Molly O’Brien: Many of us with migraine know that an ice pack or a heating pad can bring some welcome relief during a migraine attack. But why is that? Is there any science behind it, or does it just feel good? Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re going to talk about some of these very basic home remedies, ice and heat or hot and cold therapy for migraine. 

To help us understand how they work, I’d like to introduce our guest, Dr. Alicia Duyvejonck. Dr. Alicia is a nurse practitioner and headache specialist. She has worked in general neurology for more than 10 years and obtained her added qualification in headache certification in 2018. She is strongly committed to developing headache programs and headache education for both patients and providers. Dr. Duyvejonck serves on AMD’s Advanced Practice Provider Education Committee. Dr. Alicia, thanks for joining us today. Really happy to have you.

Dr. Alicia Duyvejonck: Thank you. So happy to be here. 

O’Brien: Really happy to have you here too. We’re getting back to the basics. I know many of us, at home, have ice packs. Some people have ice masks, caps, heating pads. I can’t live without mine. So today we’re going to break down how ice and heat can actually help with migraine. So, before we get to that part, can you start us off on a very basic level, how does ice actually help either treat pain or injury or help us feel a little better?

Duyvejonck: Cold therapy, or ice therapy, works in a couple of different ways. First, it works on the immune system to decrease inflammation. So when we apply ice to a part of our body, we’re going to experience some shrinking down of vessels – we call that vasoconstriction – and that helps to decrease inflammation within the vessel. When vessels become inflamed for various reasons, they become more dilated or big and inflamed, and that allows fluids and inflammatory chemicals to kind of leak out into the areas around these blood vessels. 

And so by applying the ice and shrinking those vessels down, we can tighten back up those tight junctions and decrease that inflammatory process in the area. Also it works in a neurological way, by slowing down conduction of nerves that are involved in the pain process. So by doing that, we can actually reduce pain, induce some numbness, as you might have experience with when you use ice. There’s also a thought that it helps on a metabolic level to decrease the oxygen and nutrient demands on a cellular level, if we are using that ice therapy, which may help as well.

O’Brien: And now that we have a better understanding of how cold therapy can help with pain or an injury, can you apply that specifically to how it may help with migraine or headache?

Duyvejonck: Migraine itself is a neuroinflammatory condition, so we’re talking about ice therapy and how ice therapy may help with inflammations related to injury. Even though migraine’s not necessarily a direct injury, it is still an inflammatory process or an inflammatory disease. So if we use ice or cold therapy, we can help migraine as well.

O’Brien: So when we’re talking about using cold therapy or ice to help with migraine or headache, is it actually helping treat the migraine? Is it just helping us feel better? Is the cold kind of a distraction? Is it a combination of all of the above?

Duyvejonck: I would have a tendency to say it’s probably a combination of all of the above. But, you know, I think the three ways that I outlined before, how ice works in an injury, still does apply in migraine. The other thing that’s interesting – and as many things in migraine – we don’t have a full understanding of why this works. But there is some good science in if we look at, for example, the mechanism of action of some of our as needed migraine therapies. Thinking specifically about triptans or dihydroergotamine, or DHE, these are older medications that we’ve been using for many, many years for migraine. And one of the things that these medications do is they vasoconstrict. We talked about that in the context of ice or cold therapy. We used to think that’s why they worked. We used to have this old theory of migraine called the vascular theory that this is why migraine happens is because of the inflammation in these blood vessels. 

We now know it’s much more complex. That inflammation is probably secondary, or the blood vessel changes are probably secondary to neuroinflammation. But I think it is interesting to see that these older therapies do have a secondary…this mechanism where we see vasoconstriction, and those medications are very effective for migraine. And we also see that vasoconstriction with ice therapy. So I think that’s interesting. I don’t think we have a full understanding of it. But I do think that it is helping, not just with distraction or not just with, you know, pain improvement. I do think that there is something to it, because we see this happen with other migraine therapies.

O’Brien: Is there any strategy for how we can use ice or cold therapy to help with migraine or other headache types? Is there any best practices strategy?

Duyvejonck: I have a tendency to counsel my patients to really listen to their bodies. And I’ll even say this when we get, you know, down the road to heat, you know, really listening to their bodies. What feels best to you? What gives you the best relief? And that’s probably going to be the therapy that I would recommend for you. For example, as you said, some people will want to put it maybe on their neck or on their forehead. Some people want…there’s the eye masks. Some people really enjoy that. So I think, you know, putting it where you’re feeling some of your symptoms can be very helpful. I think that that study we were referencing that wasn’t necessarily the site of the patient’s pain. So just looking at that study does kind of tell me that, you know, maybe it’s not as important as far as where we put it, but that we are doing it. But my general guidance is, you know, if you have back of the head or occipital headaches, maybe try, you know, your therapy there, the eyes, top of head, wherever kind of it feels best to you and gives you the best relief.

O’Brien: Are there times that using ice might actually make pain worse?

Duyvejonck: Migraine patients, in my experience, are a sensitive population, right? Migraine itself, when I am talking to my patients, I talk about migraine being a condition of change sensitivity. We’re very sensitive to change – any kind of change, right, good change, bad change, change inside or outside of our body. And so I do think that some people do have worsening with ice therapy, and I think it has to do with that sensitivity. That’s not scientific, but you know, there are people who are just sensitive and applying, you know, an extreme temperature to their bodies – and particularly in their heads, where they’re having a lot of the pain – can make some people worse.

O’Brien: Maybe it’s not the right therapy at that moment, during that attack, or for the person. So let’s move to the flipside. Let’s talk about heat. I love my heating pad. Heat can feel wonderful. So let’s talk about heat overall. How can heat help with pain relief, just from any type of injury or pain, we’re talking overall body?

Duyvejonck: Cold causes vasoconstriction. Heat causes vasodilation. So we’re going to have the opposite effect with heat. And this can really help to improve circulation and blood flow to the area, clear out, you know, kind of waste products and help to relax musculature. Can also give us kind of relaxation from more of an emotional or psychological standpoint as well. It can be very relaxing. Both of those things can be helpful again in a variety of headache types, especially knowing that tension, or muscle tension, really can be a large part of any kind of headache disorder.

O’Brien: When we’re talking about using heat for migraine, how kind of does it help? I mean, you kind of answered the question. So if you’re in a migraine attack – have it on your neck, something like that, or your head – like how can heat help us? And is there any best practices, location, that kind of thing?

Duyvejonck: Just in my experience with talking to patients, I think it’s more common with heat to be using more in the neck and shoulders, where I feel like it’s more common with cold and ice therapy, to use it more on the head, but it’s highly variable and very individual, patient to patient. Again, I will just put the plug in for listen to your body. If heat is what feels good, fine, use the heat. Outside of that, I see the utility of heat more in that kind of maintenance of migraine wellness. I mean, certainly, if you’re that person where heat is just what works in the moment, fine, do the heat. But in a more general view, I see heat as more useful on maybe an ongoing maintenance therapy, just like we’re doing our regular PT stretches and our gentle movement and maybe applying that heat and getting that good relaxation, maybe at different times throughout our day/week/month however it is helpful for the patient. 

I think it can really help with overall kind of muscle relaxation and decrease and emotional even relaxation, to decrease those things from contributing to migraine. You know, migraine is a genetic neurological disease, but everything in our lives – everything inside and outside of our body – contributes to it, which is kind of the horribleness of migraine, right, is everything affects us. So I really love talking about these kinds of therapies, because I always feel like it’s about the little things. All of these little things that we can do on a day-to day-basis or on an attack-to-attack basis, that can help to increase our overall migraine wellness, decrease triggers, and help to just control migraine symptomology overall.

O’Brien: So I love that idea you don’t necessarily have to use it in the moment during the attack, but to use it overall to help with and I love the phrase migraine wellness. We talked about how heat can help, how it can make us feel better, kind of promote relaxation, improve blood flow. Is there any time that heat therapy could actually make symptoms or pain could make things worse?

Duyvejonck: In some patients, heat could potentially make things worse. You know, if you’re in the midst of a terrible migraine attack, and you’re applying heat to your head or use some other kind of heat therapy – saunas, hot tubs, these kinds of things – it is conceivable that that is actually going to make things worse, because we’re actually providing additional vessel dilation, and we’re bringing increased blood flow to the area. Which if that’s what’s already going on, it is conceivable that that could make some things worse.

O’Brien: Can you tell us a little bit about best practices for ice and heat in terms of safety – how long people should apply, how often?

Duyvejonck: You know, these are generally very safe therapies. But to your point, we do have to just keep some things in mind. One, ice and heat can be therapeutic, but they can also cause injury. So we do want to be very careful in that. I’m thinking about, you know, like making sure that your heating pad or your heat pack is not too hot and making sure that whether it’s an ice pack or heat making sure that you’re not directly applying it to your skin. You want to have some layer of protection between the actual cold or heat source and your body to prevent burn. You know, you can have a chance of burns with heat therapy. Cold therapy can be very irritating if directly applied to the skin and can, in more extreme cases, cause things like frostbite. So you do want to be a little cautious there, and you do want to limit your time. You don’t want to have an ice or cold pack on for an hour. The general recommendation is going to be about 15 minutes. I like the 15 minutes on with 15 minutes off. And then if the patient feels that they would benefit from reapplication, they could certainly reapply.

O’Brien: Is there anyone who should avoid these types of treatment, maybe they have other comorbidities something like that? Can you walk us through it?

Duyvejonck: One that pops out at me just kind of right away are people with neuropathies or sensory issues, people with diabetes that may not have as good of sensation you need to be extra cautious. Because patients with diabetes or neuropathies of other kinds may not be able to feel the cold or the heat severity, and so that’s going to put them at increased risk for injury. You do want to make sure if you’re using more general heat – saunas, hot tubs, these kinds of things – people with cardiovascular issues or women who are pregnant also need to be cautious. Those kinds of therapies can cause significant circulatory changes.

O’Brien: So now that we have broken down those two topics, can you talk to us about how ice and heat can fit into an overall migraine management picture? They are excellent tools but probably not the only strategy that people should utilize. So can you talk to us just about where those fit into our migraine toolbox?

Duyvejonck: I am always talking about the migraine toolbox. The migraine toolbox is just of utmost importance. And we often think of medications in our migraine toolbox, and those are super, super important. We need those medications often for that full resolution of symptoms. But I encourage my patients to have a variety of things in their toolbox. You know, not only migraine medications but maybe antinausea medications, ice, heat, relaxation therapies, all kinds of different things. The more tools in the toolbox a patient has, I think, the more self-efficacy they have. I think self-efficacy in migraine is so important to really feel like you have some sense of control over your own attack and over your own disease. Migraine is so debilitating, and it can be so intractable, and that can be just not only physically draining but mentally draining. You know, so having these therapies that can not only help with symptoms but also help a patient feel like they’re in more control over their disease or what they can do about it can be so, so helpful.

O’Brien: As we kind of wrap up here, Alicia, I’m wondering if there’s anything else that you want to share with our audience about migraine, in general, or about using ice and heat for migraine.

Duyvejonck: But I really encourage patients to try different things and combinations of different modalities to really see what works for them. Is it the medication alone? Is it the medication combined with heat or ice therapy? Is it these things combined with neuromodulation devices and behavioral therapies? And I encourage people to try different combinations, really to see what their best strategy is, so that they can not only put those strategies, if we’re talking about a preventative standpoint, incorporating these things into their day-to-day, but also when they are experiencing the onset of an attack, that they can take their best combination of therapies and apply them immediately. Because that’s going to be your best strategy. See what combination of interventions can be helpful, and just do it upfront right away. Give your body and your brain the best chance for recovery.

O’Brien: If you had to pick ice or heat for migraine relief, what would you choose and why?

Duyvejonck: Oh, I’m an ice girl. And it’s, of course, very personal. I am a migraine patient myself. My daughter is a chronic migraine patient, and we would never want to be without our trusty ice cap that covers the back and the eyes, of course. So that would be my preference.

O’Brien: This has really been a fun conversation. I’m so glad I had a chance to speak with you today. Alicia Duyvejonck, thank you so much for joining us today and talking all about ice and heat for migraine. Your insight and expertise has been so helpful. We really appreciate it, and I know our audience will too. 

Duyvejonck: Thank you for having me. 

O’Brien: And that wraps up this episode of Spotlight on Migraine. Don’t forget to hit like and subscribe. To our followers, thank you for listening. This podcast is made possible by supporters like you. You can make a tax-deductible donation today at migrainedisorders.org. 

I’m Molly O’Brien. We’ll see you next time.

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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. AMD and the speaker do 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.