Complementary and Integrative Medication for Migraine

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This transcript has been edited for readability.

Anna Tempo, MD: Hello, everybody, and welcome. My title is Dr Anna Tempo. I am an assistant professor of neurology on the Icahn College of Medication at Mount Sinai, and I direct the Headache Medication Fellowship at Mount Sinai Hospital. In the present day, I am fortunate sufficient to be joined by my illustrious colleague, Dr Zhang.

Dr Zhang, would you wish to introduce your self?

Niushen Zhang, MD: Hello, Dr Tempo. It is nice to be right here. I am Dr Niushen Zhang. I am a medical assistant professor of neurology. I am additionally the chief of headache drugs at Stanford College. Nice to be right here.

Tempo: In the present day, we will be speaking about complementary and integrative drugs for migraine. I feel it is a subject that has sparked numerous curiosity, particularly on the affected person facet over the past couple of years. Dr Zhang, are you able to inform me just a little bit about what precisely complementary and integrative drugs is?

Zhang: There are literally many definitions of it. What we typically take into consideration are nonpharmaceutical remedy approaches or healthcare practices that might not be a part of typical drugs. The American Board of Integrative Medication provides a really well-rounded definition of this, wherein they are saying that it is a observe of medication that focuses on the entire individual, and it must be knowledgeable by proof and make use of the entire applicable remedy approaches that may assist our sufferers obtain optimum well being.

The title that we use to explain this area of medication has modified over time. Initially, it was various drugs, then it was referred to as complementary and various drugs, or CAM. The latest time period that we use is complementary and integrative drugs.

Tempo: Or CIM, for brief. I feel CIM, primarily based on what you are describing, appears like it might match nicely with headache drugs, usually, after we’re excited about the entire various factors that may doubtlessly contribute to or have an effect on an individual’s headache frequency. A few of the issues that we all the time take into consideration are life-style elements that may have an effect on complications.

Do you might have any information or something you would like to speak about by way of a few of the completely different life-style elements that sufferers can work on after they need to attempt to cut back their headache frequency?

Which Sufferers May Profit From CIM?

Zhang: First, we all the time need to take into consideration which sufferers are a greatest match for this kind of remedy. We take into consideration sufferers who could not have had ample responses to their pharmaceutical remedies, who’ve poor tolerance to those remedies, or perhaps some medical contraindication to drugs. We additionally take into consideration individuals who could also be pregnant or lactating or planning being pregnant. These remedies will also be useful for individuals who have remedy overuse headache or exhibit important stress and should not have ample stress coping expertise.

Actually, the muse is the approach to life modifications. The way in which that I clarify it to sufferers is mainly your migraine mind is hypersensitive, particularly to alter. What it likes is a really common and predictable schedule for consuming, sleeping, and train.

Particularly, what we see for train is that about 20 minutes a day of cardio train can really lower headache frequency and severity. This might be something from devoted time to strolling, mountain climbing, biking, or swimming. These can all be very useful.

For sleep, poor sleep high quality, together with issues like insomnia, can have an effect on about 30% of sufferers with migraine. In our clinic, we all the time display for any potential underlying sleep issues, like sleep apnea. We need to make sure that our sufferers obtain applicable evaluations and remedy for these situations. What we discover most useful with sleep is simply retaining the identical bedtime and wake-up time day-after-day, Monday via Sunday.

In fact, we get many questions on meals and vitamin. The reality is the proof is simply not sturdy on this space presently, for any particular dietary interventions. We all the time counsel our sufferers to maintain a really common and constant meal schedule all through the day and to keep away from skipping meals. Sufferers additionally like to ask about meals triggers, however the proof just isn’t sturdy for what meals should be averted.

In observe, we discover that meals triggers are very particular person for folks. If somebody finds {that a} sure meals persistently triggers their migraines, then it might make sense to keep away from that meals, however usually, we do not encourage folks to limit their eating regimen.

Tempo: Train and sleep come up typically in my clinic as nicely. Notably for sufferers who discover that train could set off their assaults or they’re hesitant to do any train as a result of their assaults are so frequent, I typically advocate gentler, low-impact workouts, like yoga, tai chi, or swimming, for instance, which I feel folks discover just a little bit simpler to heat as much as or incorporate into their routine.

And actually specializing in good sleep hygiene, and even issues like attempting to wind down earlier than mattress and having some kind of routine, is admittedly useful. I’ve had numerous sufferers come to me and ask, “Is there something, like nutritional vitamins or natural dietary supplements, that I can take to attempt to assist stop my assaults?” There’s fairly numerous them which have good proof. What do you normally advocate on your sufferers?

Sturdy Proof for Nutraceuticals and Behavioral Therapies

Zhang: I am glad you introduced that up. There are, I’d say, 4 which might be evidence-based and really useful for our sufferers. One in all them is magnesium. That one has a stage B advice from the American Academy of Neurology (AAN)/American Headache Society (AHS). We predict it helps with calming down neuronal hyperexcitability and stopping cortical spreading melancholy. A few of the formulations we like are magnesium glycinate, magnesium oxide, and citrate. We do need to look ahead to any free stool or diarrhea, as a result of these are a few of the frequent unwanted effects that may doubtlessly occur. The day by day dosing is about 200-600 mg/d.

Apart from magnesium, we even have vitamin B2 or riboflavin. That additionally has a stage B advice, and it is well-tolerated. Some folks do get very vibrant orange or yellow urine after they take it, and the dosing is round 400 mg. There’s additionally coenzyme Q10, which has stage C advice from AAN/AHS. It performs a job within the electron transport chain and should play an essential function in sustaining mitochondrial power shops. It is also very well-tolerated, and the day by day dosing is about 300 mg.

The final one we’ve got is one thing referred to as feverfew, which is a kind of chrysanthemum. This additionally has a stage B advice. We predict this may occasionally have some anti-inflammatory properties. Some folks do get gastrointestinal (GI) unwanted effects with that, so that you do should be careful. We do not advocate this one throughout being pregnant as a result of it might trigger early contractions and doubtlessly miscarriage. The day by day dosing for that’s 50-300 mg.

Tempo: It is nice that there are such a lot of completely different nutraceutical choices for migraine prevention. I personally discover the mix of magnesium and riboflavin to be one which I have a tendency to begin with. I feel nutraceuticals come up very often. I’ve many sufferers who ask me about them. Are there any sufferers, particularly, whom you assume would profit most from nutraceuticals?

Zhang: Just like what we talked about earlier than, lots of our sufferers simply do not tolerate a few of the pharmaceutical remedies that we’ve got, so this could be possibility to begin with. One factor I all the time ask my sufferers to remember is that the advance could be gradual with these dietary supplements. Actually, like several preventive remedy, you need to give it as much as 3 months earlier than somebody may even see most profit.

Tempo: Agreed. I feel it is onerous typically to attend that lengthy, however after they do, it actually might help. One other kind of CIM remedy that has actually nice proof in migraine prevention contains the behavioral therapies, which brings to thoughts issues like cognitive-behavioral remedy. I am curious what your ideas are about these and whether or not or not you advocate sufferers to make the most of them?

Zhang: I feel these are terrific choices. Actually, I feel one of many challenges for suppliers is learn how to broach this subject with out making your sufferers really feel such as you’re dismissing their expertise as psychiatric or psychological. I feel one strategy to method that is to assist your sufferers perceive that the contributors to their complications are normally partial and additive, and that issues like stress, nervousness, and temper issues can have a big impression on their complications.

That is why it is actually essential that we discover efficient methods to deal with these. What’s nice is that now we’ve got the very best stage of proof exhibiting that particular biobehavioral remedies, corresponding to cognitive-behavioral remedy, biofeedback, and leisure coaching, are all efficient preventive remedies for migraine.

Tempo: So far as I perceive, it appears like sufferers who’ve migraine and who may have nervousness and melancholy could profit from these. Do you ever see sufferers who haven’t got a historical past of hysteria or melancholy make the most of any of those therapies and discover them useful only for migraine?

Zhang: Completely. I’d say leisure coaching and likewise biofeedback. These are nice as a result of you can’t solely use them as a preventive remedy — issues that you simply observe every day for prevention — but additionally attain for them as acute remedy instruments while you really feel that migraine escalating or the onset of migraine.

Tempo: I feel that sounds nice, and I agree. I discover that typically broaching this subject with sufferers generally is a bit difficult as a result of on the one hand, you need to have the ability to validate their expertise, however on the similar time assist to focus on a few of the potential temper elements of their presentation or the nervousness that comes with having a migraine assault with aura, which I see very generally and I am positive you in all probability do as nicely. Utilizing issues like leisure remedy within the second throughout an aura, I feel, could be extremely helpful.

One of many different issues that I all the time get requested about is acupuncture and whether or not or not there’s proof for that by way of its efficacy in serving to with migraine prevention. I appear to get that query from lots of my pregnant sufferers. Do you might have any expertise recommending acupuncture to sufferers? What do you concentrate on the info for that?

Acupuncture and Yoga: Extra To Be taught

Zhang: We’re very data-driven and we need to present evidence-based remedies for our sufferers. Acupuncture has fairly good proof for its use as a preventive remedy in episodic migraine. There’s nonetheless sparse proof for utilizing it to deal with persistent migraine or to make use of it as an acute remedy.

On the subject of treating episodic migraine with acupuncture, there’s a superb 2016 Cochrane evaluation that properly summarizes the proof for acupuncture for this remedy. They checked out 22 trials with nearly 5000 sufferers and located that acupuncture is barely simpler than sham in decreasing frequency of complications and a minimum of equally efficient as a few of our customary prophylactic drugs.

Tempo: That is nice. So far as I do know concerning the information, it looks as if it might be possibility along with, maybe, the normal therapies that we’re utilizing, like oral drugs. Equally, yoga additionally comes up in the identical dialog — whether or not yoga could be helpful. Once more, lots of my pregnant sufferers ask this query. Do you ever advocate yoga to sufferers?

Zhang: With yoga, I feel there’s nonetheless a lot we’ve got to study by way of the way it helps our sufferers with migraine. At the moment, we simply haven’t got that a lot strong proof for that.

There was a randomized medical trial revealed in Neurology in 2020 that seemed on the impact of yoga as an add-on remedy for episodic migraine. They’d two teams. One was a medical remedy group, and the opposite underwent medical remedy for migraine remedy, in addition to yoga. They’d the yoga group observe a predesigned yoga intervention 3 days per week for 1 month with an teacher at a middle. This was adopted by, I feel, 5 days per week for two months at residence. They checked out over 100 sufferers for this research.

Ultimately, after they in contrast the medical remedy group with the yoga group, the yoga group confirmed a big lower in headache frequency, depth, and a few of the migraine incapacity scores. The conclusion was that yoga, as an add-on remedy for episodic migraine, could also be superior to medical remedy alone. I feel it is a very promising starting by way of the analysis, and I actually hope that we get extra research like this finished sooner or later.

Tempo: Sure. I feel it illustrates an essential idea that I feel many people ascribe to, in that it is actually essential to consider the affected person, what their life-style is like, and what they really feel snug with by way of a remedy routine and the way essential it’s to essentially create an individualized plan for them.

I personally use, typically, a mix of pharmacologic remedy and nonpharmacologic remedies, so the truth that that research confirmed that yoga was nice along with conventional migraine remedy hammers that time residence for me, by way of utilizing even a few of the different therapies that we have talked about along with our conventional oral or injectable therapies for migraine. Would you agree?

Zhang: I completely agree, Dr Tempo. I feel a few of the most useful remedy plans that we develop for our sufferers are those who combine each pharmacologic instruments and the nonpharmacologic instruments that we’ve got. A part of why I like headache drugs is that we really get to personalize these remedies for our sufferers.

Tempo: I utterly agree. I feel that is place for us to finish. We thanks all very a lot for becoming a member of us.

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