50% after 3 months, with that improvement persisting through 6 months (Boehnke 2004). Riboflavin is also cost effective and has minimal side effects (Condo 2009).

Feverfew: Feverfew (Tanacetum parthenium) is a small, daisylike flower (Goodyear-Smith 2010). Feverfew inhibits the production of several inflammatory mediators that may be involved in migraine, including arachidonic acid, cyclooxygenase-2, TNF-[alpha], IL-1, and MCP-1. Though a promising natural treatment for migraines, trials of feverfew extract have had mixed results (Goodyear-Smith 2010; Saranitzky 2009; Chen 2007; Pittler 2004). A combination of ginger and feverfew, at a dosage of 100 to 300 mg up to 4 times per day, has been shown to be effective for migraine prevention with minimal side effects (Cady 2011; Ernst 2000; Pareek 2011).

Magnesium: Migraine patients commonly have low magnesium levels, especially during an attack (Qujeq 2012; Talebi 2011; Sun-Edelstein 2009b). A dosage of 600 mg of magnesium daily has been shown to be effective for the prevention of migraine attacks (Koseoglu 2008), and is inexpensive and well tolerated (Sun-Edelstein 2009b). In combination with CoQ10, vitamin B2, and ginkgo, magnesium has been shown to significantly decrease the number of migraine headaches (Esposito 2011). A form of magnesium called magnesium-L-threonate may be especially effective for migraine treatment, as experimental data indicate that it enters the central nervous system more efficiently than other forms of magnesium, though it has not yet been subjected to clinical trials (Slutsky 2010).

Melatonin: Melatonin, a natural compound produced by the pineal gland in the brain, helps regulate the sleep-wake cycle (Wilhelmsen 2011). Lower-than-normal levels of melatonin have been found in migraine patients (especially during an attack), which may play a role in migraine pathology (Masruha 2008; Masruha 2010).

Some migraine patients experience an improvement in symptoms with melatonin supplementation (Vogler 2006). In one clinical study, melatonin supplementation yielded a trend of two-thirds reduction in number of migraine attacks (Alstadhaug 2010). Melatonin has been found to be safe (Gagnier 2001).

S-adenosylmethionine (SAMe): SAMe is derived from the amino acid methionine and adenosine triphosphate, a nucleic acid (De Silva 2010). It is a naturally occurring substance that is important in the function of the central nervous system (Carpenter 2011). Some data suggest that long-term supplementation with SAMe may relieve pain among migraine sufferers, possibly due to its ability to increase serotonin (Gatto 1986; Fetrow 2001).

L-tryptophan: The amino acid L-tryptophan is a precursor to serotonin. An older clinical trial found that supplementation with 2 to 4 g of L-tryptophan daily was as effective at preventing migraine attacks as the ergot medication methysergide (Sicuteri 1973). A more recent trial found that dietary tryptophan depletion exacerbated migraine symptoms (Drummond 2006).

Additional Supplements: These natural substances may help manage migraine symptoms, though definitive clinical data are lacking:

* Ginkgo biloba (Schiapparelli 2010)

* alpha-lipoic acid (Sun-Edelstein 2009a)

* vitamin B6 (Ross 2011)

* ginger (Mustafa 1990)

Suggestions

* butterbur root, standardized extract: 150 mg daily

* riboflavin: 400 mg daily

* coenzyme Q10 (as ubiquinol): 100-300 mg daily

* feverfew (dried leaf): up to 1200 mg daily in divided doses

* ginger root, standardized extract: 250 mg daily

* magnesium: 140 mg daily as magnesium-L-threonate; 320 mg daily as magnesium citrate

* melatonin: 0.3-5 mg before bed (sometimes up to 10 mg)

* S-adenosylmethionine (SAMe): 200-1200 mg daily

* Ginkgo biloba, standardized extract: 120 mg daily

* R-lipoic acid: 300-600 mg daily

* vitamin B6 (as pyridoxal-5-phosphate): 100 mg daily

* L-tryptophan: 500-2000 mg daily

In addition, the following blood tests may provide helpful information:

* Food Safe Allergy Test

* Magnesium (RBC)

* Male Basic Hormone Panel

* Female Basic Hormone Panel

* Male Comprehensive Hormone Panel

* Female Comprehensive Hormone Panel

More information on the integrative interventions and lab tests mentioned in this article is available from Life Extension, an organization dedicated to scientific innovation. To receive a free copy of Life Extension magazine, visit www.lifeextension. com/Book6 or call (toll-free) 866-606-9803 and mention discount code DPT506A.

Notes

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