Managing Migraine

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By Joshua Hallett

According to my parents, I started suffering from migraines at the age of 3 or 4. It was not unusual for me to come and request ‘my bucket’ and a wet flannel so that I could escape to my dark and quiet room. At this age I was experiencing a migraine every fortnight, which resulted in throbbing head pain, nausea, sensitivity to light and sound as well as finishing with an episode of vomiting. This is a regular occurrence for around 10% of the population, to varying degrees, with varying symptoms, many of whom remain undiagnosed and untreated.

For me, this was the start of my journey to becoming a chiropractor – as it was with spinal manipulation, a still controversial treatment method both then and now that I found a gradual reduction in severity and frequency of my headaches to around one every 6 weeks. It was life changing, and it is the reason I am in my current profession.

With the addition of further management techniques my current record is 18 months without a migraine, but truly understanding migraine as more than just a headache is where I believe most sufferers should start. I have written a summary of some of the information I have picked up along the way to help anyone who may be suffering and is looking for ways to reduce their headache burden.

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Migraine is usually considered to be a severe form of headache – yet migraine is vastly more complex than this. Migraine has traditionally been thought to be a ‘vascular condition’. However, the research base now suggests that migraine is a result of the autonomic nervous system becoming unstable, with the primary disorder being a genetically inherited neurological condition.

The autonomic nervous system controls involuntary tasks which maintain the bodies internal environment such a heart rate, blood pressure, breathing, temperature regulation, sleep cycles, hunger levels etc etc etc. The autonomic nervous system is also well known for its two parts – the ‘fight and flight response’ and the ‘rest and digest’ system, which we hope are maintained in a delicate and healthy balance throughout our lives.

Considering this updated mechanism for migraine as an alteration to the autonomic nervous system, it is not surprising that not all migraine headaches are the same and that the triggers are multifactorial, rather than from a single cause. It is my hope that the below information can provide you with management options for you or loved ones to trial, which may reduce the severity, frequency or duration of migraine attacks.

Management Advice

Vitamin D

Up to 42% of migraine sufferers exhibit a deficiency in vitamin D. Having your vitamin D levels checked by your GP can be a good start (this can be done via a blood test) to see if you may benefit from a vitamin D supplement. Vitamin D3 is synthesized in the skin when exposed to sunlight. It is also found in oily fish (salmon, mackerel and sardines), eggs, fortified milk and you can even get a boost by leaving your mushrooms out in the sun before eating them!

Low vitamin D is better known for its association with osteoporosis, hypertension, cancer and autoimmune diseases. Vitamin D levels need to be between 75-140 nmol/L for optimal bone function and above 100 nmol/L for optimal neurological function. A daily supplement of 1000IU is typically recommended, although recent evidence suggests that a dosage of 4000IU may be needed to help raise levels to a normal concentration. I recommend discussing this with your GP, as measuring these levels before and after supplementation as well as during summer and winter will allow you to maintain balanced levels and avoid over supplementing.

Coenzyme Q10

Coenzyme Q10 is an essential element in the body’s energy creation system. A recent study recorded 61% of patients achieved a 50% reduction in frequency of migraine episodes by the end of a four month trial. It typically takes 5-12 weeks to achieve more than a 50% reduction, while taking cholesterol medication (statins) may deplete natural levels of CoQ10. Supplementation while on statins may actually reduce common side effects such as muscle pain and weakness. A daily supplement of 150-300 mg/day, or 2mg per kg of your total body weight daily, is recommended.

Water intake

Increasing water consumption to 2 litres per day is recommended. Many migraine sufferers know in advance to a migraine that it is about to occur. Increasing water intake during this period has been suggested may actually help to abort an attack. Apparently avoiding excessively cold water is also recommended with this approach!

Sleep

Sleep disturbance is a known trigger of migraine attacks, while migraine sufferers also experience a lower quality of sleep compared to others. Sufferers should regulate their sleeping patterns so they wake at the same time everyday even on weekends (9 hours per night is ideal). Doing this will help increase energy levels and improve your overall sense of wellbeing.

Rose coloured glasses

Glare and high frequency sunlight trigger migraine attacks. Wearing sunglasses, and in particular rose tinted sunglasses will prevent high frequency sunlight from over stimulating your nervous system and may help decrease migraine attacks. Utilising a blue light filter (such as f.lux) on your tablet, computer or smartphone during non-daylight hours further aids to reduce the effects of blue light on the arousal centres in our brains and promotes improved sleep quality.

Diet

Coeliac disease is an autoimmune gluten hypersensitivity that is 10 times more prevalent in migraine sufferers. If you are a migraine sufferer it is important to get tested. Antibody testing for Gliadin IgA and Tissue Transglutaminase IgA and IgG is a useful screen. Genetic testing for HLA-DQ82 and HLA-DQ8 is also helpful. However, the only 100% certain way to know if you have coeliac disease is to have a small bowel biopsy, as this is the ‘gold standard’ for diagnosis.

Different food types have been shown to cause migraine headaches, however we should be aware that sometimes we may also crave particular foods before a headache strikes which can be misleading. Foods such as chocolate, caffeine, MSG, aged cheese, ‘shelf-stable’ foods and alcohol are all well known migraine precipitators. Foods that are high in magnesium and B vitamins are likely to be protective and preventing migraine as supplementation has shown this response in different studies.

Magnesium

200 mg of magnesium per day might be useful in women with menstrual migraine. It is common for women to experience migraine before or during menstruation as this is when oestrogen and serotonin levels are low. It is also possible for some sufferers to experience mid-cycle migraine, which is related to increased serotonin levels and hyperexcitability of the brain and nervous system due to changes in neurotransmitters at this time. In this example, magnesium can be thought to balance either too much or too little activation of neural changes due to hormonal fluctuations.

Exercise

Exercise is as effective in treating depression as some antidepressants due to its role in producing serotonin which can be protective against migraine attacks. Exercise further aids in modulating autonomic activity and tone. Exercise is medicine and in cases of cognitive decline and blood sugar regulation the real benefit is received if the exercise is of high intensity, not so much long duration. To get the best bang for your buck, some authors recommend trialling once per day on an exercise bike – go 100% for 20 seconds, have a few seconds rest and repeat for 3 sets. This will give you the most neurological benefit possible according to these studies.

To add to this, migraine sufferers show abnormalities in their balance and posture, looking at exercise such as Pilates, Yoga and Tai Chi may also provide additional benefit to help improve stiffness and  balance dysfunctions that may provoke headaches. This can be even more important in individuals suffering from tension-type headache.

Physical therapy (spinal manipulation, dry needling, soft tissue work)

The part of the nervous system that stimulates your sympathetic nervous system (a.k.a the flight or fight response) are located at the top of the thoracic spine. We are only starting to truly understand what occurs following spinal manipulation and how this affects the nervous system. However, it is currently theorized that dysfunctional joints in the thoracic and cervical spine may provide a background level of irritation sufficient to precipitate a headache.

Mobilisation, trigger point therapy and dry needling applied to the upper cervical joints has continued to gain credibility in recent years. Especially if a clinician can press on the neck and recreate your headache, which then leads to resolution with sustained pressure. It is believed that therapy aimed at the upper neck region can help to desensitize a sensitised brainstem which acts as a trigger for headaches. This should not be viewed as a cure for headache and migraine but if your neck is acting as a trigger then physical therapy may help to reduce the frequency, duration and severity of your headaches significantly.

MTHFR gene

The MTHFR gene (C677T) mutation is commonly found in migraine sufferers. This gene mutation prevents methylation and is associated with symptoms of anxiety and depression. It is a worthwhile pursuit for migraine sufferers to get tested for this abnormality if they experience anxiety. If the mutation is found, folinic acid can be prescribed as a supplement to prevent any adverse effects of this pesky genetic mutation.

Stress relaxation techniques

It’s no secret that emotional stress can trigger headaches and some generic stress relaxation techniques are advised if you feel this might be contributing to your symptoms.

  • Controlled deep breathing (there are excellent resources on youtube for this)
  • Meditation (guided meditation can be a good introduction to this)
  • Completing a gratitude diary (positive thinking can be considered a trained skill)

This is in no way an exhaustive list and I have kept this intentionally brief as it is my belief that we should all be proactive with our mental health and further comment is outside of my scope of expertise.

It should be mentioned that migraine headache is a chronic pain condition and therefore how we think about these headaches can create further exacerbation. We are best to avoid worrying or ruminating about the possibility of headaches and if we are concerned that we may have something more sinister going on we should have this ruled out by our GP. This can go a long way to reduce anxiety and therefore reduce the severity and frequency of headaches. Cognitive behavioural therapy has also shown in some studies to result in a reduction of physical symptoms with migraine and headache.

Pharmacology

Generally I see patients taking over the counter medication which includes paracetamol, aspirin and ibuprofen. However, there are more advanced migraine specific medications that can be used. A class of drugs called triptans can be utilised as both a preventative medication or a ‘reactive medication’ at the onset of an acute attack. I recommend broaching this conversation with your doctor or neurologist to find out more. I will also mention caution as medication overuse can be contributing to headaches. Typically overuse can occur when using ‘reactive medication’ more than 15 days a month for more than 3 months. This can be as low as 9 days a month when using codeine, opiate & triptan medication and this is another discussion worth having with your general practitioner or medical specialist. A new class of drugs which interact specifically with proteins that play a role in the migraine attack continue to show promise although remain extremely expensive. MigraineAustralia.org can be another useful resource to find out more about ‘CGRP’ treatment options.

In cases considered to be chronic (>15 days per month) and who have failed preventer medications, Botox injections are the final treatment of choice.

Prognosis

Although there is no known cure for migraine at present, we must do our best to manage it so that it doesn’t majorly impact the lives of sufferers. Migraine makes up the 6th most burdensome disorder within our society for productivity lost. It should be appreciated that migraine is a multifactorial disorder that effects the nervous system and the scientific literature is still trying to better understand the role the upper neck (particularly irritation to C1-3 cervical region) has in triggering migraine attacks. Manual therapy, dry needling and acupuncture have all been shown to improve reported symptoms of pain and disability but need to be a part of a broader management plan.

From my person experience I would recommend supplementation. In particular I recommend Migraine Care by BioCeuticals as this contains Magnesium, CoQ10, B vitamins and folinic acid along with other ingredients known to reduce the impact of headaches.

Ultimately, the greatest relief may be found with behaviour modification and realising that sometimes different things may overload your nervous system and result in headaches or a full blown migraine attack. It is my hope that these management tips can help you or someone you love reduce the pain and disability of their current migraine condition.

References:

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  • A Shoeibi, N Olfati, M Soltani et al. Effectiveness of coenzyme Q10 in prophylactic treatment of migraine headache: an open-label, add-on, controlled trial. Acta Neurol Belg 117, 103-109 (2017).
  • V Gupta. A clinical review of the adaptive role of vasopressin in migraine. Cephalalgia 17(5), 561-569 (1997).
  • P Goadsby, P Holland, M Martins-Oliveira, J Hoffman, C Schankin & S Akerman. Pathophysiology of Migraine: A Disorder of Sensory Processing. Physiol Rev 97(2), 553-622 (2017).
  • D Watson, P Drummond. Head Pain referral During Examination of the Neck in Migraine and Tension-Type Headache. Headache 52(8), 1226-1235 (2012).
  • Budgell B, Polus B. The effects of thoracic manipulation on heart rate variability: a controlled crossover trial. J Manipulative Physiol Ther 29, 603-610 (2006).