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A Better Route to Migraine Relief

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Migraines are severe, disabling headaches that affect up to 17 percent of women and six percent of men. The disorder has many variants, often making diagnosis difficult. Migraines can be excruciating for patients, incapacitating them for hours or days at a time. They are also frustrating for doctors, who often find that the condition resists their best efforts at treatment.

Fortunately, conventional management of migraines has improved dramatically over the past 10 years. An integrative approach - combining the best of these conventional techniques with evidence-based natural approaches -- can make a tremendous difference in reducing frequency and severity of attacks.

What are the symptoms of migraine headaches?
The classic, "textbook" migraine is a one-sided severe, throbbing headache, which can be preceded by some sort of "aura" (visual disturbances), and accompanied by nausea and vomiting, along with sensitivity to light and sound. Headache pain worsens with physical activity and usually interferes with normal functioning. Frequency can vary from several times a month to once a year; intensity varies as well. If left untreated, a migraine can last from a couple of hours to several days.

Not all migraine symptoms are the same, and most individuals do not experience auras. Those who do report a variety of visual sensations such as seeing spots or flashes of light, bright zigzagging lines across the field of vision, or blind spots. Other sensations can include numbness and tingling in the extremities, and, rarely, weakness or speech problems mimicking a stroke or transient ischemic attack (TIA).

Before a migraine occurs, a person can experience premonitions or "prodromes" that may include feelings of elation or intense energy, carbohydrate cravings, excessive hunger or thirst, and sleepiness, irritability or depression. These can occur several hours or even a day or two before headaches occur.

What are the causes of migraine headaches?
The exact mechanism of action of migraine headaches isn't fully understood. There are no true nerves for pain in the area where it is experienced. Pain and discomfort of this nature ultimately comes from blood vessels in the head that rapidly dilate and may become inflamed. Exactly how this happens is far from clear, but there are several plausible theories.

Some researchers believe migraines arise from functional changes in the trigeminal nerve, one of the main facial nerves that also houses a major pain pathway. Others think it comes from imbalances in the neurotransmitter serotonin, which plays a regulatory role for pain messages going through the trigeminal nerve.

The vascular instability that is the immediate cause of migraines is influenced by many factors. Food sensitivity often plays a role, since in many sufferers specific foods trigger attacks. Hormonal fluctuations are a factor, at least in women. While pregnancy tends to prevent migraines, birth control pills can elicit them. Stress is clearly involved as well, as is heredity. It may be impossible to disentangle all the elements that lead to migraine in an individual case.

Typical food triggers include aged cheeses and processed meats (particularly pepperoni and hot dogs); peanuts; bread and crackers containing cheese as well as any strong-flavored cheeses; broad beans, peas, and lentils; and beverages containing caffeine and chocolate. Wine is another culprit (red is usually more problematic than white). Fermented foods including soy sauce and miso have been implicated, as have some fish including sardines, anchovies, and pickled herring. Other foods that have been linked to migraines include avocados, bananas, citrus fruits, figs, raisins, red plums, and raspberries.

Food additives that may play a role include nitrates and nitrites (in processed meats), yellow food coloring, and monosodium glutamate (MSG) used in some canned or processed foods, as well as in Chinese foods and in soy sauce.

In addition, watch out for non-food triggers such as fatigue, lack of sleep (or sleeping too much), missing meals, changes in barometric pressure, and changes in altitude. Strong smells, such as those of paint, gasoline or heavy perfumes, and bright flashing lights can also trigger migraine symptoms.

What is the conventional treatment of migraines?
A variety of drugs are available that have been specifically designed to treat migraines. There are also several pharmaceuticals commonly used to treat other conditions that also help relieve or prevent migraines in responsive individuals.

Medications used to address migraines fall into two general categories: those that relieve pain, taken during migraine attacks to stop symptoms that have already started; and those that are taken regularly to reduce the severity or frequency of migraines.

Non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen are still first-line treatments for migraine attacks. Some over-the-counter drugs marketed specifically for migraines contain these compounds in combination with acetaminophen and caffeine. They can be effective for mild or intermittent headaches, but if taken frequently or for long periods of time, can lead to ulcers, gastrointestinal bleeding and "rebound headaches" - a headache that is just as strong, or worse, when the medicine is withdrawn.

A newer class of prescription drugs called triptans is now widely used and is especially effective when taken at the beginning of an attack. They come in oral, intranasal and injectable preparations, and although they are the drug of choice for severe migraines, they do have side effects that should not be discounted, especially in patients with heart disease or hypertension. Triptans act on serotonin levels and cause blood vessels to constrict, which counters the blood vessel dilation leading to migraine. Side effects include nausea, dizziness, muscle weakness and, rarely, if vessels narrow too much, stroke and heart attack can occur in susceptible individuals. It is important to be under close medical supervision when using drugs in this class.

Ergotamine preparations have been used for over 60 years and were commonly employed before triptans became available. They are less expensive with fewer side effects, but are also not as effective as the triptan medications.

Anti-nausea drugs are also commonly used in combination with treatments for other symptoms, and medications that combine the sedative butalbital with aspirin or acetaminophen have been used in the past to treat migraine attacks. Some combinations also include caffeine. These medications, however, have a high risk of rebound headaches and withdrawal symptoms and should be used infrequently.

In addition, medications containing narcotics such as codeine and hydrocodone are often used to treat migraine pain during acute situations (often in urgent care settings) or when people can't tolerate triptans or ergotamines. These drugs are habit-forming, can cause rebound - and should be used only as a last resort.

Preventive medications that help regulate blood vessel tone and activity, like beta blockers, calcium channel blockers and other anti-hypertensives, can often reduce the frequency, severity and length of migraines and may increase the effectiveness of symptom-relieving medicines used during migraine attacks. Certain antidepressant medications can help prevent migraines as well, as can some anti-seizure drugs, namely Depakote, Neurontin and Topamax. Side effects may include dizziness, drowsiness, lightheadedness, stomach upset, and weight gain or even weight loss (in the case of Topamax). Your doctor may recommend taking preventive medications daily if migraines aren't being adequately treated or if a predictable, but unavoidable, trigger is approaching.

What therapies do I recommend for migraines?
Eliminate coffee (including decaffeinated coffee) as well as all other sources of caffeine from your daily routine. Make sure you are not taking any OTC or prescription drugs that contain it. Once you are completely off caffeine, you can try using coffee or other forms of caffeine as an effective and immediate treatment for migraine. Drink one or two cups of strong coffee at the first sign of an attack, then lie down in a dark, quiet room.

Eliminate dietary triggers of migraine and also avoid all artificial sweeteners, including aspartame (NutraSweet and Equal).

Experiment with the herb butterbur as a preventative. This plant (Petasites hybridus), native to Europe, northern Africa and southwestern Asia has been clinically studied. Results of a small study published in the May, 2000, issue of the journal Headache showed that an extract of butterbur root significantly reduced the frequency of migraine attacks among the 58 patients participating. If you decide to try it, avoid the crude herb, which contains toxic pyrrolizidine alkaloids (PAs). Instead, choose PA-free butterbur extracts standardized to contain a minimum of 7.5 mg of petasin and isopetasin. The adult dosage ranges from 50-100 mg twice daily with meals. Side effects are rare.

You can also try feverfew (Tanacetum parthenium), 100-150 mg daily of a product standardized to contain at least 0.2 percent parthenolides. This herb helps prevent the release of substances that dilate blood vessels in the head. You can stay on it indefinitely.

Another option is coenzyme Q10 (CoQ10). A study published in the February 22, 2005, issue of Neurology found that CoQ10 was superior to a placebo in preventing migraines. Researchers tested CoQ10 among a group of 43 patients, about half of whom received a placebo. Of the patients who took CoQ10, 50 percent reported significantly reduced frequency of headaches compared to only 14 percent of those who took the placebo. Dosage of CoQ10 in the trial was 100 mg three times daily.

Vitamin B2 (riboflavin) can also be helpful, as can magnesium. The recommended dose of riboflavin is 400 mg daily - a high dose, which needs to be prescribed by a physician.

You should first try these therapies individually, and allow enough time - usually six to eight weeks - to experience a change and then judge results before trying the next.

You can also experiment with the mind-body connection by taking a course of biofeedback. With practice, biofeedback can allow you to influence the part of the nervous system that regulates the dilation of blood vessels that contribute to migraine symptoms. Once you master this technique, it can be a tool you can use to abort a headache at the start of an attack.

Finally, if you continue to have attacks, try to change the way you think about the headaches. Migraine is like an electrical storm in your head - violent and disruptive, but leading to a calm, clear state in the end. You may, upon reflection, discover that it is not so bad to let yourself have a headache once in a while. It is a good excuse to drop your usual routine and go inward, letting accumulated stress dissipate. As you come to accept migraines in this way and see them as serving a purpose in your life, you may not have them so frequently.

Andrew Weil, M.D., is the founder and director of the Arizona Center for Integrative Medicine and the editorial director of www.DrWeil.com. Become a fan on Facebook, follow Dr. Weil on Twitter, and check out his Daily Health Tips Blog.

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