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

2. Summary
The sensitive brain
Triggers
Lifestyle
Alternative treatments

3. 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.

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

5. 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

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

7. Stress and Pressure

8. 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)

9. 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

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

11. 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): 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

12. 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?

13. 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

14. 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

15. Alternative therapies

16. 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.

17. 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):
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.

18. 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)

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

20. Any Questions?