Follow Sharron on Twitter

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.

 

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.

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 Murray, MS, RN is a Health and Wellness Author. 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. 

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 Murray, MS., RN, is a Health and Wellness author. 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 

Sunday
Mar092014

EFFECTIVE HERBS FOR MIGRAINE RELIEF


"Attack is often a word associated with migraine, and for good reason. If you suffer from headaches or know someone who does, you are well aware of its crippling nature" (Ahn and Goadsby, 2013).

It is this "crippling nature" of the headache phase of the migraine attack, which may or may not respond to medications, or as in my case cause us to take too much medication, that drives several of us to seek out complementary therapies like herbs and supplements. Because many of us use herbs and supplements in combination with medications, we need to be aware of interactions between the three and how to use them safely and effectively. 

Keep in mind, that while studies about the benefits of a number of herbs and supplements for migraine treatment and prevention are increasing, information about herb-supplement-drug interactions is limited. If you are pregnant or breast-feeding, have comorbid diseases or chronic conditions, and/or are taking over-the-counter (OTC) or prescription medications, you should always consult with your doctor before augmenting your migraine treatment program. As well, you need to be aware that any herbs or supplements that affect blood clotting should be discontinued at least one-two weeks prior to surgery or other invasive procedures that may cause bleeding, such as extensive dental work. Please check with your doctor for specific directions. For more information about how to use herbs safely, please see "Herbal supplements: What to know before you buy".

As well, remember that herbs, supplements and medications are only one part of an effective treatment plan for migraine. Many sources indicate that the foundation of any approach to migraine management, holistic or otherwise, should include trigger management, a healthy diet and nutrition, exercise, and healthy lifestyle habits to be successful. Perhaps Dr. Steven Herzog, M.D., member of the American Academy of Neurology (AAN) and medical director of the Headache Insitute at Texas Neurology in Dallas says it best when speaking about the migraine management puzzle. In an article in Neurolgy Now (Shaw, 2012) he is quoted as saying, "Lifestyle modifications such as exercise, good nutrition, and avoiding triggers-along with complementary therapies such as certain vitamins and supplements all have their place."

HERBS

Herbal medicine has been practiced for centuries in numerous cultures throughout the world. Today, there are a number of herbal preparations available OTC as tablets, capsules, gels, sprays, ointments, tinctures, elixirs (essential oils) and teas that are used to prevent and treat migraine attacks. Some of the more common ones, include:

Butterbur (Petasites hybridus)*

  • Thought to have anti-inflammatory properties
  • Believed to have an effect on vessel spasm and blood flow to the brain.
  • Side effects may include headache, indigestion, fatigue, nausea and vomiting, constipation or diarrhea.
  • Should not be used if you have kidney or liver disease, without your doctor's approval (butterbur plant contains pyrrolizidine alkaloids, which are carcinogenic and hepatotoxic so best to use products that are certified and labeled "PA-free").

Feverfew (Tancetum parthenium)*

  • Believed to have anti-inflammatory properties. 
  • Thought to inhibit platelet clumping (blood clotting), influence serotonin levels, and affect vessel tone.
  • Side effects may include abdominal pain, gas, nausea and vomiting, diarrhea, and nervousness.
  • May increase bleeding times so should not be taken with other blood thinning herbs and medications such as aspirin and Coumadin, without your doctor's approval.

Ginkgo Biloba

  • Thought to inhibit platelet clumping and affect blood flow to the brain.
  • May also have ant-inflammatory properties.
  • Side effects may include dizziness, upset stomach, diarrhea, mouth sores, or irritation around the mouth.
  • May affect insulin and blood sugar levels so should not be taken if you are diabetic, without your doctor's approval.
  • Like feverfew, it should not be taken with other blood thinning herbs and medications, without your doctor's approval.

White willow bark (Salix alba)

  • An analgesic with anti-inflammatory properties similar to aspirin.
  • Side effects are similar to aspirin and include stomach upset, ulcers, bleeding, ringing in the ears, and inflammation of the kidney.
  • Should not be taken with other analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs), without your doctor's approval.
  • Should not be taken with other drugs or herbs with blood thinning properties, without your doctor's approval.
  • May make beta blockers and diuretics less effective.
  • May increase blood levels of phenytoin (Dilantin).
  • Should not be taken if you are allergic to aspirin.
  • Should not be given to children as they may develop Reye's syndrome (a disorder that damages the liver and the brain).

Turmeric (Circuma longa)

  • Thought to have anti-inflammatory properties.
  • Thought to inhibit platelet clumping and affect blood flow to the brain.
  • Should not be taken with any other blood thinning herbs and medications without your doctor's approval. 

Ginger (Gan Jiang)

  • Is a calming herb with ant-inflammatory properties like aspirin.
  • May inhibit platelet clumping and affect blood flow to the brain.
  • Thought to help with nausea.
  • Should not be taken with other blood thinning herbs and medications, without your doctor's approval. 

Cayenne (Capsicum frutescens)

  • The main ingredient, capsaicin, is believed to have anti-inflammatory properties that may interfere with sustance P  (a neuropeptide thought to be involved in the pathophysiology of migraine).
  • Thought to affect blood flow to the brain.
  • Should not be taken with other blood thinning  herbs and medications, without your doctor's approval.

 Peppermint (Mentha piperita)

  • Is a calming herb with anti-inflammatory properties.
  • Is also a nasal decongestant and may relieve the sinus congestion associated with migraine.
  • May help with nausea and vomiting.

Lemon balm (Melissa officinalis), Valerian (Valeriana officinalis), and Skull cap (Scutellaria lateriflora)

  • Thought to help with muscle relaxation and sedation.
  • Should not be taken with opioids (narcotic), combination drugs that contain opiods and/or barbiturates, muscle relaxants, or other CNS depressants without your doctor's permission as can increase your risk for respiratory depression, hypotension, coma, and accidental overdose.

*You should know that the "Evidence-based guidelines update: NSAIDs and other complementary treatments for episodic migraine prevention in adults" have been retired by the AAN Board of Directors on September16, 2015, due to safety concerns with a preventive treatment, butterbur, recommended by this guideline. Retired guidelines are considered to be no longer valid and no longer supported by the AAN. Retired guidelines will remain available on their website for reference only. 

Chinese Herbs

Chinese herbs are classified as balancing, cleansing, or regenerating tonics, medicinal herbs, and potent medicinal herbs. Tonic herbs are used to support organ network functioning and prevent imbalances. Medicinal herbs are used to correct organ network imbalances and alleviate illnesses. Potent medicinal herbs are powerful healing agents used by licensed practitioners to treat more serious illnesses.

Herbs that may be used by a licensed practitioner to treat migraine may include chrysanthemum, angelica sinensis (Don Quai), gardenia, skullcap, motherwort, abalone shell, gamber vine, gastrodia, and China root. It is important for you to know that a variety of herbs are often combined into formulas unique to the individual. Therefore, they should not be transferred from one person to another as a combination that does not match your individual diagnosis and symptoms can be harmful. As well, to avoid interactions, your doctor should be aware of all the prescribed herbs you are taking and your practitioner should have a list of your medications.

Sharron:).

Note:

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

References:

Ahn, A.,H., M.D., PhD. & Goadsby, M.D., Ph.D. (2013). "Migraine and Sleep: New Connections." Cerebrum. Nov-Dec; 2013: 15 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3997296/ 

Bravo, T.P., & Vargas, B.B. (2015). "Migraine Preventative Has Safety concerns" Neurology Times". January 28th.  http://www.neurologytimes.com/headache-and-migraine/migraine-preventative-butterbur-has-safety-concerns 

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

Shaw, G. (2012). "Heading Off Migraine: What's the evidence for non-pharmaceutical approaches?" Neurology Now, Volume 8 -Issue3 - p 23-30. doi: 10.1097/01.NNN.0000415690.22156.f6 from http://journals.lww.com/neurologynow/Fulltext/2012/08030/Heading_Off_Migraine__What_s_the_evidence_for.17.aspx

Sharron is a health and wellness author. A person with migraines, 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 aubstitute for medical advice. If you have specific concerns about your health or nutrition, please see a qualified health care professional.

Updated February 8th, 2016

Copyright 2014, Sharron E. Murray