How do you help patients with migraine who ask for methods other than, or as adjuvants to, medical therapy? A headache expert offers suggestions to pass on.
Headaches are divided into two essential classifications by the International Classification of Headache Disorders: primary headaches and secondary headaches. “Secondary headaches," explains Dr Noah Rosen, "are when a headache is secondary to another condition such as a tumor or a spinal leak. A primary headache is where the headache itself is the problem.” Migraines fall into the latter category.
Rosen says primary care physicians can recommend a number of management strategies that may circumvent or reduce the need for medication:
Lifestyle modification. “So many headache disorders are triggered events,” Rosen explains. The more researchers learn about migraines, the more they appear to be related to neuroinflammation, which can be triggered by numerous things from dietary triggers to caffeine withdrawal.
Hence, lifestyle modifications can be very important. “That includes eating regularly, hydrating well, regular sleep and stress reduction,” Rosen says.
Triggers can be elusive. Patients with migraines also should attempt to track and record their headache triggers. However, “only about 70% of [migraine patients] ever identify a trigger for their headaches,” Rosen says.
Exercise, physical therapy and massage. In the same vein as lifestyle modifications, Rosen notes there is some evidence that regular aerobic exercise can provide preventive benefits. Yoga has also been studied and shown to have some positive effects on migraine.
Physical therapy, massage, and acupuncture also have all been linked to migraine relief, but do not have enough consistently validated research to prove their effectiveness. However, all of these modalities are likely to bring temporary relief and, at the least, not cause any harm, Rosen says.
Cognitive intervention. “Other validated treatments include psychological interventions, including cognitive behavioral therapy and biofeedback, a form of computer-aided progressive relaxation training,” Rosen says.
This often accompanies mindfulness training, in which a person pays very careful, focused attention to a set of stimuli or activities.
Supplements. Rosen says that there is some evidence that a couple of over-the-counter supplements-including magnesium, riboflavin, coenzyme Q-10, and feverfew-can provide some migraine relief.
“Riboflavin and co-enzyme Q-10 work upon the energy metabolism in the cell, on the mitochondria. There are several mitrochondrial diseases that have a high association with headache disorders, so that may be the mechanism by which it has the effect.” Rosen does warn, however, that not all supplements contain the ingredients or dosage levels they claim to, and that it might make sense to seek out those products where quality control data are available.
Devices. Lastly, Rosen mentions there are a number of medical devices on the market for migraine and cluster headaches. These include nerve stimulators, electrical TENS units and trans-cranial magnetic stimulators. Clinical evidence on effectiveness varies for each item.
When it comes to how to deploy one strategy over another, Rosen says “There’s no great guideline or strategy on how to implement these.” Cost may be prohibitive on some items, because many are not covered by insurance.
Cartoon illustrates use of the Cefaly® external trigeminal nerve stimulation device.
“You have to take a realistic assessment of what is the cost of this disease to your patient and what are the best options,” Rosen says. “Even a single lost day [to migraine] can be devastating.” The physician and patient will have to work together to try out the options that work best.
“More people now have options that fit what they’re looking for,” Rosen says. “And more people have achieved, if not pain free, then a lower frequency of pain now than ever before with the advancements we’ve had in the field.”
Migraines are not just bad headaches, they’re the most common severe primary headache disorder, affecting about 12% of the population, according to Noah Rosen, MD, director of the Headache Center at the Northwell Institute for Neurology and Neurosurgery in Manhasset, N.Y.Â In this short slide show Dr Rosen higlights a variety of management strategies that may help patients avoid or reduce the need for migraine medication.Jordan Rosenfeld is a contributing author.