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Complementary and Alternative Medicine:
Does it have a place in Headache Medicine?
Brian Plato, DO
Norton Headache and Concussion Center
Norton Neuroscience Institute
Louisville, KY
[email protected]
@DrBrianMPlato
Disclosures
• Speaker / Received honorarium
• Allergan
• Depomed
Objectives
• To introduce different modalities and the
evidence base for using CAM in treating
headache disorders
• To review the AAN / AHS guidelines for the
use of CAM in the preventive treatment of
migraine
A few definitions to start
• Complementary and alternative medicine refers
to medical products and practices that are not
part of standard care
• Complementary = used along with standard
medical care
• Alternative = used instead of standard medical
care
• Integrative medicine = combining the best of
conventional medical care and the best evidencebased CAM
CAM Use in Migraine Patients
• 50% of patients with migraine reported any
CAM use
• Compared to 34% of patients without migraine
• 27% of patients with migraine reported the
use of herbals or other supplements
• Compared to 18% of patients without migraine
RE Wells, et al. Headache. 2011; 51(7): 1087-1097
CAM Use in Migraine Patients
• Patient reported reasons for CAM use:
• Conventional treatment was too expensive (11%)
• Conventional treatment was ineffective (21%)
• Provider recommendation (31%)
• Only 43% of all patients (migraine/nonmigraine) discussed their use of CAM with
their healthcare provider
RE Wells, et al. Headache. 2011; 51(7): 1087-1097
CAM topics to be discussed
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Nutraceuticals
Yoga
Acupuncture
Diet
Nutraceuticals
• A form of complementary and alternative
medicine
• A combination of the words “nutrition” and
“pharmaceutical”
• Products that are derived from food sources
that are purported to give health benefits
Nutraceuticals
•
•
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•
•
•
•
Riboflavin (vitamin B2)
Coenzyme Q10
Magnesium
Butterbur (petasites hybridus)
Feverfew
Histamine
Omega-3 polyunsaturated fatty acids
AAN / AHS Guidelines
S. Holland, et. Al. Neurology. 2012;78;1346-1353.
Riboflavin / Vitamin B2
• Acts as a cofactor for enzymatic reactions
including electron transport chain, production
of niacin and conversion of B6 and vitamin A
• Food sources include milk, cheese, liver,
mushrooms and almonds
• Recommended daily allowance is a minimum
of 1.2mg
• Excess is excreted in urine producing a bright
yellow color
Evidence for riboflavin
• Riboflavin 400mg/day compared to placebo
for 3 months
• 55 patients included
• Riboflavin group had on average 2 fewer
migraine days per month
• Study population had between 2-8 / mo
• 50% responder rate
• Riboflavin 59% vs placebo 15% (p=0.002)
• Adverse events included diarrhea and polyuria
Shoenen J. Neurology. 1998; 50(2):466-470.
Evidence for riboflavin
• Combination of riboflavin 400mg, magnesium
300mg and feverfew 100mg compared to
riboflavin 25mg (used as placebo due to
urinary color changes)
• 52 patients included
• 50% responder rate
• Active=42% vs “Placebo”=44%
• Placebo rate of 22% in pooled oral preventive studies
Maizels M. Headache. 2004;44(9):885-890.
Meissner K. JAMA Intern Med. 2013;173(21):1941-1951.
Riboflavin Takeaway?
• Probably effective (Level B)
• Few side effects
• Personal experience: Relatively cheap, not
necessarily the easiest to find in stores,
somewhat effective
Coenzyme Q10
• Present primarily in mitochondria
• Component of the electron transport chain,
involved in generation of ATP
• Has 3 states:
• Ubiquinone – fully oxidized
• Semiquinone
• Ubiquinol – fully reduced
• Which one?
• I am not aware of any evidence that either one is superior to
the other taken as a supplement as the body freely converts
between the two states
Evidence for CoQ10
• CoQ10 100mg TID vs placebo
• 42 patients included
• Active group had on average 1.2 fewer
migraine days per month
• Study population had between 2-8 / mo
• 50% responder rate
• CoQ10 48% vs placebo 14%
• Adverse events included 1 cutaneous allergy
Sandor PS. Neurology. 2005; 64(4):713-715.
Evidence for CoQ10
• Open labeled pediatric study with measurement
of pre and post treatment CoQ10 levels
• Recommended supplementation for lower CoQ10
levels or ratio of CoQ10/cholesterol
• Supplemented 1-3mg/kg per day
• Followed serum CoQ10 levels
• At follow-up:
• CoQ10 level increased from 0.46ug/mL to 1.23ug/mL
• Headache frequency decreased from 19.2 days/mo to 12.5
days/mo
• 50% reduction in 46%
Hershey AD. Headache. 2007; 47(1):73-80.
Coenzyme Q10 Takeaway?
• Possibly effective (Level C)
• Few side effects
• Personal experience: Readily available, can be
somewhat expensive, I use frequently
Magnesium
• Magnesium is an intracellular cation involved
in many intracellular processes
• Patients with migraine may have magnesium
deficiencies due to inability to absorb
magnesium, renal wasting, excessive excretion
or low nutritional intake
• Routine blood tests do not adequately reflect
magnesium stores in the body
Mauskop A. J Neural Transm. 2012; 119(5):575-9.
Magnesium and migraine
• Magnesium deficiency causes NMDA-coupled
calcium channels to be opened
• With magnesium deficiency NMDA receptors
allow an influx of calcium, leading to
generation of nitric oxide radicals
• May promote cortical spreading depression
• May promote hyperaggregation of platelets
Mauskop A. J Neural Transm. 2012; 119(5):575-9.
Teigen L. Cephalalgia. 2014 Dec 22.
Evidence for magnesium
• Review by Teigen and Boes looked at studies
assessing magnesium status in patients with
migraine as well as oral magnesium
supplementation
• Results:
• Generally an association between low magnesium
levels and migraine
• Oral preventive treatment: 1 menstrual migraine and 3
episodic migraine studies
Teigen L. Cephalalgia. 2014 Dec 22.
Evidence for magnesium
• Studies ranged from 40 – 81 patients
• Dosing was 243mg BID – 600mg/day
• Results ranged from 0-1 fewer attacks per
month
• Side effects included GI events / diarrhea
Teigen L. Cephalalgia. 2014 Dec 22.
Koseoglu. Magnes Res. 2008;21:101-108
Peikert A. Cephalalgia. 1996;16:257-263
Pfaffenrath V. Cephalalgia. 1996;16:436-440.
Magnesium for acute treatment
• 2 class II studies
• 1000mg of IV magnesium sulfate vs placebo
• Statistically significant benefit for migraine with aura at 60 minutes
» Headache relief 50% vs 13%
» Headache freedom 37% vs 7%
• Migraine without aura was not statistically significant
» Headache relief 33% vs 17%
» Headache freedom 23% vs 10%
• 2000mg IV MgSO4 vs 10mg metoclopramide vs
placebo
• No statistically significant difference between the groups
• Subgroup of migraine with aura did show benefit compared to
both placebo and metoclopramide
Bigal ME. Cephalalgia. 2002;22:345-353
Cete Y. Cepahalalgia. 2005;25:199-204.
Pregnancy category
• 2013 – FDA changed magnesium sulfate to
category D
• The administration of magnesium sulfate IV for longer
than 5-7 days may lead to low fetal calcium levels and
osteopenia and fractures
• Magnesium oxide is category B
Magnesium Takeaway?
• Probably effective (Level B)
• GI side effects
• Useful for patients with constipation?
• Personal experience: Readily available, I use
500mg/day of magnesium oxide, particularly if
patients have migraine with aura
Butterbur
• Plants belonging to the family petasites
• An extract of the root petasin has antiinflammatory effects (inhibits COX-2) as well
as regulates calcium channels
• Butterbur extract also contains pyrrolizidine
alkaloids which is a hepatotoxic product
Evidence for petasites
• Petasites extract 75mg BID vs 50mg BID vs placebo
• 245 patients, 2-6 attacks per month
• Percent change from baseline in migraine frequency
• Placebo -28%
• 50mg BID -36% (p=NS)
• 75mg BID -48% (p=0.0012)
• 50% responder rate
• Placebo 49%
• 50mg BID 56% (p=NS)
• 75mg BID 68% (p=<0.05)
• Side effects – mild GI events (belching)
Lipton R. Neurology. 2004;63(12):2240-4.
Evidence for petasites
• Petasites 50mg BID vs placebo for 12 weeks
• 33 patients
• Attack frequency per month
• 50mg BID = 3.41.8
• Placebo = 2.92.6
• 50% responder rate
• 50mg BID = 45%
• Placebo = 15% (p=NS)
Diener HC. Eur Neurol. 2004;51(2):89-97.
Butterbur controversy
• Butterbur extract contains pyrrolizidine
alkaloids, which is a hepatotoxic substance
• This must be carefully removed in the
manufacturing process
• A review of 21 commercially available
products found that 7 contained PAs and only
7 contained the amount of petasin reported
on the product’s label
Avula B. J Pharm Biomed Anal. 2012;70:53-63.
Butterbur controversy
• Petadolex brand was previously registered with
German health authority, but lost this approval in
2009 due to a reported change in manufacturing
process
• 40 cases of liver toxicity have been reported,
including 9 cases of acute hepatitis and two
requiring liver transplantation
• For comparison – the rate of hepatotoxicity with
acetaminophen is 2.98 adults per 100,000 in US
population
Medicines and Healthcare Products Regulatory Agency. 2012. Consumers are
advised not to take unlicensed Butterbur (Petasites hybridus) herbal
remedies. All Herbal Safety Warnings and Alerts 27 January 2012.
NIS 1998-2008
Butterbur Takeaway?
• Established efficacy (Level A)
• GI side effects
• Hepatotoxicity
• Personal experience: I am generally not
recommending it; patients who have
previously taken butterbur have not had a
robust response (bias)
Feverfew
• Medicinal herb grown in Europe, North
America and Chile
• May inhibit platelet aggregation and release of
serotonin
• Anti-inflammatory effects through the
inhibition of prostaglandin synthesis
Evidence for feverfew
• CO2-extract of feverfew MIG-99 6.25mg TID
• 170 patients included
• Compared average number of migraine attacks per 28
days in months 2 and 3 compared to baseline
• Decrease in number of attacks:
• Active=-1.9
• Placebo=-1.3 (p=0.00456)
• Responder rates:
• Active=30%
• Placebo=17% (p=0.047)
• Side effects include GI upset and mouth ulcers
Diener HC. Cephalalgia. 2005;25(11):1031-41.
Evidence for feverfew
• Cochrane Review 2015
• Reviewed 6 studies with 561 patients (Diener
study accounts for almost 1/3 of patients)
• Positive trials
• Diener study
• 3 other smaller studies (17-60 patients)
• Negative trials
• Trials of 50 and 147 patients did not find statistical
significance
Wider B. Cochrane Database Syst Rev. 2015 Apr 20;4.
Feverfew Takeaway?
• Probably effective (Level B)
• CHS recommends AGAINST it’s use
• Few side effects
• Personal experience: Have not used much in
isolation, used in combination products
• Avoid use in pregnancy – may cause
contractions and promote bleeding
Histamine
• Affinity for H3 receptors and may inhibit
neurogenic inflammatory response in
migraine
Evidence for histamine
• Three studies (all from the same center) show the
efficacy of histamine for migraine prevention
• Dosed as 1-10ng 2x/week
• Studies compared to placebo, sodium valproate
and topiramate
• Showed benefit compared to baseline and placebo
• Similar benefit to oral medications
• Side effects include burning and itching at
injection site
Millan-Guerrero. Can J Neurol Sci. 2006;33:195-199.
Millan-Guerrero. Eur J Neurol. 2007;14:1079-1084.
Millan-Guerrero. Eur Neurol. 2008;59:237-242.
Histamine Takeaway?
• Probably effective (Level B)
• Few side effects
• Personal experience: I have used a few times,
was somewhat difficult to get compounded
and not that effective
Omega-3 polyunsaturated fatty acids
• Have immunomodulatory effects
• Decrease the release of 5HT
• Have anti-inflammatory effects
Omega-3 PUFA
• One study of 3gm BID vs placebo
• 196 patients
• 4 month period of study
• Mean number of attacks during the last month of
treatment
» Active=1.2
» Placebo=1.26 (p=NS)
• Number of attacks during the total 4 months
» Active=7.05
» Placebo=5.95 (p=0.036)
Pradalier A. Cephalalgia. 2001;21(8):818-22.
Omega-3 PUFA Takeaway?
• Inadequate evidence (Level U)
• Few side effects
• Personal experience: I have not recommended
Marijuana
• Great review by Dr. Eric Baron in Headache
Currents
• Please read this!
Marijuana – Terms to know
• Cannabis is the plant genus
• Delta9-tetrahydrocannabinol (THC) is the
psychoactive cannabinoid
• Cannabidiol (CBD) is the non-psychoactive
cannabinoid
• High THC / low CBD = marijuana
• High CBD / low or no THC = hemp
History of cannabis use
• Introduced to Western world in 1839, suggested
for analgesia and muscle relaxant
• Daily doses of cannabis suggested for prophylaxis
in 1872
• 1915 – Osler advocated use of cannabis when
treating migraine
• Legally, cannabis began being labeled as poison in
the early 1900s and by mid-1930s was regulated
as a drug in every state
• In 1970 marijuana was labeled as a schedule 1
substance (same as heroin and LSD)
Medicinal uses in modern times
• In 1996 California passes the Compassionate
Use Act allowing the use of marijuana for
medical purposes
• Now 23 states have legalized medical
marijuana
• AK, AZ, CA, CO, CT, DE, HI, IL, ME, MD, MA, MI,
MN, MT, NV, NH, NJ, NM, NY, OR, RI, VT, WA +
DC
Endocannabinoid system
• Cannabinoid receptors
• CB1 = peripheral and central nerve terminals
» Influences neurotransmitter release
• CB2 = peripheral tissues
» Influences release of cytokines and cell migration
• THC has agonist activity at these receptors
• Endogenous cannabinoids
• AEA
• 2-AG
• Have activity at the CB1 and CB2 receptors
Use of cannabis in headache
• THC and CBD have analgesic properties
• Increase pain thresholds
• 15-20mg of THC is similar to 60-120mg of codeine
• Cannabinoids are active through CB1 receptors in
brain and brainstem
• PAG, nucleus trigeminal caudalis, trigeminal ganglia
• AEA inhibits dural blood vessel dilation
• AEA levels are decreased in CSF of patients with
chronic migraine
• ?Secondary to increased activation of trigeminal vascular
system
Dronabinol
• Pure isomer of THC
• Approved by FDA for chemotherapy
associated nausea/vomiting and anorexia and
weight loss associated with AIDS
• Has slower peak effects
• Lower peak blood levels (compared to
smoking)
Evidence for cannabis use in migraine
• No controlled trials
• Small case series with benefits similar to
ergotamine and aspirin
• Small case series of patients with headache
following cessation of marijuana use
• ?MOH with withdrawal headache
• Other case reports of refractory patients
• Surveys of marijuana users report ~5% using
for migraine treatment
Noyes. Compr Psychiatry. 1974;15:531-535.
El Mallakh RS. Headache. 1987;27:442-443.
Cannabis and cluster
• Case report of refractory cluster patient
responsive to smoked marijuana and
dronabinol 5mg
• Survey of chronic cluster patients found 26%
regularly consumed cannabis
• Another survey found that ~75% reported
some efficacy
Robbins MS. Headache. 2009;49(6):914-916.
Donner A. J Neurol Neurosurg Psychiatry. 2007:78:1354-1358.
Leroux E. Cephalalgia. 2013:33;208-213.
Adverse Effects
• Many variables
•
•
•
•
Route of administration
Concurrent medication use
Cannabis strain
Growing conditions
• Sedation, euphoria, dysphoria, distortion of senses,
ataxia, dependence
• Personal note: I have had 2 patients on topiramate who
later used recreational marijuana and had acute
psychosis; of all my other patients on medications – no
one else has ever mentioned acute psychosis to me
Cannabis and Stroke
• French series of 67 patients with RCVS
• 55% of patients have vasoactive drug exposure
• Most common was cannabis (30%)
• Multiple studies have also linked cannabis to
ischemic and hemorrhagic stroke
• ?Vasospasm
• ?Hypotension
• ?Synergy with other substances
Ducros A. Brain. 2007;130(Pt 12):3091-3101.
Napchan U, Buse DC, Loder EW. Headache Currents 2011.
Cannabis Takeaway?
• No controlled trials
• Does have a rationale physiological
explanation for use in headache disorders
• If possible, clinical trials are warranted
• For me, it is not legal in the state that I
practice
Yoga
• Yoga originates from Ayurveda-ancient
knowledge aiming to realize the true sense of life
and to find remedies for diseases
• A mind-body technique
• Interest in yoga to improve chronic and acute
pain
• May increase tissue oxygenation and release of
endorphins
• May decrease sympathetic nervous system
activity and reduce inflammatory markers
Slade SC. J Manipulative Physiol Ther. 2007;30:301-11.
Yadav RK. J Altern Comp Med. 2012;18:662-7.
Yoga and migraine without aura
• 72 patients assigned to either yoga or self-care
for 3 months
• Yoga group had reductions in:
•
•
•
•
•
•
Headache intensity
Frequency
Pain rating index
Total pain rating index
Anxiety and depression scores
Symptomatic medication use
John PJ. Headache. 2007;47:654-661.
Effect on endothelial function
• 32 patients with migraine
• Divided into medical treatment vs medical
treatment + yoga for 12 weeks (3 sessions/
week)
• Intercellular and vascular cell adhesium
molecule (ICAM and VCAM) levels used to
assess endothelial dysfunction
• Following intervention statistically significant
decrease in VCAM in yoga group
Naji-Esfahani. IJPM. 2014;5(4):424-9.
Effect on migraine and autonomic
function
• 60 patients randomized to conventional care or
conventional care + yoga
• Yoga 5x/week for 6 weeks
• Compared headache frequency and severity pre- and
post- intervention
• Also compared autonomic functions including heart
rate variability, R-R interval changes and
sympathovagal balance
• Benefits seen both in headache as well as vagal tone
and reduced sympathetic activity
Kisan. Int J of Yoga. 2014;7:126-132.
Kisan. Int J of Yoga. 2014;7:126-132.
Yoga Takeaway?
• Improved endothelial function
• Improved autonomic function
• Improved headache frequency and severity
• All in small studies
• No major side effects or contraindications if
done with guidance (at least initially)
• We use frequently and offer weekly classes
Acupuncture
• A component of traditional Chinese medicine
that originated over 3000 years ago
• An array of procedures that stimulate points of
the body by penetrating the skin with needles
stimulated by either the hands or electrical
devices
• TCM views the body as a balance of Yin and Yang,
and health is achieved by a balanced state
• Qi is the energy that circulates throughout the
body and flows through the major and minor
meridians
Acupuncture for analgesia
• Mechanism of action is not understood
• May suppress the nociceptive trigeminal
nucleus caudalis and spinal dorsal horn
neurons
Sheng LL. Neurosci Res. 2000;38:331-339.
Zhao CH. Headache. 2005;45:716-730.
Evidence for acupuncture
• Cochrane review of acupuncture for migraine
prophylaxis
• 6 trials compared acupuncture to no
treatment (“routine care only”)
• 14 trials compared acupuncture to sham
intervention
• 4 trials compared acupuncture to prophylactic
drug treatment
Linde K. Cochrane Database Syst Rev. 2009 Jan 21;1.
Acupuncture for migraine prophylaxis
• Significant heterogenity between trials
• Compared to no prophylactic treatment,
acupuncture shows benefit
• Compared to sham acupuncture, “true”
acupuncture shows no beneficial effect
• Compared to prophylactic medications
acupuncture had slightly better outcome with
fewer side effects
Linde K. Cochrane Database Syst Rev. 2009 Jan 21;1.
Acupuncture vs preventive meds
• 100 patients comparing 600mg valproic acid
to 20 sessions of acupuncture
• Acupuncture group had improved pain intensity and
pain relief score with less rizatriptan use
• Adverse events V=48% A=0%
• 66 patients with CM compared topiramate
100mg vs 24 acupuncture treatments
• Reduction in moderate to severe headache days
• A: 2010 T: 2012
• Side effects A:6% T:66%
Facco E. Minerva Anestesiol. 2013;79(6):634-42.
Yang CP. Cephalalgia. 2011;31(15):1510-21.
Diener study
• 2006 study in Lancet Neurology
• Compared verum acupuncture vs sham
acupuncture vs standard drug therapy (AEDs,
CCBs, BBs)
• 10+ sessions in 6 weeks
• 1295 patient enrolled
• 125 withdrew following randomization (most due to not
being assigned to an acupuncture arm)
• Outcome was difference in migraine days at
baseline compared to weeks 23-26
Diener HC. Lancet Neurol. 2006;5(4):310-6.
Diener outcome
• Reduction in migraine days per 4 weeks
• Verum group=2.3
• Sham group=1.5
• Standard medical therapy=2.1
• Results did not reach statistical significance
between the different groups
• “Efficacy of a treatment, especially with no
adverse events or contraindications, is more
important than knowledge of mechanism of
action of this particular therapy.”
Diener HC. Lancet Neurol. 2006;5(4):310-6.
Cost of acupuncture
• On average, in the Louisville area is between
$50-70 per visit
• Probably on par with most medium/large
cities
• Out of pocket, most of my patients can’t
afford 1+ treatments per week
Headache Currents – Feb 2015
• “Acupuncture Is All Placebo and Here Is Why”
• Brian McGeeney, MD
• Good read analyzing the effects of placebo and inexact
science of acupuncture combined with patient
expectations
• Placebo response is greater in interventions that are
more invasive
• Pharmacological = 22% responder rate
• Acupuncture = 38% responder rate
• Surgery = 58% responder rate
McGeeney B. Headache. 2015;55(3):465-469.
Meissner K. JAMA Intern Med. 2013;173(21):1941-51.
Acupuncture Takeaways?
• Effective
• No established benefit over “sham” treatment
• No established benefit of conventional
medical treatment over acupuncture
• No contraindications or adverse events
• Concerns over placebo?
• OnabotulinumtoxinA (6.7 fewer headache days)
Dietary changes and migraine
• Fasting
• Specific foods/drinks as trigger for migraine
• Alcohol
• Monosodium glutamate
• Gluten sensitivity
• Obesity and migraine
Fasting and migraine
• Increased frequency of migraine during
Ramadan
• 9.4 vs 3.7 days / mo
• Yom Kippur
• 39% of fasters develop headache vs 7% of non-fasters
Abu-Salameh. J Headache Pain. 2010;11:513-17.
Mosek A. Neurology. 1995;45(11):1953-5.
Alcohol
• Patients with migraine more likely to have
“migraine-like” symptoms following alcohol
consumption, but not other hangover symptoms
• In one study low amounts of alcohol intake did
not increase frequency of migraine attacks
• However if alcohol was taken with stress there was a
significantly higher frequency of migraine
• Red wine compared to vodka
• 9/11 patients exposed to red wine triggered migraine
• 0/8 exposed to vodka triggered migraine
Zlotnik Y. J Neurosci Rural Pract. 2014;5(2):128-34.
Nicolodi M. Drugs Exp Clin Res. 1999;24(2-3):147-53.
Littlewood JT. Lancet. 1988;1(8585):558-9.
MSG
• Glutamate (endogenous or exogenous) binds
to cell membrane and stimulates NOmediated neurotransmission pathway (NOMNP)
• This activates the release of NO which induces
vasodilation
• Ingested glutamate in sensitive individuals can
lead to stimulation of NO-MNP
MSG
• Has a unique taste called “umani”
• Considered a “natural” substance and a
component of food, so does not necessarily
appear on food labels
• Foods with high glutamate content:
• Parmesan cheese, soy sauce, walnuts, tomato juice,
grape juice, mushrooms, broccoli, chicken, fish
Gluten-related disorders
• Autoimmune: Celiac disease
• Allergic: IgE-mediated food allergy
• Non-autoimmune, non-allergic: non-celiac
gluten sensitivity
• Symptoms include:
• Diarrhea, abdominal bloating, neurological
manifestations
» Gait and limb ataxia
» Peripheral neuropathy
Gluten sensitivity and migraine
• Compared with controls:
• 30% of patients with celiac disease have “chronic
headaches”
• 56% of patients with gluten sensitivity
• OR of 3.79 for migraine in celiac disease
• OR of 9.53 for migraine in gluten sensitivity
Dimitrova AK. Headache. 2013;53(2):344-55.
Am Fam Physician. 2014 Jan 15;89(2):99-105.
Gluten-sensitivity takeaway
• Migraine is more prevalent in patients with celiac
disease
• Many patients will have improvement in migraine frequency
and severity with gluten free diet
• Non-celiac gluten sensitivity is of unknown
prevalence and unknown mechanism
• ?Placebo
• ?Due to reduction of short-chain carbohydrates
• In patients with migraine and GI symptoms I bring
it up and discuss the logistics of a gluten free diet
Migraine and obesity
• Migraine and obesity are co-morbid
• Obese individuals are more likely to have
chronic migraine
• ?Linked through inflammatory mediators released by
adipose tissue
• No clear evidence that either bariatric surgery
or weight-loss diets improve migraine
Diets reviewed for migraine
• Serena Orr Cephalalgia June 2015
•
•
•
•
•
Low sodium
Low fat
Elimination diets
Ketogenic diet
High n-3 and low n-6 fatty acid diet
Water
• Small trial of patients with headache and
water consumption of less than 2.5L/day
• Instructed to increase water consumption by
1.5L/day
• No significant change in headache frequency, but
improved perceived benefit and improved MSQOL
Spigt M. Fam Pract. 2012;29(4):370-5.
Dietary changes for migraine takeaway
• Benefit might be paying attention to diet rather
than the specific diet recommended
• No specific diet better than another, most diets
viewed as generally healthy may be beneficial
• Consider avoiding major triggers (MSG, alcohol,
etc), perhaps eliminating gluten if associated GI
symptoms
• I suggest all patients to increase water
consumption to a goal of 2.5L / day
Overall thoughts on CAM
• Patients are using it
• Patients may even stop YOUR treatment to
begin CAM treatments
• Less than half will tell you about it
• Of the treatment modalities discussed today,
very little harm associated with them
• Can serve as a starting point for treatment
• “Try this and if it doesn’t work out we’ll go another
direction”
Thanks
[email protected]
@DrBrianMPlato