Migraine Management Lifestyle and Alternative Treatments Dr David PB Watson Hamilton Medical Group Aberdeen Department of Neurology ARI

Summary The sensitive brain Triggers Lifestyle Alternative treatments

Triggers suggest that migraine is a disorder of the brain The case for the sensitive migraine brain Normal life events trigger or are associated with attacks in those predisposed Dehydration Kelman, p 396, Fig 2 Kelman, p 394, C1, Par 1, L 1-15 Sleep disturbance Diet Environmental stimuli Hunger The triggers (with their frequencies) in this study were stress (79.7%), hormones (eg, estrogen levels in women) (65.1%), hunger (57.3%), sleep disturbance (49.8%), Stress Changes in oestrogen level in women R1, p 1434, C2, Par 2, L 1-4 R1, p 1434, C2, Par 3, L 1-2, 14-16 R1, p 1434, C2, Par 3, L 4-13 Coppola G et al. Cephalalgia. 2007;27:1429–1439; Kelman L. Cephalalgia. 2007; 27:394–402; Pietrobon D et al. Nat Rev Neurosci. 2003;4:386–398. R2, p 391, C1, Par 2, L 6-9 R2, p 390, Legend to Fig. 3 R3, p 1, Abs, Par 1, L 1-2 R3, p 1, Abs, Par 1, L 7-8 R3, p 1, Abs, Par 1, L 8-12 References: 1. Coppola G, Pierelli F, Schoenen J. Is the cerebral cortex hyperexcitable or hyperresponsive in migraine? Cephalalgia. 2007;27(12):1429–1439. 2. Pietrobon D, Striessnig J. Neurobiology of migraine. Nat Rev Neurosci. 2003;4(5):386–398. 3. Kelman L. The triggers or precipitants of the acute migraine attack. Cephalalgia. 2007;27(5):394–402.

Routine The migraine brain likes routine Regular meals Regular sleep Regular exercise Regular hormones

Migraine Triggers A high percentage of migraine patients report triggers The mean number of triggers in one study was 6.7 per patient Kelman L. Cephalalgia 2007;27:394–402. 1. Kelman L. Cephalalgia 2007;27:394–402. 5

Trigger 1 - Stress Stress Tension Can increase migraine frequency and severity Relaxation Can reduce migraine frequency and severity

Stress and Pressure

Symptoms of Stress headache palpitations abdominal cramps sleep disturbance indecisiveness anxiety impatience difficulty relaxing difficulty concentrating recurrent fatigue irritability depression increase in eating, drinking or smoking increased caffeine consumption pacing fidgeting nervous habits (nail-biting, foot-tapping)

Stress Management Tips if you're stressed the first step to feeling better is to identify the cause. be physically active take control connect with people have some ‘me time’ challenge yourself avoid unhealthy habits try volunteer work work smarter, not harder be positive accept the things you cannot change massage – good for relaxation

Trigger 2- Hormones Mainly migraine without aura Menstrual migraine and oestrogen withdrawal Perimenopausal headache oestrogen fluxes Pregnancy generally good for migraine

Trigger 3- Missing meals Main food trigger is missing meals and hunger Caffeine withdrawal and dehydration can cause headache Food Trigger Myths A review of clinical studies suggests there is no evidence that foods trigger migraine. Crawford P, Simmons M. Journal of Family Practice 2006;55(1):62-6. There is no evidence to support avoidance of cheese or chocolate, or exclusion diets eadachin2006;7(4):188-95.Wober C et al: Cephalalg07;27(4):304-14 Omega-3 fatty acids do not reduce the incidence of migraine. Pradalie001;21(8):818-22

Case Study slide a 28 year old female nurse Normal migraine frequency one every 1-2 weeks Last 6 months full migraine every 4 days and back ground headache most other days Taking lots of painkillers to get through What changed?

Case study slide b Promoted to nurse practitioner in hospital Working 12 hour shifts 2 day , 2 night, 3 off Studying for prescribing degree Caring for gran Long distance relationship

Case study slide c Solution = breaking arm!! Return to work 4 days, 3 days off, 4 nights, 4 days off Partner moved to Aberdeen Gran died Given study leave

Alternative therapies

Acupuncture A well conducted study compared acupuncture and sham procedures and compared them to a controls on a waiting list. Patients receiving acupuncture or sham acupuncture fared significantly better for most outcome measures. But there were no significant differences between the acupuncture group and the sham acupuncture group. There are obvious problems in this study with the control group being on a waiting list, any intervention will have a powerful placebo effect.

Herbal Remedies Feverfew, butterbur, coenzyme Q & oral niacin may have a role in migraine prevention Riboflavin in a dose of 200 mg per day has been compared to placebo and found to have a responder rate of 59% versus 15% for the number of migraine days Schoenen J, Jacquy J, Lenaerts M.; Neurology 1998;50(2):466-70. some studies that seem to suggest that feverfew, butterbur and coenzyme Q may have a role in migraine prevention as may riboflavin which has a reasonable trial to support its use.

Physical Therapies No Evidence Weak Evidence that spinal manipulation, osteopathy or chiropractic treatment have any role in the preventive treatment of migraine. Weak Evidence for TENS (Transcutaneous electrical nerve stimulation)

Summary Migraine brain does not like change Lifestyle changes can make a significant difference Alterative therapies can help some patients

Any Questions?