Migraine and Cluster Headaches

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Migraine headaches in the United States population may be more common than asthma and diabetes combined, and affects women three times as much as men. The U.S. CDC (Centers for Disease Control and Prevention) states that the prevalence of chronic migraine headaches in the U.S. increased nearly 60 percent between 1980 and 1989, with an alarming upward trend since statistics were first gathered. In 2009, the CDC estimated that about 23 percent of adult women in the U.S. experienced migraines or severe headaches, and migraine studies show that perhaps more than 30 million people in the United States experience chronic migraine headaches, with about 75 percent of the female migraine sufferers experiencing at least one migraine per month. By 2013, large health surveys in the United States showed that overall prevalence of migraine at between 16.2 and 22.7 percent of the population, with female incidence rising to 26 percent. A variety of types of migraines and severe headaches are noted, and a variety of associated health problems, and symptoms other than headache as well. This makes sense considering the origin of the term migraine, coming from the Greek hemikrania, or half of the brain, implying an imbalance of function between the right and left brain, which is usually coordinated by the brainstem and thalamus. While migraines have been classified according to symptom presentation to date, more emphasis is now placed on a differentiation based on the underlying causes and associations with other health problems to improve treatment considerations, and progress from the one-size-fits-all approach in standard medicine, which has not yielded great results. In 2013, large health surveys noted that 80 percent of migraines treated clinically in standard medicine were treated with triptans, with nearly half of these being one drug, sumatriptan, or Imitrex, a serotonin-1b and 1d receptor agonist that does not prevent the migraine episodes and does not address the changing understanding of the pathophysiology of the varied migraine syndromes. Obviously, we need to integrate a broader approach into migraine treatment, and Complementary and Integrative Medicine and Traditional Chinese Medicine (CIM/TCM) presents an array of therapeutic protocols that can prevent migraines, address underlying dysfunctions, and treat the associated health problems that contribute to the complex migraine syndromes.

When the symptom of your health problem is debilitating, it is important to choose a plan of therapy that you are sure will work to decrease the frequency and intensity of the migraine or cluster headaches. Medical doctors in Europe are finding surprising success in incorporating acupuncture and herbal / nutrient medicine into their treatment protocol, and they have spent much time and money on scientific studies that prove that these treatments are effective, and that a holistic approach in treatment is necessary. This Integrative and Complementary approach is meant to produce significant reduction of frequency and severity of migraine and cluster headaches and reduced problematic overuse of headache medications and their adverse effects and rebound effects. Repeated short courses of acupuncture therapy, and individualized and changing herbal and nutrient medicine protocols work together to provide a holistic and effective therapy to address both underlying causes and the symptoms themselves. Even when taking migraine medications, it is important to address underlying health concerns and causes.

Modern medicine is finding that the mechanisms of migraine and cluster headaches are very complex and difficult to treat with pharmaceutical medication. For the patient, this is frustrating, and trying to find the right combination of treatment strategies to get your life back on track is a challenge. In the past, migraines were classified as a vascular headache that occurred because of an extreme reaction of vasodilation that suddenly increased pressure to parts of the brain and resulted in a long period of debilitating pain. Presently, we know that this was just part of the answer to the cascade of dysfunctions that result in the debilitating migraine neurovascular reflex. We now know that there are many forms of migraine and cluster vascular headache and that treatment strategies must target not only vasodilation, but the autonomic nervous system, protein metabolism, and balance of neurotransmitters both in the brain and brainstem, as well as the gut. The definition of migraine even now extends to primarily neurological syndromes that often involve little headache, with opthalmic and hemiplegic migraine becoming more prevalent. Overall regulation of the autonomic nervous system and regaining of control may involve attention to the hormonal system, especially in menstrual migraines, and the immune responses associated with nitric oxide levels. Restoration of normal homeostasis in these systems, neural, vascular, and metabolic, is the only way to bring these devastating symptoms of migraine and cluster headaches under control. Medications are only designed to bring temporary relief, not to address this dysfunctional homeostasis and contributing disease mechanisms.

In the last decade we have seen not only a realization that migraine syndromes are varied and complex in pathophysiology, but that a large number of potential triggers and causes exist, too often ignored. For instance, oral contraceptives are highly associated with onset of migraine syndromes, and the increased use of Sildonfil, or Viagra, has been linked to both triggering and onset of the migraine syndromes via its effects on the vasodilation metabolism of the cerebral artery. You may access links to these studies in the section of this article entitled Additional Information. In addition, the overuse of pain medications and off-label drugs prescribed to treat migraine have been implicated in medication overuse headache syndromes, and additional study is sure to find more links to migraine pathology from chronic and complex pharmaceutical effects.

Treatment strategy must take into consideration both triggers of the migraine as well as correction of the neuroendocrine regulation. Restoration of healthy homeostatic maintenance of brain cells, immune responses, vascular maintenance, and nerve function must all be addressed for optimal success. This implies that an allopathic approach of blocking one specific physiological mechanism is not an optimal strategy for treatment of migraine and cluster headache. Treatment requires a more holistic approach to achieve success.

For many patients, the treatment outcome must be to first reduce the frequency and intensity of the complex migraine neurovascular mechanism, and then work toward restoring healthy function and maintenance enough to eventually eliminate the problem. Migraines and cluster headaches cannot be looked at therapeutically like a typical headache, and the patient should not expect any pill to offer immediate relief like they get from aspirin in a tension headache. Treatment will only produce results with persistence and holistic correction of symbiotic mechanisms. Often, various pharmaceutical approaches can be utilized temporarily in the overall treatment scheme, if they provide relief, as the patient corrects the underlying array of homeostatic dysfunctions. Chronic use and overuse of pharmaceuticals, though, to treat migraine and cluster headache syndromes has been shown to produce a pattern of rebound headaches for a great percentage of patients, and is increasingly discouraged in standard medicine. Settling for minimal relief with pharmaceutical treatment and giving up on the more complex course of holistic therapy is often chosen, but leaves the patient with a debilitating recurrent problem for life. Current research definitively supports Complementary and Integrative Medicine in the treatment, yet the belief persists that it does not work. Some of this sound and abundant research is available at the end of this article in Additional Information and Links to Scientific Studies.

The Alarming Incidence of Medication Overuse Headache Patterns, or Rebound Migraine Headaches

Patient choices in pharmacological medication involve a variety of medications that affect neurotransmitters and their receptors, some with alarming side effects and adverse long-term effects, and most with the potential of creating a medication overuse headache pattern. This type of headache, formerly called a rebound headache, involves temporary partial relief of the migraine, but a return of the original migraine intensity and symptoms when the drug is cleared in the brain. Many experts warn that this pattern often prompts increased use of the drug to try to relieve the headaches that are caused by the drug. A simple approach with pharmacological therapy is to first try an ergot, or dihydroergotamine nasal spray (e.g. Migranal), and perhaps a topical herbal cream or ointment, while exploring a more thorough and holistic approach with Complementary Medicine. Since the drug of choice, a triptan, or selective serotonin receptor agonist, is contraindicated with ergot medications, this is seldom suggested or prescribed. Given the history of limited success with pharmacological treatment of migraine and cluster headaches, the intelligent patient will pursue a course of therapy and avoidance of triggers that results in fewer and milder headaches by correcting the underlying problems. Integrating a holistic approach into the treatment of migraine and cluster headaches is becoming more and more popular, and is often now suggested by migraine experts and treating physicians.

How common is a rebound headache syndrome from medication overuse? In 2011, Dr. Charles Argoff, Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York, wrote and article for Medscape Neurology, where he stated, "it (rebound analgesic headache syndrome) is not as uncommon as you may think. Very often in the insidious, subtle, "Oh, its not going to happen to this patient" manner, many physicians think that because this is a generic medication, easy to prescribe, and because patients often respond to it (that it is a benign medication). But over time - over years - sometimes less - patient will become physically dependent on the butalbital/acetaminophen/caffeine preparation and have rebound headaches when they don't take it." The case used as an example involved a woman in her early-40s who had been prescribed topiramate and valproic acid with little success. The woman had been advised to first try an over-the-counter migraine medication, which she first used once or twice a month, but over a period of two years, had grown into a dependence on the drug and used it daily. A visit to the emergency room resulted in the prescription of the Floricet (butalbitol/acetaminophen/caffeine). The use of this prescription then increased from several times a month to several times a week. Finally, the patient was taking the medication daily, as the frequency of her migraines increased. Instead of addressing the underlying problems with the headache mechanism, her medical doctor prescribed additional medications. Finally, the intractable headaches were debilitating, and the patient turned to the pain center at Albany Medical Center. Here, Dr. Argoff reduced her medication slowly until the headaches occurred with a frequency of a few times per month. Dr. Argoff recommends acknowledging this scenario and utilizing tapering or detox regimens to help the patient deal successfully with this strategy of reducing medications to stop analgesic rebound headaches. Complementary Medicine plays a large role in this successful detox and tapering regimen, both utilizing herbal and nutrient medicines, and acupuncture, as well as a holistic protocol with diet and lifestyle to treat the headaches, the adverse effects of the medications, and reduce triggers. Added to this is the treatment of the underlying physiological problems that cause the headache syndrome. Complementary Medicine and TCM will provide a set of medical protocols outside of pharmacological means to insure success.

In 2012, more and more migraine clinics are utilizing a treatment protocol for chronic frequent migraine syndromes that recognizes the rebound effects of medication as a cause of refractory migraines, and a gradual decrease and minimization of standard triptan and NSAID medications is employed, while preventive measures are integrated in a holistic manner. Utilizing Complementary and Integrative Medicine, acupuncture, herbal and nutrient medicine, and physiotherapies to address the underlying health issues and achieve a more holistic preventive treatment protocol is a sensible approach, along with changes in diet and behavior. Both migraine syndromes with a complex spreading cortical depression and refractory type migraine syndromes will benefit from this approach (see study links below in information resources). The treatment of the various migraine syndromes is not an easy undertaking, but CIM/TCM can increase the success, and can be integrated with standard care in an individualized manner to accommodate each person's lifestyle.

This means that the patient would have a better chance of overall success by incorporating a knowledgeable Complementary Care physician, such as a Licensed Acupuncturist and herbalist, into the treatment strategy. Such a physician could help with dietary and lifestyle advice to avoid triggers that are tailored to the individual, as well as supply evidence-based treatments to reduce the mechanisms of the headache episodes. In addition, the Complementary Care physician would be able to help you improve overall health and solve the imbalances that led to your condition. In the last few years, scientific understanding of the complex migraine mechanisms has blossomed, and even standard medicine has reluctantly incorporated herbs and nutrient medicine into the protocol. A Licensed Acupuncturist with the right treatment specialties is able to bring more knowledge of herbal and nutrient medicine to the table than an M.D., and provide proven effective acupuncture and soft tissue mobilization to the overall treatment plan within the same office visit. Mechanical stresses related to myofascial pain syndromes and impingement on the nerve and blood circulation may be a significant contributor to the migraine and cluster pathology. Chronic myofascial syndromes may induce autonomic nervous system imbalances that are a signifcant contibutor to the underlying causes of the neurovascular responses creating migraine and cluster headache patterns. Most scientific studies reveal that immediate relief from a thorough and holistic treatment protocol is not expected, but that effective treatment will produce results after 2-3 months. In clinical practice, many types of migraine and cluster patterns do respond fairly quickly to a treatment combining herbal and nutrient medicine with acupuncture stimulation and myofascial release, though. Scientific studies, by nature, do not study such a comprehensive approach, but instead study one specific type of therapy at a time. These studies do not reveal the effectiveness of a thorough and comprehensive treatment strategy.

For the patient, this commitment to prolonged therapy often involves a challenge to understand how Complementary and Integrative Medicine (CIM/TCM) actually works, and whether it is a proven scientific treatment that offers some guarantee of success. In many difficult medical problems, the patient must often stick with the treatment protocol for some time to achieve success. One or two acupuncture visits is not going to make this problem go away. This article is intended to help the patient, and other physicians, to understand the recent positive research on acupuncture and migraine headache therapy, and to understand the approaches now taken with herbal and nutrient chemicals.