Migraine support with Dr Kellie

I have been a migraine sufferer almost all my life.  I can remember doing a trial avoiding histamines as a kid.  I understand how intrusive they are.  And if they aren’t laying you out flat, it’s one of those heavy headaches that can make it really hard to get through the day.

I’ve found that there are a lot of people that have normalized their headaches.  It’s just what we do—we have to get through the day, and if there are a few days that are miserable, it is what it is.  Many people don’t even really discuss it with their family doctors, managing with over-the-counter pain management.

Checking in with a family doctor and possibly a referral to a neurologist is important, especially if your migraines are new or different, so that other underlying conditions can be ruled out. From there, one of the first treatment options is to try rescue medications called triptans.  Triptans, like Imitrex or Ralpax, can work well and feel essential for day-to-day functioning.  Unfortunately, they are very expensive and won’t address the frequency of the migraines, and all these rescue options can and do cause rebounding. For me, while Ralpax worked well at first, over time I started to get a rotten rebound headache 48 hours after every dose.

Migraine Prevention

With more frequent headaches and migraines, it's often better to look at preventative medications and options.  And this is where Naturopathic Medicine fits into this picture.  A few years ago, I was referred to an amazing Neurologist.  She was understanding of Naturopathic medicine and said something that I found valuable.  She said something to the effect of "It's your job as a Naturopathic Physician to help decrease the things that will push you into a migraine headache, the things that will tip you over your migraine threshold.  It's my job, as your Neurologist, to help you find the things that will make your migraine threshold more stable, so those triggers can’t push you over as easily."

Some of the prescription medication options that are helpful for stabilizing that migraine threshold include low-dose amitriptyline, calcium channel blockers, beta blockers, and several seizure medications, including topiramate and lamotrigine; CGRP antagonists (gepants); and others[1].   Amitriptyline is an older generation antidepressant, which might seem odd but at low doses it can be very helpful for managing chronic pain conditions, including migraine and fibromyalgia[2].  Side effects are varied, but with amitriptyline and beta- and calcium channel blockers, they commonly include fatigue, dry mouth, and constipation. Again, it seems odd that antiepileptic drugs are used for migraines, but there is a good amount of research supporting their use[3].  In particular, topiramate has strong evidence behind it and can be titrated down after 6 months of use with ongoing benefit.  Unfortunately, its side effects can be more profound  and can include cognitive side effects like fatigue; mood changes, including suicidal ideation; dizziness; word-finding problems; slowed thinking/mental processing; and concentration/attention and memory difficulty, as well as numbness or tingling in the hands or feet, and it absolutely cannot be used in pregnancy. Gepants (one of my favourite medication names!) are really interesting; they can be used as preventative medications and as rescue meds. This is handy because they don't usually cause rebounding; they become preventative when they are used more frequently. Unlike triptans that are significantly more effective at the very onset of a migraine, Gepants can be used later into the headache. This is helpful because migraines can sneak up and look like a tension headache and then escalate. And rescue medications are expensive; lots of folks don't want to use them until they are sure the headache won't be managed with the usual headache tricks.

Naturopathic options for migraines and headaches

So how do we use Naturopathic Medicine for migraines.  There are lots of avenues to follow, as there can be many triggers for headaches, and it's important to look at the individual’s full picture to decide on a therapeutic course. There is often a strong hormonal influence, and so helping the body to support the estrogen/progesterone balance is a strong starting point[4].  I often use herbal medicine or bioidentical hormone replacement to support progesterone or estrogen balances.

There is also excellent research to support the use of specific herbs or supplements in headache prevention.  Melatonin has been examined in several ways, including head-to-head trials with amitriptyline and valproic acid.  It has consistently been shown to be effective in reducing the frequency, duration,  and intensity of migraines[5].  I also use a blend of magnesium, CoQ10, butterbur, feverfew, and B2 for migraine prevention, which is well tolerated and can be very effective [6][7][8].

The take-home message here is that many people suffer from migraines and headaches and feel they have to power through and so don’t consider seeking treatment.  However, there are a host of therapeutic options, both pharmaceutical and herbal or nutraceutical.  It’s also very important to check in with your Primary Care provider and/or a Neurologist to ensure there aren’t any underlying issues that need to be addressed immediately. From there, the best approach looks at the frequency, timing, known triggers, and other symptoms such as menstrual or digestive complaints.  No one should have to push through without support.

[1] DW, R. (2019). Other Preventive Anti-Migraine Treatments: ACE Inhibitors, ARBs, Calcium Channel Blockers, Serotonin Antagonists, and NMDA Receptor Antagonists. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30880363 [Accessed 1 May 2019].

[2] Group, C. (2019). Amitriptyline in the prophylactic treatment of migraine and chronic daily headache. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/21070231 [Accessed 1 May 2019].

[3] SD, P. (2019). Current Status of Antiepileptic Drugs as Preventive Migraine Therapy. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30880369 [Accessed 1 May 2019].

[4] Li W, e. (2019). Changes in hormones of the hypothalamic-pituitary-gonadal axis in migraine patients. - PubMed - NCBI. [online] Ncbi.nlm.nih.gov. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29366620 [Accessed 1 May 2019].

[5] Long R, et al (2019). Theraperutic role of melatonin in migraine prophylaxis: A systematic review. – PubMed – NCBI.[online] Ncbi.nlm.nih.gov. Available at https://ncbi.nlm.gov/pubmed/30653130 [Accessed 1 May 2019].

[6] Guilbot A, et al (2017). A combination of coenzyme Q10, feverfew and magnesium for migraine prophylaxis: a prospective observational study. – PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at https://www.ncbi.nlm.nih.gov/pubed.28854909. [Accessed 1 May 2019].

[7] Rajapakse T, et al (2019).  Phytomedicines in the Treatment of Migraine. -PubMed – NCBI. [online] Ncbi.nlm.nih.gov.  Available at  https://www.ncbi.nih.gov/pubmed/30627973. [Accessed 1 May 2019].

[8] Talebian A., et al (2018). Prophylactic effect of riboflavin on prediatric migraine: a randomized, double-blind, pacebo-controlled trial. -PubMed – NCBI. [online] Ncbi.nlm.nih.gov. Available at https://ncbi.nlm.nih.gov/pmc/articles/PMC5878019/er.