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Voice-over: Welcome to Spotlight on Migraine hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

Thank you to our 2023 education sponsors.

Alternative treatments such as supplements, mind/body therapies, physical therapy, and acupuncture can be helpful non-pharmacological additions to conventional migraine management plans. Headache specialist, Dr. Abigail Chua, discusses the pros and cons of alternative treatments and how to begin integrating them into your overall treatment plan.

Abigail Chua, DO: So, the title of this talk is Going Through the Data of Using Combination Therapy for Migraine, but more specifically, what we are going to be focusing on is talking about integrating alternative treatments to more conventional migraine management plans. So, when we talk about medicine and health care, most of us are familiar with conventional medicine. So, this is what we’ve all been exposed to. This is what we are use to seeing, especially in this country. So, conventional medicine is considered modern, evidence-based, allopathic, very disease focused.

But there has been this emergence of using alternative treatments or more traditional ancient treatments for certain diseases, one of which is headache. Now unfortunately, when we talk about these treatments, a lot of people feel that this is like oil and vinegar; they do not go together. So, some people feel that they may have to choose one or the other without knowing that they can combine the two of them.

So, why would someone turn to alternative therapy? So, most common reason is concern for safety or side effects from pharmaceutical treatments, but also affordability and access to these treatments can definitely impact their decisions. Something I think is important is that alternative treatments can give a patient a more sense of control, so they are choosing what they want, they are controlling how they are taking it, and because again, of ease of access and maybe affordability, it gives them more power over their condition.

So, in terms of headache specifically, it’s less than 20% of specialists with headache actually regularly use or prescribe or recommend alternative treatments for headache. This contrasts to how many people actually try it, however. So, in adults, 20-80% of adults have used alternative treatments for headache, and in children, more than 75% have used alternative treatments for headache. The thing that I think stands out on this slide is that only about 50% of patients actually report to their physician or clinician that they’re using these treatments. And this is a big deal because this can interact with other medications, but also the question is really why? Why are they not telling us that they are using this?

So, this could be because they have a fear of being judged or maybe it’s because they don’t really consider these medications to be relevant; either the patient doesn’t think so or the clinician doesn’t think so. But I would argue that they are actually very relevant and this slide kind of highlights why.

So, we are just going to take a step back for a second and remember that migraine is a disease that is multifactorial, so a lot of things can affect it as we learned earlier today, with triggers and cravings and promontory events. So, we have modifiable or non-modifiable risk factors that can put someone at risk for having chronification or worsening of their disease. So, things like certain foods, their mood, stress, other medical conditions such as fibromyalgia or having a head injury, all of this can impact how someone’s disease progresses. So, because migraine is so multifactorial, it only makes sense that migraine treatment should be multidisciplinary.

So, going away from this idea of alternative treatment, having an other type of treatment, we want to think of these as another type of treatment that we can build into our plans for headache so that they interact and are more organized and coordinated so that we are not worrying about maybe things that we don’t know are going on with certain side effects or we are not aware that patients are doing something that may potentially interact with something.

So, in terms of the options for complementary and integrative treatment for headache, there are a lot of them. So, I broke them down to 3 different categories. So, there are nutraceuticals, which are foods and drink supplements that can be used in a medicinal way. Then, there are mind and body treatments such as yoga, mindfulness that someone mentioned earlier, cognitive behavioral therapy, and then physical or manual therapies such as osteopathic or chiropractic manipulation and physical therapy.

I don’t have time to go through all of these today. So, what we are going to do instead is go through certain cases that I want to highlight the options that are out there for everyone so that you are aware of what you can try, but then also to show you that these treatments can be very easily integrated into something that we are more used to seeing with conventional headache treatment.

So, the first case here is James. James is 37 years old. He’s a man. He’s had headaches since his teens. Right now, he is having about 1 to 2 headaches a week. These attacks last at least 4 hours, sometimes 8 hours. He has a lot of nausea, a lot of light sensitivity with these attacks. And what’s really concerning him is that he is a stay-at-home dad, he has 2 toddlers, and he is worried about how these headaches are going to impact his ability to care for his children.

James has no significant past medical or surgical history. His exam was otherwise unremarkable except he did have a little bit of tenderness in his neck and his shoulders when we examined him, but otherwise he was fine. He says his sleep is okay. Most of us probably get this amount of sleep, 5 to 6 hours a night. He wakes up kind of groggy, but he has a cup of coffee and he is fine. He’s not really taking any medications right now. He’s on a multivitamin, uses an over-the-counter headache medication for those 1 or 2 headache-days a week, but is not on anything else.

So, based on the features of his headache, we have diagnosed James with episodic migraine without aura, without status migrainosus. So, he is given sumatriptan 50 mg to take at the onset of his migraine attacks so he can help shorten them so that they are not going on for 4 to 8 hours at a time. And then he is given a headache log because that is always homework whenever you see a headache specialist, and then he is asked to come back after 3 months.

So, James comes back. He is still having 1 or 2 headache-days a week. However, they are much shorter in duration, so they’re lasting 30 minutes to about 45 minutes. He is very happy with his results, but are you happy with his results? I think we can always do better, right? So, the American Headache Society consensus statement from 2021 suggests that anyone who has at least 4 to 5 headache-days a month should be considered to start a preventive treatment to help control their overall condition, decrease their headache and migraine frequency. James is not really interested in doing this. He has kids. He is worried about side effects. He does not want to be drowsy at all, but he mentioned the idea of maybe taking a supplement that can help headaches, and he is maybe interested in doing this.

So, there were older guidelines from the American Academy of Neurology and American Headache Society. These have been retired, but we still use this data because this is what we have currently. So, this is a list of the most common supplements or nutraceuticals that we use for migraine preventive treatment. Feverfew, which is an herb, has level B, which means probably effective, level of evidence for migraines. Magnesium, riboflavin also level B. CoQ10 has level C, which means it’s possibly effective, and then butterbur actually has level A evidence, which means that it is effective. But the concern with butterbur is that sometimes it can contain alkaloids that can damage the liver. So, there are certain brands of butterbur. There is actually one in your goody bags today that is actually considered safe and fine to use.

So, we’re going to talk about the 2 most common nutraceuticals that we use in headache or migraine preventive treatment. The first is magnesium. I’m not going to go too much into this because we have a great talk coming up right after me about magnesium, but I was going to highlight a few things. So, magnesium is essential for every living organism, and low levels of magnesium have been shown to play a role in triggering certain parts of migraine attacks such as aura. It can make platelets stickier, clump together. It can cause your blood vessels to tighten, or what is called vasoconstriction, and then in terms of studies specific to migraine, they have shown that lower levels have been seen in attacks of menstrual migraine and also migraine in general. When someone is taking magnesium, probably the most common side effect that we hear about is diarrhea. And again, we are going to hear all about this in the next talk.

Next, is riboflavin. So, riboflavin is a water-soluble vitamin. It plays a lot of different roles in the body, but it’s been shown to have a role in inflammation, stress, neurotoxicity, and also mitochondrial dysfunction. So, mitochondria are the cells in our body that produce energy, and dysfunction of these cells has been implicated in a lot of neurologic conditions such as Parkinson’s, multiple sclerosis, Alzheimer’s, and migraine.

Common side effects of supplementing with riboflavin, the most common thing we see is bright yellow urine. It also can cause some nausea or GI upset. And then a fun fact, this may be a little bit less known, if you have a patient who is breastfeeding and taking either riboflavin or a B complex vitamin, their breast milk will also be very bright yellow. So, that’s just something to note because people don’t really know that. It can be concerning. It is not dangerous to them or the baby.

All right, so James comes back. It’s now 4 months later. His headache frequency is max about 4 times a month at most. He is very happy. He’s tolerating the magnesium, tolerating the riboflavin. No side effects. None of that drowsiness he was worried about, and the sumatriptan knocks out his headache in less than an hour. But now he is saying, you know what doc, my neck has been really bothering me. I wake up in the morning, it’s really stiff. I’m kind of feeling a little bit dizzy. You ask him some questions about his sleep. He is not snoring. He is not waking up in the middle of the night gasping for air.

You examine him and remember he had a little bit of tenderness and tightness on his first visit, but now you have really noticed that his jaw muscles are tight, the muscles on his temples are tight, the back of his head is really tight, and even the front muscles of his neck, the sternocleidomastoid, are all really, really tight. He notices that this pain gets worse during the day, you know as he is carrying his 2 toddlers around, it just kind of gets worse. So, most of the time we go to something easy like a muscle relaxer, which is something you can take when the pain kind of gets bad, but again, James is absolutely against it. He just cannot get drowsy.

So, what’s a good option for him? Physical therapy. Now, he just has to have time with 2 toddlers at home, but if he does have time then physical therapy is a nice option. So, 80% of people with migraine do have neck pain, usually during the attack, but it also can occur beforehand. Studies have shown that people who have neck pain with their attacks have higher headache-related disability, harder-to-control attacks, and more severe attacks. Physical therapy combined with appropriate migraine treatment can decrease how often someone has attacks, also decreases how bad or severe those attacks feel. Trigger-point injections, myofascial release, basically addressing those tight areas in the muscles also can be very, very effective, and most of the time you want to combine this with some kind of home treatment to really get lasting effects.

Next case is Tessa. So, Tessa is 57 years old. She is a woman who has had headaches since she was in college. She is having headaches about 4 to 6 days a week. They’re lasting 4 to 12 hours, but if they are really bad, she says they are going on for days and days and days at a time. They are debilitating, causing a lot of light sensitivity, and she is really worried about her job. She is a lawyer. She has a lot of brain fog, and she is really having a hard time functioning.

Her only past medical history is some anxiety that is untreated. Her exam is normal except she has a little bit of high blood pressure, a little bit of high heart rate. She says she is really nervous about this visit because she has been waiting months and months and months to see somebody for headache, but otherwise it’s normal. She does have some pretty bad sleep. She has a hard time shutting her brain down at night, winding down.

For medications, she is taking propranolol, which is a type of blood pressure medication, but she is actually using it only as needed for public speaking because it makes her nervous and that helps calm her down. She also has rimegepant as an acute headache treatment, which she is not so sure if it’s working or not. So, for her, she has been diagnosed with chronic migraine because she is having at least 15 days of headache a month, 8 of which fulfill criteria for migraine. She does not have aura, but she definitely does have status migrainosus, or those headaches going on for 3 or more days.

So, for her, we talk about definitely the need for preventive treatment. She is having a lot of headache attacks, need to bring that number down. But, actually instead of starting a brand-new treatment, we use what she has already got. So, she has propranolol. Propranolol is used as a migraine preventive treatment. So, we just took it from an as-needed anxiety medication to an everyday, twice-a-day treatment. All right. So, we continued her rimegepant because it can be more effective once the total headache frequency is decreased and again, she is asked to start a headache log. But, what about her sleep?

So, earlier in this talk, we talked about sleep being a modifiable risk factor for worsening headache, so we definitely should address that at this visit. We don’t want to give her medications because we just started a new one, so maybe something like progressive muscle relaxation, part of that mind/body complementary and integrative treatment. So, progressive muscle relaxation is very easy to learn. It takes 5 to 10 minutes every day. It’s a non-pharmacological method of deep muscle relaxation.

So, we know that muscle tension is the body’s way of expressing anxiety, and by blocking that tension we can decrease anxiety. Progressive muscle relaxation actually has level A evidence for migraine prevention, and again, easy to treat, effective in reducing chronic pain, stress, insomnia, and there are actually some studies using smartphone apps to help patients learn how to do this effectively.

So, it’s been 4 weeks later. Tessa’s headaches are basically unchanged, but she feels maybe slightly less anxious on the propranolol. She’s using the progression muscle relaxation every night. She likes it. She knows that preventives take a long time to kick in, at least, you know, 2 to 3 months to really see maximum benefit, but she is struggling right now. She has a lot of work deadlines. She has an important presentation coming up. She has worsening headache. She is stressed out. What can we do for her right now? Maybe acupuncture is something that would be helpful to her.

So, acupuncture has been practiced for thousands of years in China. In America, 20% of children and 40% of adults have tried it. We don’t really know how acupuncture works in terms of headache or chronic pain, but the idea is that it balances chi or life energy, and the thinking is by inserting these needles in the body you are blocking certain receptors from sending pain to the brain, and then thereby decreasing the pain. So, acupuncture has evidence in headache, but what we know is usually acupuncture takes time, so at least 6 to 8 sessions before you get any lasting benefit. So, how is this going to help Tessa right now because she needs help now?

So, interestingly, there is a different form of acupuncture called battlefield acupuncture. So, acupuncture can be done in several different ways. The ear is considered a microsystem of the whole body. So, there is auricular acupuncture, but even beyond that, this is battlefield acupuncture, which was actually created by a United States Air Force Colonel, Richard Niemtzow. So, he took these very small, tiny acupuncture needles and developed certain spots that create rapid, very quick, almost instantaneous relief, but it is very short lived. So, this is actually used in the military very frequently. It’s used now and it’s very widely used at the VA. Lots of clinicians are trained to do this, and these needles are easy to carry in your pocket.

So, battlefield acupuncture is a great way to create a transition or a window of time where maybe patients feel a little bit less pain, so that things like their oral medications or maybe traditional acupuncture can start working without the stress of when is this all going to work.

All right. So, I promise I’m almost done. So, just some pros, some summaries about complementary and integrative treatment for headache and migraine. So, these treatments are common. We just have to be aware that they exist. The nice thing is, this is not that or this. These treatments can be very easily integrated into conventional medicine, as I have just showed you today with those 2 cases. And the great thing about integrative medicine is that it is creating a partnership but also patient autonomy. So, we can work together, patients still have control of what they are comfortable trying, but then still open to other possible treatments.

Just some limitations with these studies for these alternative treatments. So, flaws in design, small number of study participants, it’s difficult to control for placebo in a lot of these trials, and also, it’s difficult to create sham or like fake acupuncture because people still respond to those things. Access to these treatments is difficult. They are usually not covered by insurance, and then knowledge of the patient, but also the clinician is a factor.

The last thing I am going to end with. When patients ask me, “What do you think about this treatment, should I do it, have you heard of it? I have 4 basic easy things that I tell the patients.

Number one, does it make sense? Is there evidence for this? Does it make sense in terms of the pathophysiology of the disease we are considering using it for? Two. How much does it cost? Again, a lot of these aren’t covered by insurance, so you don’t want to encourage your patient to try something that is just out of their price range. That’s going to cause more stress. It’s not fair to anybody. Third, is it safe? What is the data on this? Is it going to interact with something you are already on? Do we know what this could potentially do to you? And then fourth, always keep in mind, is what you’re going to try legal or not, depending on the state, depending on what you are trying to do, depending on your job? This can make a big impact on your life, so you kind of have to think about that as well.

Voice-over: Thank you for tuning into Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

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*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.