insights

Non-Drug Therapies for Migraine Patients

Headache disorders are the third cause of disability worldwide,1 and migraine and severe headache affect roughly one out of every six US adults (one in five women).2 Headache is consistently the fourth or fifth most common reason for visits to the emergency department.2

Migraine and tension-type headaches are the most prevalent headache disorders,3 and migraine, specifically, is associated with other physical and psychiatric comorbidities like anxiety and depression.4 Yet despite these associations, some studies have found that prevention treatments are underutilized in clinical practice.5

“I’m seeing more and more migraine patients come in to my practice looking for help outside of the typical medications,” says IFM educator Lisa Portera-Perry, DC. “Functional Medicine is such an excellent tool to be able to discern the issues and the underlying mechanisms (the triggers and mediators) that keep our migraine patients caught in these [chronic pain] patterns.”

Several randomized controlled trials have found that petasites (like butterbur), coenzyme Q10 (CoQ10), and magnesium citrate are beneficial prophylactic medications in patients with migraine.6,7 Riboflavin, which improves energy metabolism similarly to CoQ10, was also found to be effective and well-tolerated.8

Dr. Lisa Portera-Perry is a passionate advocate of Functional Medicine and its application for patients presenting with a wide variety of structural, neuromuscular, and autoimmune-related chronic illnesses.

Nutritional Strategies

While the exact pathophysiology of migraine remains unclear, there is evidence that inflammation plays a role, and food has been identified as a triggering factor.9 About 25% of patients report that their symptoms can be triggered by certain foods.10 In some patients, food sensitivities may be involved; IgG antibodies may be correlated with inflammation;9 IgG can suppress inflammation acutely, but long-term elevated IgG is associated with systemic inflammation.11

A 2007 study found preliminary evidence that IgG-based elimination diets successfully controlled the migraine without the need for medication,9,12 and a 2011 randomized controlled trial of a food elimination diet based on IgG antibodies for the prevention of migraine headaches showed a significant reduction in the number of migraines or migraine-like headaches at four weeks.10

Other allergens may also play a role. In an interesting 2017 study of 49 migraine patients and 49 healthy individuals, the frequency of migraine attacks was higher in allergy-test-positive patients than in negative ones.13 The allergy tests were positive for house dust, red birch, hazel tree, olive tree, nettle, and wheat.13

A larger, 2018 study in children suggests that children with allergic diseases, including atopic dermatitis, allergic conjunctivitis, allergic rhinitis, and asthma, are at increased subsequent risk of migraine when they reach school age, and the risk shows a cumulative effect of more allergic diseases and more allergy-related healthcare.14

Stress Management

Stress is also a well-known trigger for headaches, and there is evidence that behavioral interventions, such as cognitive-behavioral therapy and biofeedback, compare favorably with preventative medication for migraines.15 Because emotion and pain are closely intertwined in the brain, therapies such as cognitive behavioral therapy, yoga, biofeedback, and meditation are increasingly utilized to augment management of migraine and pain.16

A small study in 2014 showed that mindfulness-based stress reduction had a beneficial effect on headache duration.17 People who practiced meditation had less severe headaches and about 1.4 fewer migraines a month, though those effects weren’t statistically significant (likely due to the small sample size). Meditators’ headaches were significantly shorter—about three hours less per headache—than the control group’s. A 2018 meta-analysis found that meditation is a promising treatment option for patients, as it may reduce migraine pain intensity.18

Research studies have shown that frequency and intensity of migraine attacks may be reduced with yoga and acupuncture therapy.19 However, long-term studies on the effectiveness of these interventions has been lacking. A 2016 update to a 2009 Cochrane review suggests that adding acupuncture to symptomatic treatment of migraine attacks reduces the frequency of headaches.20 Contrary to the previous findings, the updated evidence also suggests that there is an effect over sham, but this effect is small. The available trials also suggest that acupuncture may be at least similarly effective as treatment with prophylactic drugs.20 The following year, in 2017, a randomized clinical trial published in JAMA found that among patients experiencing migraine without aura, true acupuncture may be associated with long-term reduction in migraine recurrence.21

Conclusion

Clearly, research indicates that there is a need for non-drug options to relieve migraine, and there is a wealth of non-pharmacological therapies for clinicians to consider. Each person’s genetic, biochemical, and lifestyle factors are considered in the Functional Medicine model, and clinicians leverage that data to direct personalized treatment plans.

Learn more about migraines and fatty acids in the diet

What are some alternatives to opioid therapy for chronic pain? Learn more here.

References

  1. Steiner TJ, Birbeck GL, Jensen RH, Katsarava Z, Stovner LJ, Martelletti P. Headache disorders are third cause of disability worldwide. J Headache Pain. 2015;16:58. doi:10.1186/s10194-015-0544-2.
  2. Burch R, Rizzoli P, Loder E. The prevalence and impact of migraine and severe headache in the United States: figures and trends from government health studies. Headache. 2018;58(4):496-505. doi:10.1111/head.13281.
  3. Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies. Headache. 2013;53(3):427-436. doi:10.1111/head.12074.
  4. Green MW. Headaches: psychiatric aspects. Neurol Clin. 2011;29(1):65-80. doi:10.1016/j.ncl.2010.10.004.
  5. Silberstein SD. Preventive migraine treatment. Continuum. 2015;21(4 Headache):973-989. doi:10.1212/CON.0000000000000199.
  6. Pringsheim T, Davenport W, Mackie G, et al. Canadian Headache Society guideline for migraine prophylaxis. Can J Neurol Sci. 2012;39(2 Suppl 2):S1-59.
  7. Köseoglu E, Talaslioglu A, Gönül AS, Kula M. The effects of magnesium prophylaxis in migraine without aura. Magnes Res. 2008;21(2):101-108.
  8. Sándor PS, Di Clemente L, Coppola G, et al. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology. 2005;64(4):713-715. doi:10.1212/01.WNL.0000151975.03598.ED.
  9. Alpay K, Ertas M, Orhan EK, Ustay DK, Lieners C, Baykan B. Diet restriction in migraine, based on IgG against foods: a clinical double-blind, randomized, cross-over trial. Cephalalgia. 2010;30(7):829-837. doi:10.1177/0333102410361404.
  10. Mitchell N, Hewitt CE, Jayakody S, et al. Randomized controlled trial of food elimination diet based on IgG antibodies for the prevention of migraine like headaches. Nutr J. 2011;10:85. doi:10.1186/1475-2891-10-85.
  11. Aschermann S, Lux A, Baerenwaldt A, Biburger M, Nimmerjahn F. The other side of immunoglobulin G: suppressor of inflammation. Clin Exp Immunol. 2010;160(2):161-167. doi:10.1111/j.1365-2249.2009.04081.x.
  12. Arroyave Hernández CM, Echavarría Pinto M, Hernández Montiel HL. Food allergy mediated by IgG antibodies associated with migraine in adults. Rev Alerg Mex. 2007;54(5):162-168.
  13. Bektas H, Karabulut H, Doganay B, Acar B. Allergens might trigger migraine attacks. Acta Neurol Belg. 2017;117(1):91-95. doi:10.1007/s13760-016-0645-y.
  14. Wei CC, Lin CL, Shen TC, Chen AC. Children with allergic diseases have an increased subsequent risk of migraine upon reaching school age. J Investig Med. 2018;66(7):1064-1068. doi:10.1136/jim-2018-000715.
  15. Powers SW, Kashikar-Zuck SM, Allen JR, et al. Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: a randomized clinical trial. JAMA. 2013;310(24):2622-2630. doi:10.1001/jama.2013.282533.
  16. Dahlke LA, Sable JJ, Andrasik F. Behavioral therapy: emotion and pain, a common anatomical background. Neurol Sci. 2017;38(Suppl 1):157-161. doi:10.1007/s10072-017-2928-3.
  17. Wells RE, Burch R, Paulsen RH, Wayne PM, Houle TT, Loder E. Meditation for migraines: a pilot randomized controlled trial. Headache. 2014;54(9):1484-1495. doi:10.1111/head.12420.
  18. Gu Q, Hou JC, Fang XM. Mindfulness meditation for primary headache pain: a meta-analysis. Chin Med J. 2018;131(7):829-838. doi:10.4103/0366-6999.228242.
  19. Halappa NG. Prevention of chronic migraine attacks with acupuncture and Vamana Dhauti (yogic therapeutic self-induced emesis) interventions. Int J Yoga. 2019;12(1):84-88. doi:10.4103/ijoy.IJOY_11_18.
  20. Linde K, Allais G, Brinkhaus B, et al. Acupuncture for the prevention of episodic migraine. Cochrane Database Syst Rev. 2016;(6):CD001218. doi:10.1002/14651858.CD001218.pub3.
  21. Zhao L, Chen J, Li Y, et al. The long-term effect of acupuncture for migraine prophylaxis: a randomized clinical trial. JAMA Intern Med. 2017;177(4):508-515. doi:10.1001/jamainternmed.2016.9378.

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