Overview and Pathophysiology
90% of all headaches are either migraine headaches, tension-type headaches, or a mixture of the two. The remaining 10% consists of disorders of tissues of the head and neck, sinuses, TMJs, dental structures, and soft tissues of trauma and post-trauma. Primary tumor, infection, and metastatic cancers constitute a small fraction of possible causes.
Red flag symptoms of life-threatening disorders: early morning headaches that awaken the patient, visual dimming or double vision, headaches that are increasing in frequency or severity over weeks to months, headaches worsened by postural changes, explosive onset of new severe head pain, and headaches associated with mental status changes, focal motor or sensory deficits, syncopy, seizures, fever, or stiff neck.
Recent evidence points to a role of potent vasodilators, such as substance P and calcitonin gene-related peptide, released by peripheral nerve endings of fifth cranial nerve on blood vessels in the scalp and meninges. This leads to sterile inflammation and edema of blood vessels, with increased sensitivity to mechanical stimulation, resulting in pain.
Glutamate, nitric oxide, and vanilloid receptors are also implicated in migraine. In the periphery, release of serotonin by platelets in the early stages seems to increase the pain and prolong the headache. Genetic influences are evident in a majority of patients.
Characteristics of migraine:
- Subacute onset of throbbing head pain (unilateral or bilateral) associated with nausea and vomiting, photophobia, or sonophobia.
- Headaches are heralded by visual or other auras in about 20 of those with migraine.
- The duration is usually more than 4 hours and may last up to 72 hours of fluctuating intensity.
- Precipitating factors include menses, specific foods, stress or letdown following stress, changes in weather, infection, fatigue, and bright sunlight.
Integrative Therapy: Nutrition
- A careful assessment of lifestyle issues related to sleep, nutrition, exercise, and stress management is important.
- Dietary choices clearly influence migraine. Regularity in the diet may be the key for migraine control. Dietary triggers are found in 8-20% of patients with migraine. Red wines, dark beers, aged cheese, some nuts, onions, chocolate, aspartame, and processed meats containing nitrates are common offenders.
- Caffeine excess can contribute to chronic daily headache. Caffeine withdrawal can temporarily exacerbate migraine or tension-type headache, whereas as caffeine taken during migraine can reduce pain in some patients due to its vasoconstrictive effects on the scalp and meningeal vessels.
- Obesity, metabolic syndrome, and inflammatory bowel disorders are associated with migraine and chronic headache perhaps related to the inflammatory associated with these conditions.
Integrative Therapy: Supplements
- Oral potassium magnesium aspartate (500-1000 mg/day at bedtime) may effective in the prevention of migraine reduction in cerebral cortical neuronal excitability. May cause diarrhea.
- Riboflavin (vitamin B2 200mg twice a day with meals) has a significant effect in prevention of migraine. It may also have synergistic preventive effects when used concurrently with a beta-blocker. Well tolerated. Urine color turns to intense yellow. Safe in pregnancy.
- Coenzyme Q 10 (300 mg/day) can reduce migraine attack frequency as much as 50%. Well tolerated and safe in pregnancy.
- Rational for use of omega-3 fatty acids in migraine prevention includes their anti-inflammatory properties, vascular relaxation effects, and inhibition of serotonin release from platelets. It is best to increase omega-3 acid levels from nutrition rather than as supplements.
Integrative Therapy: Botanicals
- Feverfew (125 mg/day) in as a well-designed study have shown a 70% reduction in frequency and severity of patients with migraine. The mechanism of action may be related to its inhibiting effects on platelet aggregation and inflammatory promoters or possibly its effect in dampening vascular reactivity to amine regulators of blood flow. Aphthous ulcers and GI irritation in 5-15% of its users.
- Melatonin (2-12 mg at bedtime) is used in the management of migraine to improve sleep and circadian rhythms. Sleep maintenance rather sleep induction with melatonin. Higher doses (greater 15 mg) are needed to acutely induce sleep over several days. Fatigue, drowsiness, abdominal cramps, and irritability are common side effects.
- Valerian (100-300 mg/day) is also useful for insomnia when taken at night with no significant residual drowsiness on awakening. It is non-addictive, and used as an anxiolytic when given during the daytime. The mechanism of action includes stimulation of the CNS gamma-aminobutylic acid (GABA) along with enhanced release and inhibition of reuptake of GABA. GI irritation is the most common side effect and has a very unpleasant smell.
Integrative Therapy: Preventive Pharmaceuticals
- The decision to start preventive therapy is based on headache frequency of more than two per month or more than 3 days per month lost to headache and willingness of the patient to take a medication for at least 3 months.
- Often patients achieve satisfactory results at doses well below the maximum, particularly with tricyclic antidepressants.
- Effective preventive agents allow time for patients to work on lifestyle issues, including management of stress, sleep, nutrition, exercise, as well as to develop life skills, such as relaxation, biofeedback, and self-hypnosis.
- Magnesium, vitamin B2, coenzyme Q10, and daily aspirin mix well with conventional preventive agents.
- Tricyclic antidepressants: amitriptyline 10-50 mg at bedtime and nortriptyline up to 100 mg at bedtime. Dry mouth, morning drowsiness, and constipation are significant side effects.
- Beta-blockers such as propranolol (60-180 mg daily), atenolol, and metoprolol are effective. Side effects include fatigue, depression, insomnia, dizziness, and nausea.
- Anticonvulsants are also effective as preventive migraine agents including gabapentin (Neurontin), topiramate (Topamax), zonisamide (Zonegran), and levetiracetam (Keppra). Topamax is the most consistently effective of the four most commonly used drugs in this class, but cognitive side effects and nausea can be limiting.
- NSAIDs are commonly used. Gastric side effects are common and patient compliance is poor.
- Botulinum toxin has been found to prevent migraine when injected in small quantities at multiple sites into the muscles of the forehead, temples, posterior neck, and the trapezius muscle. Effects last an average of 2-4 months.
Integrative Therapy: Abortive Pharmaceuticals
- NSAIDs: Ibuprofen (800 mg) and Naproxen (200-400 mg) can block headache progression when give the first few hours when headache is building. Individual variation in responsiveness to NSAIDs are high.
- Triptans (sumatriptan, rizatriptan, eletriptan, zolmitriptan, and almotriptan) are the most effective agents available for aborting migraine. They act bu blocking the release of inflammatory cytokines from the distal nerve endings of the trigeminal system onto the scalp and meningeal vessels and by their vasoconstrictive effects on the scalp vessel. Long-acting forms including nartriptan and frovatriptan can be effective when recurrent rates are noted with the more rapidly acting triptans. Triptans are contraindicated in pregnancy, cardiovascular disease, complex migraines, and poorly controlled hypertension. Side effects include transient pressure sensations in the chest, neck, and head. Cost is a major factor.
Integrative Therapy: Mind-Body Therapies
- Biofeedback has demonstrated effectiveness in treating both migraine and tension-type headache. Biofeedback may also enhance the effectiveness of preventive and abortive migraine medications. The training requires a significant time and commitment.
- Relaxation techniques including progressive muscular relaxation, focused breathing exercises, and guided imagery are as effective as biofeedback.
- Cognitive-behavior therapy a stress management approach designed to help patients identify maladaptive thought patterns and emotional states such as anger and anxiety that can precipitate and amplify headaches. Acknowledgment of present moments, shifting of habitual thought patterns, and modification of physiological responses are the key steps in this approach.
- Mindfulness meditation has been shown to have positive effects on mood, cardiac function, blood pressure, and muscle tone when practiced regularly. Effects are believed to be mediated by the development of nonjudgmental awareness of feelings, thoughts, and sensations combined with a sense of gratitude while optimizing the sympathetic and parasympathetic nervous system balance.
Integrative Therapy: Biomechanical Therapies
- Chiropractic and osteopathic manipulation approaches are often used for patients whose migraine have a cervicogenic or musculoskeletal component. Review of recent articles found evidence in support of effectiveness of spinal manipulation for episodic and chronic migraine but not tension-type headache.
- Massage and trigger point therapies can be useful as adjunct to biofeedback and relaxation training when there is significant reactive muscle tension in the upper body with limitation of head and neck movement.
Integrative Therapies to Consider
- For acute therapy, consider aromatherapy (lavender, rosemary, peppermint, chamomile, and eucalyptus), therapeutic touch, sleep induction with oral hypnotic, methylprednisolone IV, and valproic acid.
- For prevention, consider yoga, tai chi, reiki, craniosacral therapy, naturopathy, and ayurvedic medicine.
- Tension-type may exist in a spectrum of migraine.
- History and physical examination suggest intermittent muscle traction of pain-sensitive tendons and connective tissue of the head and neck.
- Pain is typically bilateral, non-throbbing, and band-like, with trigger points at the base of skull, temples, masseters, and forehead. Also, the pain is slow in onset and intermittent with little or no nausea or sensory sensitivity.
- Positive responses to NSAIDs suggest that inflammatory and myofascial influences dominate, with modest secondary contributions from vascular structures.
Treatment of Tension-Type Headache
- There is considerable overlap with migraine in an integrated treatment approach to tension-type headaches.
- Lifestyle issues surrounding stress, sleep, exercise, and diet are central to effective management and all need to be reviewed carefully for both work and home environments.
- Examination of TMJs is important in all patients because daytime clenching, nocturnal bruxism, and joint disease can all contribute to pain of tension-type headaches.
- Patient education in ergonomics, posture, and breathing if often useful in treating tension-type headaches.
- Mind-body approaches and hypnosis can be usefully integrated with conventional therapies.
- Patients should be strongly encouraged to reduce consumption of sugar, caffeine, and red meat along with increasing omega-3 fatty acids to reduce the sympathetic nervous system activity and enhance the production of anti-inflammatory prostaglandins. Foods that are very in omega-3 include mackeral, salmon, cod liver oil, herring, oysters, sardines, anchovies, caviars (fish eggs), flax seeds, chia seeds, and walnuts.
- Drugs (NSAIDs and muscle relaxants) have a limited role because of rebound headaches and the tendency to reduce motivation to attend to needed lifestyle adjustments.
- Some benefits reported with osteopathic and chiropractic manipulation.
- Acupuncture is associated with significantly improved clinical outcomes.
- The current evidence clearly suggests that acupuncture is effective as adjunct to usual care in the treatment of migraine, but the degree to which placebo effects contribute to this efficacy is unknown.
- Acupuncture points are selected by combining local points with distal points according to the headache and the channels affected.
- Occipital headache: GB 20, UB 60 SI 3.
- Frontal headache: ST 8, Yingtang, GV 23, LI 4, ST 44.
- Temporal headache: Taiyang, GB 8, TH 5, GB 41.
- Parietal headache: GV 20, SI 3, UB 67, LV 3.
- Hyperactivity of Liver Yang: LV 2, GB 34.
- Deficiency of qi and blood: CV 6, ST 36.
- Both wet and dry cupping over sub-occipital, cervical, upper trapezius, frontal head, temples, and tai yang are effective for migraine and tension-type headaches.
- Wet cupping over GV 20 is effective with patients willing to shave a quarter sized area on the top of head.
- Cupping treatment combined with either osteopathic or chiropractic manipulation or massage on the same visit is more effective than cupping therapy alone.
- Intensity of cupping: weak to medium for 2 to 5 minutes.