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Sharron's book is now available at Amazon www.amazon.com, Barnes and Noble www.barnesandnoble.com, and wherever books are sold. The book can be purchased in print form or ebook format.

Conari Press, an imprint of Red Wheel/Weiser, LLC  is the publisher of Sharron's book, Migraine: Identify Your Triggers, Break your Dependence on Medication, Take Back Your Life -  An Integrative Self-Care Plan for Wellness," released June, 2013. Follow Sharron on Twitter @murraysharron, and her page Sharron Murray, MS, RN on Facebook, for tips to help you battle your migraines and achieve wellness.

 

Thursday
May292014

Migraine, Comorbidities, and Exercise - A delicate balance

 

"Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it." -Plato

Everyone knows that physical movement, or exercise, is believed to have a positive effect in the preservation of health and promotion of wellness. However, for those of us with migraine, the reality is exercise can be a "damned if you do and damned if you don't" situation.

For example, if we have pain and exercise, we may aggravate our pain. If we are pain-free and exercise, we may trigger a migraine attack. On the other hand, if we don't exercise because of pain or fear of a migraine attack, we deny ourselves the option of a preventive treatment for migraine.

In addition, we need to be aware that lack of exercise deprives us of the health benefits regular activity provides for a number of diseases and disorders shown to be comordid with migraine. These include obesity, cardiovascular disease (heart disease, angina, high cholesterol, high blood pressure, stroke), circulation problems, arthritis, chronic pain disorders, pulmonary disorders (asthma, sinusitis), anxiety, and depression (Buse, Manack, et al, 2010). 

This is important for us to know because an increase in the frequency of our attacks is correlated with an increase in a number of these comorbidities and may contribute to our progression from episodic to chronic migraine.  A few more things to consider are:

What, then, do we do?  

"If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health". - Hippocrates.

Perhaps, for those of us with migraine, our answer lies in the words of Hippocrates. We find the right amount of exercise, not too little and not too much, to suit our individual needs. 

To help us find the right amount of exercise and tailor the activity to meet our individual needs, this article addresses:

  • the health benefits of exercise.
  • the types of exercise we should consider.

The health benefits of exercise

The health benefits of exercise are numerous. As you read through the following list, keep in mind your personal comorbidities and risk factors for progression from episodic to chronic migraine.

Regular exercise can: 

  • improve circulation to our extremities and warm up our cold hands and feet.
  • boost our energy and help with fatigue.
  • promote hormonal stimulation and enhance our sexual function.
  • increase our metabolism, burn fat, help us maintain a healthy weight, and prevent obesity.
  • balance our blood sugar, decrease insulin resistance, and help prevent diabetes.
  • improve our sleep by restoring normal body rhythms.
  • elevate our HDL (good) cholesterol and help protect us from heart disease.
  • decrease or normalize our blood pressure and help decrease the risk of stroke. 
  • improve our muscle tone, strength and endurance.
  • strengthen our bones, cartilage and ligaments and lower our risk for osteoporesis.
  • increase our serotonin and dopamine levels and help reduce anxiety and depression.
  • improve our mental function.
  • raise our endorphin levels (bodies' natural pain reliever).
  • reduce levels of our stress hormones, promote calmness and relaxation, and decrease the effects of stress on our bodies.

Types of exercise we should consider

To begin with, if you haven't exercised in a long time because of pain, fear of a migraine attack, or other health considerations, you should have a physical examination by your doctor or other health care professional. At your appointment, you might want to ask for a consultation with a qualified physical therapist to plan and initiate an exercise program that is best for your situation. Also, if you pick an exercise that is new to you, always seek guidance from a qualified instructor to learn the proper technique. 

Keep in mind, any form of activity that moves our bodies, increases the work of our heart and lungs, and burns calories is considered exercise. These activities include walking, running, gardening, climbing stairs, working out at the gym, sports, swimming, hiking, biking, dancing, yoga and tai chi.   

That said, for those of us with migraine, the type of exercise we choose, apart from the overall health benefits, may be significant in either reducing the frequency and severity of our migraine attacks or precipitating a migraine attack. Low - to moderate - intensity exercises such as walking, cyling, and yoga, as well as sports that rely on endurance rather than power like, swimming, jogging, and tai chi are thought to decrease the frequency and severity of our migraine attacks by:

  • increasing our serotonin levels.
  • raising our endorphin levels.
  • helping in stress reduction.

Here, it is interesting to note, "A Study to Evaluate the Feasibility of an Aerobic Exercise Program in Patients With Migraine", (Varkey et al, 2009), demonstrated moderate-intensity exercise (indoor cycling), including warm-up and cool-down periods, was well tolerated by the patients. Patients were reminded to consider stress, proper sleep, good nutrition and hydration during the study. 

Another study aimed to evaluate the effects of exercise in migraine prevention (Varkey et al, 2011) showed exercise (based on indoor cycling) was found to be equal to the well-documented methods of relaxation and topiramate with regard to the reduction of migraine frequency. The report goes on to say this non-pharmacological approach may be a treatment option for patients with migraine, who do not benefit from or do not want to take daily medication. And, adds "from a wider health-based perspective, it should be stressed that patients with migraine are less physically active than the general population, and that exercise has positive effects in terms of general well-being and the prevention of disease."

In addition, a pilot study, "Aerobic exercise as a therapy option for migraine," (Darabaneanu et al, 2011), showed migraine patients in the exercise group (running program) had both a reduction in the number of migraine days per month and the intensity of attacks. As well, the increase in fitness level resulted in a lowered stress level. 

Now, we need to know that strenuous and high-intensity exercises such as running, jumping rope, and heavy weight lifting, as well as sports that include short bursts of speed alternated with periods of moderate-intensity like singles tennis, basketball, and soccer, are believed to precipitate or aggravate our attacks because: 

  • although they increase our endorphins, they also increase our epinephrine levels heart rate and blood pressure.
  • if prolonged, the increase in our epinephrine levels may propel our bodies into the "fight or flight response" and decrease our serotonin levels.
  • some exercises, like heavy weight lifting, may cause muscle tightness or spasms in our upper body.

Here, it is interesting to note, a recent study investigated the lifetime prevalence of exercise-triggered migraine (ETM) attacks and if patients with ETM experienced specific prodromal or ictal migraine symptoms (Koppen and vanVeldhoven, 2013). Results included

  • life time prevalence of ETM attacks was high regardless of migraine type (with or without aura) or gender.
  • possible rise in cardiac output and systolic blood pressure triggers ETM attacks.
  • those experiencing ETM attacks more frequently had neck pain as the initial symptom explained by activation of upper cervical nerve fibers and release of neuropeptides.
  • higher brain lactate levels were associated with higher migraine frequency and could explain the triggering of migraine attacks by high-intensity exercise.
  • the majority of patients stopped practicing high-intensity exercise, but were able to continue other low-intensity exercise.

In my case, this study is enlightening. I have had migraines since I was five years old and participated in high-intensity exercises and competitive sports until my migraines became chronic. Whether it was running, singles tennis, downhill skiing, or hiking with a backpack, I always got zapped with a migraine attack, often accompanied by intolerable nausea and vomiting. It wasn't until my migraines became high episodic to chronic that I noticed the aggravating neck pain. At that point, I was forced to reduce my activities to walking, as well as a routine of light weight lifting, to keep my cardiovascular risk factors under control and maintain muscle tone and bone density.  

"Movement is a medicine for creating change in a person's physical, emotional, and mental states."  - Carol Welch

For those of us with migraine, lack of movement because of migraine attacks deprives us of a valuable health activity, along with participation in the sports we enjoy, and negatively affects our physical, emotional, and mental states. On the other hand, low-to -moderate intensity exercises may decrease the frequency and intensity of our attacks and help us enjoy the benefits of better overall health and quality of life. So, to exercise, or not to exercise? It would seem, the delicate balance lies within us as individuals.

A few other things to keep in mind include

  • if we feel a migraine coming on, a short walk in the fresh air might help.
  • exercising during a full blown attack may be extremely painful and is probably best avoided.
  • if we can't talk without stopping for a breath during any form of exercise, then the activity it is too strenuous or intense.
  • exercising in the heat is not wise as the activity may trigger a migraine from heat intolerance.
  • stay hydrated, and avoid hypoglycemia.
  • wear a hat and sun glasses when exercising outdoors.
  • should not exercise close to bedtime as it may interfere with sleep.
  • pick something fun.
  • set realistic goals and, given our unique situations, do what we can do to achieve them.

Keep in mind, aerobic (cardiovascular) recommendations for moderate-intensity exercise include at least 30 minutes of the activity per day, repeated 5 days a week, along with strength and stretching exercises twice a week for flexibility and stamina. However, we can break up our activities into fifteen minute periods, three times a day, and achieve the same benefits. Then, increase the time as we get stronger. As well, walking is a great way to start. 

Note:

This article is part of the series "Bridging The Gap Between East and West: Principle III: Exercise For Optimal Health With Migraine".

Sharron :).

References:

Buse, D.C., Manack, A., Serrano, D., et al. (2010). "Sociodemographic and comorbidity profiles of chronic migraine and episodic migraine sufferers." J Neurol Neurosurg Psychiatry. Apr;81(4):428-32. doi: 10.1136/jnnp.2009.192492. 

Buse, D.C., Silberstein, S.D., et al. (2013). "Psychiatric comorbidities of episodic and chronic migraine." J Neurol. Aug;260(8):1960-69. doi: 10.1007/s00415-012-6725-x.  

Darabaneau, S., Overath, C.H, et al. (2011). "Aerobic Exercise as a therapy option for migraine: a pilot study". Int J Sports Med.  Jun;32(6):455-60. doi:10.1055/s-0030-1269928.

Katsarava, Z., Buse, D.C., et al. (2011). "Defining the Differences Between Episodic Migraine and Chronic Migraine." Curr Pain Headache Rep. February; 16(1):86-92.                 

Koppen, H., & van Veldhoven P., LJ., (2013). "Migraineurs with exercise-triggered attacks have a distinct migraine." The Journalof Headache and Pain. 14:99 doi:10.1186/1129-2377-14-99.    

Murray, S., M.S., R.N., Migraine; Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life - An Integrative Self-Care Plan For Wellness. San Francisco: Conari Press, 2013.

Ni. M., L.Ac., D.O.M., PH.D. Secrets of Self-Healing. New York: Avery, 2008.

Varkey, E., RPT, Cider, A.,RPT et al. (2009). "A Study to evaluate the feasibility of an aerobic exercise program in patients with migraine." Headache."  Apr;49(4):563-70. doi: 10.1111/j. 1526-4610.2008.01231.x. 

Varkey, E., Cider. A., et al. (2011). "Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls." Cephalalgia. October; 31(14): 1428-1438. doi: 10.1177/0333102411419681.

Sharron is a health and wellness author. A person with migraines herself, her most recent book is "Migraine.." (see references)

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN, and her website www.sharronmurray.com

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional.

Copyright 2014, Sharron E. Murray

Tuesday
Apr222014

Effective use of medications for migraine relief -5 Ways to overcome unmet needs and improve our treatment outcomes

 

"Half of the modern drugs could well be thrown out of the window, except that the birds might eat them." -Martin Henry Fischer

In the throes of a violent migraine attack, we all want a drug that will eradicate our pain. Unfortunately, for many of us, such a drug does not exist. In an effort to relieve our pain, we plow through unpleasant side effects of our medications, may exceed the recommended dose of one or more of the drugs we take, accidentally take too much of a drug, or take a medication more often than we should and end up with medication overuse headaches (MOHs). We become vulnerable to anything, or anyone, that offers to put an end to our agony in the name of a "cure" and, in our frustration, may feel like tossing the lot of our medications out the window.

In an important step toward reducing barriers to our care and improving treatment outcomes, a recent study examined  unmet treatment needs among persons with episodic migraine (Lipton, Buse, et al, 2013). Results showed the three most common unmet needs were:

  • moderate or severe headache-related disability,
  • treatment dissatisfaction related to efficacy (effectiveness), safety and overall satisfaction of a comprehensive list of acute and preventive medications, and
  • excessive opiods and/or barbiturate use or probable dependence.

To help us overcome these unmet needs and achieve optimal therapy, this article adapts physician guidelines for successful migraine management (American Headache Society, PDF), as patient-centered strategies. Let's take a look:

1. Establish a partnership with our physicians:

  • The role of our physicians is to help us understand the nature and mechanism of migraine disease and the non-pharmacological and pharmacological options that are available for treatment. In other words, our doctors are guides to help us make wise choices for our migraine treatment programs, including how they fit into our overall health.
  • Our role as patients is to reach the best possible decision about choices for treatment through an educated discussion with our doctor. This should involve an evaluation of our lifestyle, as well as attitudes and beliefs about taking medication (side effects), herbs , and supplements .

 2. Educate ourselves:

  • To facilitate an educated discussion, ask questions and encourage a dialogue with our physicians.
  • Listen to the answers with an open mind.  For example, you may want a medication your doctor denies out of concern for your overall health, or that the medication may harm you. In my case, the best thing a doctor ever did for me was tell me he wouldn't refill my Imitrex prescription for 18 pills a month.
  • If you are confused about the information your doctor relays, ask for clarification. Knowledge gives us a feeling of empowerment and helps us actively participate in our management program. In the same example, this stunning news came in a visit to a new doctor. When I asked for clarification, he told me I had MOHs (known as rebound at that time) and we would have to explore other ways to manage my attacks.

3. Work with our physicians to set realistic goals

  • While being completely pain-free might not be an option, decreasing the severity of pain and frequency of attacks is achievable.
  • Given our individual situations, identify ways to reduce the frequency of our attacks and limit the negative effects of migraine on our daily lives. In my case, my doctor and I decided that I needed to be more diligent about trigger management; eating and sleeping habits; participation in the biofeedback and diaphragmatic breathing exercises I had been taught, but rarely practiced; and, give acupuncture a chance. As well as decreasing the frequency of my attacks, this plan allowed me to wean off Imitrex at my own pace, without any harmful effects.
  • If preventive medication is going to be part of our therapies, identify side effects that we find intolerable. In my situation, I have a condition, which makes me blister from many preventive medications, including antiepileptics. As well, I like to exercise, which rules out beta blockers like propranolol. Other examples include, if weight is a problem for you, drugs with a high risk of increasing weight should be avoided.

4. Work with our physicians to establish a tailored, non-pharmacological treatment plan:

  • Keep a diary (notebook, electronic, or you can always mark up a calendar like I did) to help our doctors identify possible triggers and suggest strategies to help us minimize or avoid them.
  • A diary can also help our doctors recognize the frequency and patterns of our migraine attacks, identify the severity of our pain and functional disability; assess the effectiveness of our treatment; and, recognize the need to adjust doses, alter routes of administration, and add, or change our medications.
  • Adopt healthy lifestyle habits, including regular sleeping, eating and exercise patterns. 
  • Participate in stress management  and relaxation strategies such as cognitive behavioral therapy, biofeedback, meditation, and diaphragmatic breathing techniques. Besides helping us relax and decreasing the frequency of our attacks, some of these techniques can reduce gastric stasis and allow our medications to be absorbed faster. 
  • Keep in mind, although non-pharmacological therapies produce a slower response than pharmacological interventions, they allow us to have an active role in our program.
  • Note, non-pharmacological therapies are particularly important when we have comorbid conditions, such as cardiovascular disease, that may limit our drug options. 

5. Work with our physicians to establish a tailored, pharmacological treatment plan:

  • Given our individual situation and the frequency and severity of our attacks, our treatment plan may include acute and preventive treatment.
  • Acute treatment may involve over-the-counter (OTC) and prescription medications to treat our pain and other symptoms during an attack, such as aspirin; acetaminophen; non-steroidal anti-inflammatory drugs (NSAIDs); combination analgesics that contain caffeine, opioids and/or barbiturates*; neuroleptics/antiemetics; and, corticosteroids. As well, we may be prescribed medications to abort an attack at the onset or stop its progression to severe pain, such as triptans and ergotamines. Acute medications have been classified into categories related to their effectiveness (Marmura, M.J., Silberstein, S.D., & Schwedt, T.J., 2015).
  • We need to be aware that excessive amounts of acetaminophen can result in severe liver injury, while over indulgence in NSAIDs comes with increased risk of gastrointestinal and cardiovascular disorders. As well, using multiple drugs at the same time, alcohol consumption, and combining medications with herbs and supplements, without our doctor's knowledge, can increase can our risk for a number of other problems, including bleeding disorders and poor renal function.
  • If we use acute therapy more than 2 days per week, we need to talk to our doctor about preventive therapy to reduce our risk for MOHS, and the chance of progression to chronic migraine. Preventive therapy may be started earlier if triptans and ergots are contraindicated because we have vascular disease, or if our response to acute medication is poor.
  • Preventive treatment may involve long-term therapy with daily administration of prescription medications proven to be effective to decrease the frequency of our attacks. These medications have been classified into categories related to their effectiveness (Silberstein, 2012) and include: antiepileptic drugs, beta bockers, antidepressants, ACE inhibitors and calcium channel blockers. Currently, Botox (botulinum type A) is only approved as a preventive for chronic migraine.  
  • With preventive therapy, we need to be aware that unpleasant side effects may limit our tolerance and decrease our compliance. As side effects are different for every medication, we need to be sure our doctor communicates adverse effects on initiation of each medication. Some of the less tolerable adverse effects you might want to ask about include weight gain, memory loss, depression, and drowsiness. 
  • On the other hand, with preventive therapy, we need to know that if we work with our doctor to select a preventive medication that can work for comorbid disorders we may have, this can treat both (or more) of these illnesses at the same time. For example, if you have sleep disturbances, depression, or neck pain, amitriptyline may be a good choice; or, if you have hypertension and anxiety, a beta blocker may be the best medication for you. As well, a preventive medication should take our lifestyle into consideration; and, our doctor needs to be aware of all the medications, herbs, and supplements we take to avoid potential drug interactions.
  • If adverse effects become intolerable, we need to communicate this to our physician so the daily dose of the drug can be tapered down, eventually stopped and, perhaps replaced with one that is more acceptable.    

*A word about opioids and barbiturates

We need to be aware that recent studies show opioids do not work well in migraine. In assessment of the frequency of opioid use for acute migraine treatment (Buse, Pearlman, et al, 2012), results demonstrated opioids are associated with more severe headache-related disability; comorbidities like depression, anxiety, and cardiovascular disease; increased headache frequency, and, increased headache-related health care resource utilization. Other reports indicate opioids interfere with triptan effectiveness, increase response to pain stimuli (hyperalagesia), prevent reversal of migraine central sensitization and increase the progression of episodic to chronic migraine (Tepper, 2012, Johnson, Hutchinson, et al, 2013). In a review of MOH (Tepper, 2012), use of any opioids and barbiturates was reported to increase the likelihood of transformation (chronification) from episodic to chronic migraine. The report goes on to say opioids and butalbital should be avoided in acute migraine treatment. As well, we should know that data from the AMPP revealed opioid users were more likely to be occupationally "disabled" compared with nonusers and users with probable dependence were more likely to be "on disability" (Lipton, Buse, et al, 2013).       

Given the information addressed in this article, it would seem the role of effective communication between ourselves and our doctors is crucial to help us overcome our unmet treatment needs and achieve optimal therapy. For us, we need to listen to our doctors and respect them for their knowledge. For our doctors, they need to listen to us and know "the most important part of the patient is the person inside of the patient" (Girgis, 2014).    

Note:

This article is part of the series, " Bridging The Gap Between East and West: Principle II: Herbs, Supplements, and Medications for Maintaining and Restoring Optimal Health With Migraine."

Sharron :).

References:

American Headache Society. "Acute Migraine Treatment." PDF. Retreived May 5, 2014 from www.americanheadachesociety.org/.../NAP_for_Web_-_Acute_Treatment_of_Migraine.pdf

Buse, D.C., PhD.,  Pearlman, S.H., PhD., et al. (2012). "Opioid use and dependence among persons with migraine: results of the AMPP study." Headache. Jan;52(1):18-36. doi: 10.111/j. 1526-4610.2011.02050.x.  

D'Amico, D., Tepper, S. (2008). "Prophylaxis of migraine: general principles and patient acceptance." Neuropsychiatr Dis Treat." Dec;4(6): 1155-1167. Retrieved May 5, from  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2646645/

Girgis, L., M.D., (2014). "Marcus Welby versus the 21st Century." Medcity News.  

Johnson, J.L., Hutchinson, M.R., et al. (2013). "Medication-overuse headache and opioid-induced hyperalgesia: A review of mechanisms, a neuroimmune hypothesis and a novel approach to treatment." Cephalalgia. Jan;33(1):52-64. doi: 10.1177/0333102412467512. Epub 2012 Nov 9.

Lipton, R.B., M.D., Buse, D.C., PhD., et al. (2013). "Examination of Unmet Treatment Needs Among Persons With Episodic Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study." Headache. Sep;53(8):1300-11. doi: 10.1111/head.12154. Epub 2013 Jul 23.

Marmura, M.J., Silberstein, S.D., & Schwedt, T.J. (2015). "The Acute Treatment of Migraine in Adults: The American Headache Society Evidence Assessment of Migraine Pharmacotherapies". Headache. 55;(1):3-20.   

Murray, S., M.S., R.N. Migraine:Identify  Your Triggers, Break Your Dependence on Medication, Take Back Your Life. San Francisco: Conari Press, 2013.

Silberstein, S.D., M.D., F.A.C.P., Holland, S., PhD., et al. (2012). "Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults." Neurology.April 24;vol.78 no.17 1337-1345. doi: 10.1212/WNL.ObO13e3182535d20 

Tepper, S.J. (2012). "Opioids should not be used in migraine." Headache. May;52 Suppl 1:30-4. doi: 10.1111/j.1526-4610.2012.02140.x. 

Tepper, S.J., (2012). "Medication-overuse headache." Continum (Minneap Minn). Aug;18(4):807-22.doi: 10.1212/01.CON.0000418644.3203.

Sharron is a health and wellness author. A person with migraines herself, her most recent book is "Migraine..." (see references)

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS,RN, and her website www.sharronmurray.com

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please contact a qualified professional.

Updated, March 24, 2015.

Copyright 2014, Sharron E. Murray

Monday
Apr142014

The Hypothalamus, Homeostasis, and Migraine -"Rock steady down the line"  

 

There is no cure for migraine. However, the more we know about our disease, the more we are able to gain control over our attacks and our lives. 

A number of studies have associated migraine with several areas in the brain including the brainstem, the cortex, the thalamus, and most recently the hypothalamus. In this article, to gain more knowledge about the vulnerability of our "migraine brain" and how this sensitivity to change affects the frequency of our attacks, we explore

  • the hypothalamus and homeostasis, and
  • hypothalamic activity and migraine. 

HYPOTHALAMUS AND HOMEOSTASIS   

The hypothalamus is an endocrine gland located deep within the brain above the brainstem. The main function of the hypothalamus is to regulate homeostasis, or our bodies' equilibrium (balance). To maintain homeostasis, the hypothalamus controls and integrates the overlapping functions of our endocrine system and the sympathetic and parasympathetic branches of our autonomic nervous system (ANS). In addition, it is responsive to, and regulated by, transmissions from the neurotransmitters, norepinephrine (noradrenaline), dopamine, and serotonin.

Through these mechanisms, the hypothalamus regulates a number of our bodies' functions including

  • blood pressure and heart rate, 
  • fluid and electrolyte balance, 
  • body temperature, 
  • metabolism, 
  • digestion, 
  • hunger,
  • thirst, 
  • sleep-wake cycles, 
  • alertness, 
  • ovarian and testicular function, 
  • sex drive, 
  • emotions like anger and joy, and 
  • behaviors such as aggression. 

For example, take hunger. When our stomach is empty it releases the hormone ghrelin, which activates parts of the hypothalamus that makes us feel hungry. When we have eaten, the hormone leptin is released by the body's fat stores and causes the hypothalamus to inhibit hunger and create a feeling of fullness.

Another example of how the hypothalamus maintains homeostasis, and one that is critical to our survival, is our bodies' response to a real or perceived threat (stressor). In this instance, the hypothalamus takes charge and through the sympathetic branch of our ANS and the hypothalamic-pituitary-adrenal axis (HPA), tells our adrenal glands to release a flood of hormones including, but not limited to, epinephrine (adrenaline), norepinephrine (noradrenaline), and cortisol. Our heart rate, blood pressure, and respirations increase, our skeletal muscles tighten and get ready for action, and almost all of our other body systems gear up to fight the challenger. We feel focused, energetic, and alert and sleep is inhibited. We know this as the "fight or flight" stress response. When the threat has passed without harm, levels of our stress hormones, and in turn our bodies' systems, return to normal.

HYPOTHALAMIC ACTIVITY AND MIGRAINE

Recent studies and reports (Denuelle et al, 2007, Charles, 2013 and Maniyar et al, 2013) have shown hypothalamic activation with migraine. This hypothalamic activity is thought to be especially important in the premonitory (prodrome) phase of our migraine attacks and could explain many of the symptoms we experience including 

  • changes in mood,
  • alterations in wakefulness and alertness,
  • fatigue
  • food cravings,
  • yawning,
  • fluid retention, and
  • thirst.

Other arguments for hypothalamic involvement include

  • the circadian rhythmicity of the onset of migraine attacks, with a peak incidence in the early morning,
  • the fact that sleep disturbances like insomnia and prolonged sleep are migraine triggers, and,
  • the correlation of hormonal fluctuations with migraine frequency in females  (Denuelle, 2007).

Triggers

Although more research is necessary to determine where, how, and why our migraine attacks are triggered, it has been suggested that the key may lie in the hypothalamus as migraine is commonly activated by a change in homeostasis (Alstadhaug, 2009 and Maniyar et al, 2013). Given the number of body functions the hypothalamus regulates to maintain homeostasis, some examples of migraine triggers that may fall into this category include

  • magnesium deficiency,
  • hormonal fluctuations,
  • dehydration,
  • hunger- dieting, fasting, skipped meals (hypoglycemia),
  • change in sleep patterns (oversleeping, disrupted, inadequate),
  • fatigue (exhaustion) 
  • emotions,
  • fever,
  • allergies, illnesses like flu and colds, 
  • foods and beverages (Many of these can affect neurotransmiters like serotonin and glutamate. Those with additives, dyes, chemicals, MSG, and other artificial ingredients may cause sensitivities and inflammatory or immune reactions), and
  • stress*.

*Stress may contribute to the initial onset of migraine attacks in those of us with a predisposition to the disease. Other potential effects of stress on migraine are thought to include: can act as a trigger for migraine attacks, increase our susceptibility to other triggers; amplify attack duration and severity; increase attack frequency and the risk for progression to chronic migraine; and, as migraine itself can be a stressor, create a vicious cycle. We should know that recent studies have shown "increasing stress resulted in increasing headache days" and "there is a striking association between reduction in stress and the occurrence of migraine headaches".

Stressors

Given the stress response is an adaptive mechanism regulated by the hypothalamus to maintain homeostasis in the face of a real or perceived stressor, we need to take a closer look at stressors. In an in-depth report from the University of Maryland (Seekers, 2013) on the causes, diagnosis, treatment, and prevention of stress, common stressors are listed as: 

  • noise,
  • video games,
  • cell phones,
  • crowding,
  • loneliness,
  • hunger,
  • danger,
  • infection,
  • pain,
  • work pressures,
  • relationship problems, and
  • financial worries.

Health- related problems

The report goes on to say that if these stressors are persistent (chronic), they can wear out the HPA axis and increase our susceptibility to a number of diseases and disorders like heart disease, hypertension, asthma, obesity, diabetes, cancer, erectile dysfunction, decreased libido in women, menstrual irregularities, sleep disturbances, depression, anxiety and panic disorders, allergies, infections, and immune disorders like colds and flu. 

*For those of us with migraine, we need to be aware that some of these health-related problems can make us more susceptible to our migraine triggers. For example:

  • Persistent emotions like worry and fear related to job pressures, or unhappy relationships, can lead to alterations in our sleep patterns, fatigue,
  • Colds and flu can make us susceptible to dehydration and hypoglycemia, and
  • Menstrual irregularities can aggravate hormonal fluctuations and exacerbate our hormonal migraines.

Conditions and factors that may make us more likely to have health-related problems, influence our response to stress and make us at higher risk for stress

Conditions most likely to produce health-related problems are thought to include:

  • persistent stressors that a person cannot easily control such as work pressures and unhappy relationships,
  • persistent stress after an acute traumatic event, and 
  • persistent stress accompanying a serious illness.   

 Factors  that may influence a person's response to stress are thought to include:

  • people who have been abused in childhood - they may have long-term abnormalities in the HPA axis,
  • people who may over-respond to stressful events,
  • genetic factors that effect the relaxation response of stress, and 
  • immune regulated diseases such as rheumatoid arthritis may weaken the response to stress.

 Factors  that may make individuals at higher risk for stress are thought to include:

  • older age as the stress response may become less efficient, and there may be an increase in stressors like medical problems, loneliness with loss of spouse and friends, change in living situations and financial worries,
  • women, in particular working women whether married or single,
  • financial strain, especially with long-term unemployment and if there is no health insurance,
  • people who are targets of racial or sex discrimination, and
  • people who are less educated, divorced, widowed, isolated, lonely, and those who live in cities.   

*For those of us with migraine, additional conditions and factors to consider include 

  • fear of pain associated with a migraine attack,
  • whether one has enough medication to handle the pain,
  • whether insurance will cover the cost of medication,
  • fear of when an attack may occur, for example the first day of a new job or the onset of a vacation,
  • decrease in productivity because of migraines can increase work pressure,
  • loss of jobs because of the frequency of attacks can not only interfere with relationships, but  lead to persistent financial worries, and 
  • comorbid diseases and disorders.

Rock steady down the line

In an editorial, "Stress and migraine"  by Peter J. Goadsby, M.D., PhD, (2014), he says, "There is an emerging consensus that the migraine brain is vulnerable to change, such as sleep and stress, and therefore best kept stable."  In the study, "Reduction in perceived stress as a migraine trigger" (Lipton et al, 2014), the study co-author Dawn Buse, PhD, says "This study highlights the importance of stress management and healthy lifestyle habits for people who live with migraine". 

As I think about these statements, a quote by Dr. Alvin Augustus Jones comes to mind. "In the Soul Train Life, your daily routine is your rhythm for success. Never permit unscheduled events or unorganized passengers to derail your soundtrack. Rock steady down the line and always stay in beat with your heart."  

While researchers continue to define the exact relationship between the hypothalamus, homeostasis, and migraine, to help me understand my migraine brain, I think of it as the "Soul Train Life". Consistency in my daily routine is paramount to a successful wellness plan. Healthy lifestyle habits (e.g., eating and sleeping patterns, exercise) and stress reduction practices (e.g., biofeedback, meditation, guided imagery, and breathing techniques) help me keep "unscheduled events or unorganized passengers" (triggers and stressors) from derailing my soundtrack, or in other words setting off a migraine attack.

I hope, along with the information in this article, this analogy helps you understand more about your migraine brain, decrease the frequency of your migraines, and experience a more full, happy, and healthy life with migraine.   

Rock steady down the line,

Sharron :)

References:

Alstadhaug, K. B. (2009). "Migraine and the Hypothalamus". Cephalalgia.29(8): 809-17. doi: 10.1111/j.1468-2982.2008.01814.x http://www.ncbi.nlm.nih.gov/pubmed/19604254

Anderson, P. (2013, July 02): Migraine Really Is a Brain Disorder". Medscape Medical News.   http://www.medscape.com/viewarticle/807274?nlid=31945_1049&src=wnl_edit_dail&uac=206244BX

Charles, A. (2013). Migraine: A Brain State". Current Opinion in Neurology 26(3): 235-239. Retrieved July 5, 2013 from http://www.medscape.com/viewarticle/805027_3  

Chrousos, G. P. (2009). "Stress and Disorders of the Stress Syndrome". Nature Reviews Endocrinology. 5(7): 374-381. Retrieved June 30, 2013 from http://www.medscape.com/viewarticle/704866_print

Denuelle, M., MD., et al (2007). "Hypothalamic Activation in Spontaneous Migraine Attacks". Headache. 47(10):1418-1426. Retrieved April 4, 2014 from http://www.medscape.com/viewarticle/568627_print

Goadsby, P.J. (2014). "Stress and migraine". Editorial. Neurology. Published online before print March 26. as 10.1212/WNL.0000000000000349. http://www.neurology.org/content/82/16/1388.short  

Hypothalamus/Endocrine Awareness Center for Health. "The Hypothalamus Gland". Retrieved August, 2013 from https://eaware.org/hypothalamus-gland/

Lipton,R.L., M.D., Buse, D.C., PhD., et al (2014). "Reduction in percevied stress as a migraine trigger." Neurology. Published online before print March 26. http://www.neurology.org/content/early/2014/03/26/WNL.0000000000000332.short?rss=1

Maniyar, F.H., et al (2013). "Brain activations in the premonitory phase of nitroglycerin-triggered migraine attacks". Brain. 137(1):232-241. doi.1093/brain/awt320. First published online before print November 25, 2013. Retrieved April 12, 2014 from http://brain.oxfordjournals.org/content/137/1/232.short?rss=1 

Seekers, J. "Stress". ( 2013, June 26). University of Maryland Medical Center. Retrieved from http://umm.edu/health/medical/reports/articles/stress  

Sharron is a health and wellness author. A migraine sufferer herself, her most recent book, "Migraine: Identify Your Triggers, Break Your Dependence On Medication, Take Back Your Life- An Integrative Self-Care Plan For Wellness" (2013), is a Conari Press publication.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN and her website www.sharronmurray.com. 

This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified health care professional.

Copyright 2014, Sharron E. Murray

 

 

 

Saturday
Mar292014

MIGRAINE: What's Stress "Let-Down" got to do with it? And, did someone say-Stress management? 

 

"It isn't stress that makes us fall - it's how we respond to stressful events." Wayne Goodall 

To begin with, stress does not cause migraine. However, a number of studies have shown stress plays an important role in our migraine attacks, which are the episodic manifestations of our neurological disease. It is thought that stress is a contributing factor in the onset of our attacks, exacerbation and frequency of our attacks, and the progression of our episodic attacks to chronic migraine. As well, the headache associated with our migraine attack itself has been shown to be a stressor.

We need to be aware that a recent study, "Association Between Stress and Headache Frequency" (Schramm et al, 2014), showed, "increasing stress resulted in increasing headache days". The participants in this study experienced tension-type headache, headache in migraine, and headache in migraine with coexisting tension-type headache.

What is Let-Down Migraine?

Some studies have shown a reduction in stress to be responsible for the migraine attack known as a "let-down" or "weekend" migraine. In this instance, we need to know that a new study, "Reduction in perceived stress as a migraine trigger" (Lipton et al, 2014), shows reduction in stress from one day to the next is associated with migraine onset the next day.

In a report released by Albert Einstein College of Medicine (2014), the study lead author, Richard Lipton, M.D. stated, "This study demonstrates a striking association between reduction in perceived stress and the occurrence of migraine headaches." That said, to understand how a decline in perceived stress can trigger our migraine attacks, it is wise to be familiar with the stress response. 

Stress Response

To help me understand the stress response, I prefer to think of it in three phases:

  • Alarm,
  • Response, and
  • Relaxation. 

Let's take a look at each of these phases in a bit more detail.

Alarm phase

When we perceive a threat, environmental, chemical, physical, or emotional, our hypothalamus, an endocrine gland deep within the brain that controls and integrates the overlapping functions of the endocrine and autonomic nervous systems, takes charge.

Response Phase

If the threat does not go away, the sympathetic branch of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal axis (HPA) are activated and a flood of hormones are released from the adrenal glands to fight the "challenger" (stressor). These hormones include, but are not limited to, epinephrine (adrenaline), norepinephrine (noradrenaline), and cortisol. Our heart rate, blood pressure, respirations, and alertness increase; our senses become sharper; and, glucose and fats are released from storage sites in our bodies to provide energy. The function of our immune systems is enhanced and ant-inflammatory actions are increased to fight infection. As well, an increase in endorphins, our bodies' natural pain relievers, decreases our perception of pain. We know this as the "fight or flight" response, or acute phase, of stress. As long as the threat is perceived as dangerous, levels of these hormones stay elevated and we remain energized and on high alert. 

Relaxation phase

Once the threat has passed without harm, our parasympathetic branch of the (ANS) dampens our stress response and levels of our hormones return to normal. We may find ourselves fatigued, our minds and bodies exhausted. It is in this phase that our complaints show up. For example, if a stressor such as a traumatic injury has caused us pain and the sensation has been diminished, we feel it now.

For those of with migraine, we need to be aware that it is here, over 6 to 24 hours, when acute stress ends, HPA activation declines, and cortisol (glucocorticoid) and other hormone levels fall, a let-down migraine has been shown to occur. In addition, we should know that other factors and triggers may be responsible for an increased probability of a migraine in this phase. These include missed medications, skipped meals, dehydration, or disturbed sleep during the stressful event.

As I reflect on my forties, let-down migraines were the pattern of my life. I would power through a stressful event and the day after experience incredible fatigue, unexplained irritability and a debilitating headache phase accompanied by nausea and vomiting and several other associated symptoms. As the years passed, the stressful events, followed by the migraine attacks, increased. Without effective intervention, I rapidly progressed from episodic to chronic migraine and medication overuse headaches (Imitrex). 

"Hope is beng able to see that there is light despite all of the darkness." -  Desmond Tutu

Stress Management

To appreciate the necessity of stress management in our treatment programs, we need to know that migraine attacks with recurrent episodes of pain, central sensitization, and accompanying hormonal and inflammatory changes may alter our brain structure and function. The more frequent our attacks are, the more we are at risk for these changes.

In the study, "Association Between Stress and Headache Frequency", the authors mention in the conclusion  that their findings are important for tailored anti-stress treatment approaches in headache patients. In the study "Reduction in perceived stress as a migraine trigger", according to a report by Albert Einstein College of Medicine, the study co-author Dawn Buse, Ph.D., stated, "This study highlights the importance of stress management and healthy lifestyle habits for people who live with migraine".

Given this information, it is in our best interest to include stress management strategies in our migraine treatment programs to help reduce stress and decrease the frequency of our attacks. Techniques and therapies that helped me achieve these goals, and that I continue to practice daily to control my stress level and keep it from building up, include: positive thinking, prayer, daily biofeedback exercises, deep breathing techniques, diaphragmatic breathing, guided imagery, meditation, and healing touch (energy healing technique). As well, regular exercise (moderate) and acupuncture sessions are beneficial. Along with these, others that may assist you, include: cognitive behavioral therapy, yoga, tai chi, massage, physical therapy, chiropractic, reflexology and, energy healing techniques like Reiki. 

Although more research is necessary to provide evidence of effectiveness for some of these strategies, many of them have been shown to be effective by

  • relaxing tense muscles in our neck and shoulders,
  • reducing muscle spasm and inflammation and relieving pressure on adjacent nerves,
  • balancing the sympathetic and parasympathetic branches of our ANS and promoting calmness,
  • quieting our mind and calming our bodies,
  • stabilizing our stress hormones and neurotransmitters like serotonin,
  • increasing our endorphin levels,
  • balancing the flow of energy in our bodies,
  • increasing self-awareness, and
  • balancing our emotions.

We need to be be aware that these techniques and therapies have an even better effect when they are practiced at regular intervals over time; combined with trigger management, a healthy diet and lifestyle practices; and, for some people, with a preventive medication. As well, it is great for us to know that after initial instruction, a number of them can be practiced in the comfort of our own homes or offices to protect against increases in stress and keep our attacks at bay. 

Sharron :).

References

Albert Einstein College of Medicine (2014, March 27). "Migraine attacks Increase Following Stress Let-Down". Albert Einstein College of Medicine.

Lipton, R. L., M.D., Buse, D. C., PhD., et al (2014). "Reduction in perceived stress as a migraine trigger". Neurology. Published online before print March 26.

Schramm, S., Lehmann,N., Bock, E., Katsarava, Z., & Moebus, S. (2014). "Association Between Stress and Headache Frequency". Neurology. April 8, vol. 82 no. 10 Supplement S41.007.

Sharron is a health and wellness author. A migraine sufferer herself, her most recent book, "Migraine: Identify Your Triggers, Break Your Dependence on Medication, Take Back your Life-An Integrative Self-Care Plan For Wellness" (2013), is a Conari Press Publication.

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, M.S., R.N. and her website: www.sharronmurray.com   

This article is not intended as a substitute for medical advice. If you have any specific concerns about your health or nutrition, please consult a qualified health professional.

Copyright March 29th, 2014, Sharron E. Murray

Sunday
Mar162014

EFFECTIVE SUPPLEMENTS FOR MIGRAINE RELIEF

 

In general, our nutritional needs should be met through a healthy diet. However, for many of us with migraine, maintaining a healthy diet that meets our nutritional needs is a challenge. Food and beverage triggers, food cravings, nausea and vomiting, and comorbid diseases with diet restrictions of their own can limit our selection of items and absorption of nutrients.

You might want to ask your doctor for a referral to a nutritionist to help plan your diet and recommend appropriate supplements to avoid nutritional deficiencies if you

  • Find the task of selecting items suitable for your needs overwhelming
  • Have a number of comorbid diseases, and/or
  • Have poor renal or liver function.

That said, many of us seek help for migraine and headache relief through supplements, along with herbs and other complementary therapies, for additional reasons, including 

  • Dissatisfaction with our conventional medical treatment,
  • Unpleasant side effects from medications, and
  • The expense of medications.  

The most common supplements (nutraceutical options) we use to prevent and treat our migraine attacks are

  • Magnesium,*
  • Riboflavin (Vitamin B2),*
  • Coenzyme Q10 (CoQ10),* and
  • Fish oil.  

Keep in mind, while evidence for the effectiveness (efficacy) of some of these supplements is increasing, more research is necessary to establish evidence-based guidelines for others. That said, let's take a closer look at each of them.

Magnesium

Magnesium is a mineral in our bodies that is important for a number of functions, including

  • Protein synthesis,
  • Neuromuscular function,
  • Regulation of nerve cells (calms our nervous system)
  • Regulation of blood sugar
  • Maintenance of vessel tone (keeps our blood vessels from going into spasm), and
  • Regulation of the neurotransmitter, serotonin.

A number of studies have shown that people with migraine have low levels of brain magnesium during attacks. As well, many sources report that we may have lower levels of serum magnesium than others. Additional reasons that may be associated with magnesium deficiency are

  • A diet lacking in magnesium (foods high in magnesium include whole, unprocessed foods such as green, leafy vegetables, nuts, wheat germ, bananas, soy products, milk, and unrefined grains),
  • Alcohol intake as may deplete magnesium from the body,
  • Caffeine intake as may deplete magnesium from the body,
  • Menstruation as levels drop right before onset, and
  • Comorbidities that may also exhibit magnesium deficiency such as mitral valve prolapse, anxiety disorders, and epilepsy.

Symptoms of magnesium deficiency include irritability, agitation, anxiety,confusion, insomnia, restless leg syndrome, muscle spasms, twitching, seizures, weakness, poor coordination, nausea and vomiting, irregular heart rate and rapid heart rate.

Although the most common side effect of magnesium replacement is diarrhea, you should be aware that too much magnesium can lead to toxicity. Symptoms may include hypotension, flushing, slow heart rate, lethargy, drowsiness, respiratory paralysis and death.

As well, you need to know that many medications can interfere with blood levels of magnesium such as diuretics, some antibiotics, calcium channel blockers and other blood pressure medications, chemotherapy drugs, steroids, hormone replacement therapy, and digoxin. In addition, if you have poor renal function you must be careful with magnesium intake as you are unable to excrete excessive amounts via your kidneys. 

Riboflavin (Vitamin B2)

Riboflavin is a water-soluble vitamin that is important for a number of functions in our body, including

  • The breakdown of proteins, fats, and carbohydrates, and
  • Maintenance of the body's energy supply.

It is thought that mitochondrial dysfunction (mitochondria generate the energy for other cells to do their jobs, including those in the brain) and impairment of energy production, may play a role in migraine pathophysiology (Sun-Edelstein and Mauskop, 2011). Some studies have shown that riboflavin, through enhancing mitochondrial function, may help decrease the frequency and severity of migraine attacks. 

Foods high in riboflavin include milk, cheese, eggs, nuts, enriched breads and cereals, whole grains, mushrooms, sweet potatoes, and leafy green vegetables.

Side effects of riboflavin replacement are thought to be minimal. Apart from bright yellow urine, diarrhea may occur.

Coenzyme Q10 (CoQ10)

Coenzyme Q10 is a vitamin-like substance found throughout the body that is thought to

  • Provide energy to cells, and
  • Have antioxidant effects.

Because of its role in mitochondrial function and energy generation, it is believed to work against migraine in much the same way as riboflavin.

Mild side effects of CoQ10 replacement may include loss of appetite, nausea, vomiting, diarrhea, and rash.

Because some sources report that CoQ10 may decrease blood pressure, you should discuss the use of this supplement with your doctor if you are taking

  • High blood pressure (antihypertensives) medications like captopril, diltiazem, and many others.
  • Preventive medications for migraine like beta blockers and calcium channel blockers that may affect your blood pressure.

Because some sources indicate CoQ10 may  increase the risk of bleeding when taken with drugs that increase bleeding, you should discuss this supplement with your doctor if you are taking drugs like advil, ibuprofen, and naproxen. As well, you should discuss this supplement with your doctor if you are taking Coumadin, which is used to slow blood clotting, since CoQ10 may interfere with the effectiveness.

Fish Oil (Omega-3)

Fish oils come from fatty fish. Fatty fish are believed to contain omega-3 (Eicosapentaenoic acid). EPA is thought to

  • Reduce inflammation and swelling,
  • Relax blood vessels, and
  • Inhibit platelet clumping (blood clotting).

Fish richest in EPA are those that inhabit deep, cold water such as tuna, salmon, trout, sardines, herring, and mackeral.

Some studies have suggested that omega-3 may help to decrease the frequency and severity of migraine attacks by affecting prostaglandin levels and serotonin activity.

Because EPA is thought to inhibit platelet clumping, it should not be taken with other blood thinning herbs and medications without your doctors approval. As well, it should be discontinued one-two weeks prior to surgery, or other invasive procedures that may cause bleeding. Please check with your doctor for specific directions.

*You should know that the evidence-based guidelines for NDAIDS and other complementary treatments for episodic migraine prevention in adults have been retired by the AAN Board of Directors on September 16, 2015, due to serious concerns with a preventive treatment butterbur, recommended by this guideline.  Retired guidelines are no longer considered valid and are not supported by the AAN. Retired guidelines remain on their website for reference use only.

Note:

This article is part of the series "Bridging The Gap Between East and West: Principle II: Herbs, Supplements, and Medications For Maintaining and Restoring Optimal Health With Migraine." 

Sharron :).

References:

Murray, S., M.S., R.N. Migraine:Identify Your Triggers, Break Your Dependence on Medication, Take Back Your Life. San Francisco: Conari Presss, 2013.

NIH  National Institute of Health. (2011, October 21). Co-enzyme Q-10: MedlinePlus Supplements. Retrieved March 18, 2014 from http://www.nlm.nih.gov/medlineplus/druginfo/natural/938.html.

Sun-Edelstein, C., M.D., & Mauskop, A., M.D. (2009). "Foods and Supplements in the Management of Migraine Headaches". Clin J Pain. Volume 25, Number 5. pp 446-452. Retrieved from www.clinicalpain.com.

Sun-Edelstein, C., M.D., & Mauskop, A. M.D. (2011). "Alternative Headache Treatments: Nutraceuticals, Behavioral and Physical Treatments". Headache. March, 2011. pp 469-483.

Sharron is a health and wellness author. A person with migraine herself, her most recent book is "Migraine (see references)".

Follow Sharron on twitter @murraysharron, her Facebook page: Sharron Murray, MS, RN and her website www.sharronmurray.com.

This article is not intended as a substitute for medical advice. If you have specific concerns about your health or nutrition, please consult a qulaified health professional.

Updated February, 8th, 2016

Copyright 2014, Sharron E. Murray