Welcome to the official Newsletter of Advanced Medical Care.
Read This If You're Ready to
Say Goodby To Migraines.
Migraines are complicated and there are lots of options for prevention and treatment. The purpose of this article is to educate you, so that you can decide what you want to do to control your own migraines. "Esse tuum medicum" (Be your own doctor). Some options require a prescription or other medical intervention and some you can do on your own.
Are Migraines a Big Problem?
Migraines are the 2nd leading cause of disability, worldwide, (2021, Migraine and Disability)
Migraines are the #1 leading cause of lost work days due to disability in the world among people less than 50 years of age (J Headache Pain 22, 29 (2021)).
Migraines cost Americans about $17 billion per year in direct costs. (National Institutes of Health)
Migraine related absenteeism costs American businesses about $13 billion a year, but that cost goes up to $78 billion per year when all costs, including presenteeism are added in. (Annals of Neurology; 2020) Presenteeism occurs when people show up for work, but due to illness are not able to work up to full capacity.
How Many People Get Migraines?
"Migraine affects more than 10% of people worldwide, occurs most often among people aged 20 to 50 years, and is about 3 times more common in women than in men. In a large US survey, 17.1% of women and 5.6% of men reported having migraine symptoms." (JAMA Network, Jan 4, 2022) About 1 out of every 6 females and 1 out of every 18 males, but possibly much higher than that due to the many that are undiagnosed.
How Do I Know If My Headaches Are Migraines?
Typical Symptoms of Migraines:
Intense throbbing or dull aching pain, usually on one side of your head, or behind one eye, but sometimes on both sides.
Headache is worse with activity.
Sometimes nausea or vomiting.
There may be changes in how you see, blurred vision or blind spots.
Often sensitivity to light, noise, or odors.
Why Don't More Migraineurs Get Medical Help?
Many migraineurs don't think doctors can help them, or they don't have insurance, or they don't trust doctors, etc, and never seek medical help and thus remain undiagnosed and untreated.
When migraineurs do seek medical help, over 50% receive the wrong diagnosis.
Even when migraineurs get the correct diagnosis, they often receive outdated, ineffective treatment.
An Ounce of Prevention is Worth a Pound of Cure!
What Can I Do To PREVENT My Migraines?
Migraineurs have two biochemical abnormalities:
HIGH LEVELS OF HISTAMINE and Inflammation
LOW ENDORPHIN LEVELS, about 50% lower than normal
If you can decrease your histamine level and get your endorphin level back up to normal, your migraines will be history. Hence your goal is to lower histamine and increase endorphins.
Lower Histamine Levels
to Prevent Migraines
Lower Histamine by Eliminating Dietary Triggers. Here are the Most Common DIETARY Triggers.
MSG or monosodium glutamate
Both dark and milk chocolate
Cheese & aged dairy products
Artificial sweeteners (e.g. aspartame)
Caffeine. Go here to find out the truth about caffeine
Cured meats, like bacon or ham
Any food you are allergic to
Any food with a strong smell
You may have dietary triggers that aren't on this list. If you pay attention, you should be able to identify and eliminate your triggers.
Lower Histamine by Eliminating LIFESTYLE Triggers
Stress. Learn proper stess management.
Lack of sleep. Go here for help improving your sleep.
Change in sleep schedule. Commit to a fixed schedule.
Alcohol, particulary red wine (we call it a migraine if it occurs right away, or a hangover if it happens the next day)
Lights. Go here for information about using light to stop migraines.
Odors. Avoid perfumes, strong food smells, chemicals or gasoline.
Dehydration. Drink plenty of water!
Medication overuse. The pill you took yesterday, causes a rebound headache today. You are at risk for this if you use pills to treat acute headaches more than 2 days a week or 10 days a month, even if the pills are prescribed.
Tobacco use. Smoking is known to increase the frequency and intensity of migraines. For help quitting go here.
Lower INFLAMMATION by Following a Healthy Diet
A study published last year showed that an anti-inflammatory diet (lots of fruits and vegetables, whole grains, no added sugar, no sugary drinks, no corn oil, no soy oil) reduced headache frequency. Go here, here and here for information about anti-inflammatory diets.
A Mediterranean diet (fruits and vegetables, whole grains, seafood, nuts and legumes, olive oil, eggs, fish, and poultry with lesser amounts of red meat) also reduces migraine frequency and intensity, according to a study published in January of this year.
Avoiding all triggers, and following a healthy diet will lower your histamine and inflammation level, and your headaches will begin improving.
Increase Endorphin Levels
to Prevent Migraines
Endorphins are produced by your own body and are similar to narcotic medications: they prevent and relieve pain and headaches, but without the side effects. Migraineurs have about half as much endorphins as non headache sufferers.
The good news: multiple medical studies show that aerobic exercise causes a rapid increase in endorphin levels. As endorphin levels increase headaches will go away or decrease in frequency, and the remaining headaches don't last as long and are less painful. One recent study showed a 50% drop in migraine intensity and frequency after just 6 weeks of exercise.
For exercise to be aerobic your heart rate needs to increase. Walking is moderate level aerobic exercise and running or jogging is vigorous level aerobic exercise. Moderate level aerobic exercise, e.g., a daily walk will increase your endorphins and your headaches will decrease. A good plan is to take a 30 minute, brisk walk, 5 days a week. Exercise is one of the most consistently reliable ways to decrease headaches. For more exercise information go here.
Step 1 and 2 Are Highly Effective:
When You Eliminate Your Triggers, Eat a Healthy Diet and Take a Daily Walk
Your Migraines Will Start to Improve in 2-3 Weeks.
If Necesary, Go On To Step #3
Use Supplements or Medications
to Prevent Migraines
OTC Supplement for Migraine Prevention
CoQ-lO, 100 mg three times a day caused about half of the patients to experience a 50% reduction in migraines, in a double blind, placebo controlled study.
Riboflavin (B2) 400 mg per day resulted in 59% of patients experiencing a 50% or greater reduction in headaches in a double blind, randomized trial.
Magnesium. A large double-blind, placebo-controlled, randomized study on 81 migraineurs receiving 600 mg of trimagnesium dicitrate taken once daily, showed a decrease of 41.6% in headache frequency compared to just 15.8% for those taking placebo. Although magnesium seems to help all migraines, it is considered particularly effective for menstrual related migraines.
Petadolex, an herbal extract, is used for migraine prevention. Two randomized, double blind, placebo controlled trials have shown that this herb works. The first one was published in the very prestigious journal NEUROLOGY and
showed a 55% reduction in the use of Rescue Medicines to treat migraines. The last one was published in the journal HEADACHE and demonstrated that 71% of the people using Petadolex had at least a 50% reduction in migraines. Take 75 mg of Petadolex twice per day for 1 month and then reduce to 50 mgs twice a day. Go here for more information about Petadolex or to order Petadolex (about $60.00 for a month supply).
These 4 supplements above are recommended by the American Academy of Neurology and the American Headache Society as effective for the prevention of migraine. Advantages of these supplements is that they are OTC and readily available. The Petadolex is sometimes available at health food stores, but you may need to use the link provided above. Insurance doesn't cover these supplements so you have to pay out of pocket, however they are inexpensive.
Prescription medications for migraine prevention
Topamax (topiramate), is effective for migraine prevention and neuropathy. May promote weight loss. Covered by insurance. Disadavantages are the side effects: drowsiness and fuzzy brain.
Beta-blockers such as Inderal (propranolol) and Lopressor (metoprolol). Covered by insurance. Disadvantages are side the effects of erectile dysfunction and general sexual dysfunction, they should not be used if you have asthma or allergies, and they may cause depression.
Calcium-channel blockers. These include Calan (verapamil), and Norvasc (amlodipine). Side effects can include constipation and low blood pressure.
Tricyclic antidepressants (TCAs) like Elavil (amitriptyline) or Pamelor (nortriptyline). Disadvantages include weight gain and low energy. TCAs can also cause severe problems if you have heart disease or are pregnant.
Selective Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs) such as Cymbalta (duloxetine) and Effexor (venlafaxine) also help prevent migraines. May also help with depression and/or anxiety but may cause weight gain, although probably less than the TCAs.
CGRP inhibitors. CGRP inhibitors are a new class of drugs approved to prevent migraines, including Qulipta (atogepant, $1,200 to $1,350 for 1 month supply) and Nurtec (rimegepant sulfate, $1,000 to $1,200 for 1 month supply). According to WebMD, the long-term safety of these new drugs is unknown.
Use Supplements or Medications
to Treat a Migraine
Rescue medicines: Any medicine you take to stop a headache that has already started is a Rescue Medicine. All Rescue Medicine, OTC or Rx, must be limited to 2 days or less per week. When you exceed 2 days per week, or 10 days per month you risk Medication Overuse Headaches, also known as Rebound Headaches. This means the medicine you are using to treat your headaches is making them worse.
Ginger is an exception to the 2 day rule! There are a number of studies showing that ginger can be used to treat migraines, but the most interesting study (Phytother Res. 2014 Mar;28(3):412-5) showed that just 250 mg of powdered ginger stopped migraines as effectively as Imitrex with less side effects. For years Imitrex (sumatriptan) was the #1 migraine drug. Take powdered ginger capsules as soon as you notice a headache starting. Check your local health food store for powdered ginger. There are many good brands to pick from. I like Natures Way Ginger capsules, 550 mg, 180 caps, ($9.74 the last time I checked). These caps are twice as strong as the ginger caps in the study and should work even better.
Imitrex (sumatriptan) and all the rest of the family of triptan drugs (Axert, Relpax, Frova, Maxalt and Zomig). These drugs are effective, although according to the study cited above, not anymore effective than ginger. Kristi Torres, Pharm.D. (03/28/2022) warns that patients with pre-existing heart disease or risk factors for heart disease may not be candidates for triptan therapy. Torres defines risk factors to include high blood pressure, high cholesterol, smoking, obesity, diabetes, family history of heart disease, menopausal women, or men over 40 years of age.
CGRP inhibitors approved for acute migraines include Nurtec (rimegepant sulfate) and Ubrelvy (ubrogepant). These drugs are considered very effective, but are quite expensive and long term safety is still unknown.
OTC meds including Excedrin Migraine, Advil Migraine, and Aleve Headache Pain tablets have varying degrees of effectiveness and are definitely subject to the 2 day rule to avoid medication overuse headache. Generally, by the time we see patients in the office for migraines, it is because these readily available drugs aren't working, or are already causing medication overuse headaches.
How Do I Turn This Into a Workable Plan?
Do everything you can on Step 1 and 2. That's the hard part. Those steps require change which is never easy. But they make a huge difference. Most people use magnesium from Step 3 while they are working on 1 and 2. Magnesium is kind of a no brainer, because it is so cheap and so effective. Many people control their migraines with just Step 1 and 2 plus magnesium.
Some people have triggers they can't (or won't) avoid. For example a shift worker whose sleep schedule constantly changes. Or an employee that can't eliminate the flashing lights at work. Or somebody that is not willing to stop eating the food that triggers their migraines. If you can't (or won't) eliminate your triggers, you have to rely more on the preventive meds in Step 3. Start with the supplements in Step 3. Petadolex is highly effective, and if used with the other 3 supplements in Step 3, may be all you need to control your headaches.
If you can't afford or don't want to pay out of pocket for the supplements in Step 3, you might consider one of the prescription medications from Step 3. I prescribe Topamax frequently, because it is pretty effective and promotes weight loss, which many of us need. Most people aren't too bothered with the fuzzy brain side effect, but if you are, then you need to consider one of the other meds.
After you have implemented Step 1, 2 and 3, use Step 4 for any occaisonal headaches that might break through. The goal is to do a good enough job with Step 1, 2 and 3 that you don't need Step 4.
If your headaches are infrequent to begin with, and it just isn't worth it to you to do Step 1, 2 and 3, then you should go right to Step 4 and find a rescue medicine that works for you.
Synergy is Your Friend
It would be nice if taking 1 pill would fix all migraines, 100% of the time for 100% of the people. But no pill is that successful. Even the new, extremely expensive CGRP inhibitors have success rates south of 40% for treatment and prevention.
But synergy is your friend. When you combine multiple things, e.g., exercise, that has a 50% succes rate, with magnesium that has a 41.6% success rate, with an anti-inflammatory diet that has a 30-40% success rate, you start to get real relief. Instead of trying multiple different drugs or treatments in a serial fashion trying to find 'the one' that works for you, combine multiple treatments simultaneously. That is the formula for 100% success.
Does This Approach Always Work?
Some people may need more aggressive options. Whether it is because they aren't putting much effort into Step 1 and 2 or not taking their preventive meds or their system just doesn't respond, is hard to say. But there are other options for these poor responders. Let's call this Step #5.
Nerve Blocks or Injections for Migraines
Sphenopalatine ganglion block is a procedure that involves the delivery of a local anesthetic to the sphenopalatine ganglion (SPG)—a group of trigeminal nerve cells located in the back of the nasal passages—to relieve headache pain. I have used this procedure for patients with chronic migraines with good results. Generally has good insurance coverage. This block treats an existing migraine and helps reduce future migraines.
Occipital and supraorbital nerve blocks are often done together for migraine relief. The occipital nerve block is injected at the base of your skull, while the supraorbital nerve block is injected into your supraorbital nerve located on your upper eye bone. These are easy to perform, and also covered by insurance, and they produce fast results. The headache is usually gone in 1-2 minutes. These blocks also treat an existing migraine and helps reduce future migraines.
Histamine injections. This involves injecting a small amount of histamine subcutaneously. This is done as a series, a couple of times a week. Paradoxically, the body responds by reducing total histamine, which results in migraine reduction. In my experience with my patients these histamine injections are very effective. These histamine injections do not treat an existing migraine and are only done to prevent future migraines.
These nerve blocks and histamine injections have been evaluated by the American Academy of Neurology and the American Headache Society and both groups recommend these procedures as effective for treating and preventing migraines.
Questions? Call 360-264-2492 to schedule an appointment if you need help with your migraines. In person appointment is best, but telemedicine is an option.
Take care and BE HEALTHY!
Member of the International Headache Society
Member of the American Headache Society
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