Migraine and Cluster Headaches

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


Migraine Headaches and the Importance of Knowing Which Type you have and Treating the Underlying Causes as well as the symptoms:

Standardized treatment does not make sense for migraine headaches. Different patients have different factors triggering the migraines, and different types of migraine and cluster syndromes have different underlying causes and symptom presentations. All of these need to be addressed in the treatment protocol, and a single type of migraine medication is not sensible, but such strategy has persisted unchanged for decades, with triptan drugs prescribed in 80 percent of cases. This strategy has failed in standard medicine, and integration of Complementary Medicine is sorely needed to improve outcomes and prevent episodes of migraine pathology.

As study of migraine mechanisms evolves, we learn that there are a number of important mechanisms in this type of headache, and hence, a pill that allopathically targets a single chemical reaction has not worked well for every patient. This is why Complementary and Integrative care is very important to success. No matter whether you utilize a pharmaceutical medication or not, acupuncture, herbal medicine and dietary changes may greatly improve the outcome. The first step is to understand and assess what type of migraine you have by noting with a diary when they occur and how this corresponds to triggers, whether these are related to the hormonal changes of the menstrual cycle, what you eat, weather changes and the environmental triggers, etc.

Chronic headache syndromes often involve a number of types of headache causes combined into a more complex syndrome. Headaches can be distinguished by classification of cause as vascular, inflammatory, lesion generated, degenerative, traumatic, endocrine, and autoimmune. This is why the migraine and cluster headache syndromes are so difficult to cure. Both extracranial and intracranial tissues may be involved, as is evident from the success with a small percentage of patients who receive Botox injections extracranially and experience symptom relief, as well as patients who obtain much relief from soft tissue therapies and myofascial release. Muscle tension, or traction, headaches can be a migraine trigger, or secondary to migraines. Common inflammatory headaches include sinus allergy headaches, as well as fibromyositis, a chronic inflammatory condition of the muscle and connective tissues. Lesions in temporomandibular joint syndrome (TMJ) or tumor growths, may produce pressure and irritation on facial nerves, increasing the potential of a migraine trigger or episode.

A number of studies have identified a brainstem cellular dysfunction associated with migraines, typically referred to now as the vestibular migraine effect. Our understanding of the migraine pathology has expanded greatly with improved imaging techniques of the brain, and we now understand that bioelectrical disturbances in the brain trigger an excess of neuronal activity, or hyperexcitation, that leads to a cortical spreading depression in the brain cortex, brainstem and thalamus, with biochemical changes as well. In other words, the pathology involves a more holistic quantum field of effects and dysfunctions. While this information is leading to more radical therapies that are not yet evidence-based, it is apparent that vestibular system involvement and dysfunction is probably related to almost all migraines, and most of these do not involve a neuro-anatomical anomaly. The vestibular system refers to a broad system that originates in the Scarpa's ganglion at the distal internal auditory meatus near the vestibule of the inner ear, and travels via CN VIII (cranial nerve 8, or the Vestibulocochlear nerve), which is located alongside CN VII (Trigeminal nerve). This system links a number of vestibular pathways of the brainstem, including the oculomotor nuclei, the thalamus, the cerebellum, the brainstem and spinal cord, and the temporoparietal lobe of the cortex. Key regulatory centers in the brain experience dysfunction associated with increased oxidative stress and poor mitochondrial function. The mitochondria are parts of our cells that turn oxygen into energy, and many neurological dysfunctions are associated with poor mitochondrial function and oxidative stress. When these brainstem regulatory centers overreact to a normally inocuous stimuli, a signal is sent that results in rapid vasodilation, especially of the temporal arteries which lie alongside the optic portion of the trigeminal nerve. A number of factors will increase the severity of this neurovascular reaction. The holisitic approach in Complementary and Integrative Medicine (CIM/TCM) tries to correct various factors that contribute, improving mitochondrial health, decreasing oxidative stress, helping to improve inflammatory regulation, aiding neurological health, and helping the body to decrease excess histamine response. Many receptors in the brain respond to both hormones and neurotransmitters, and if there is a hormonal imbalance, this too can be addressed with Complementary and Integrative Medicine. One can surely utilize any pharmaceutical means to decrease symptoms and also utilize a sensible holistic approach to deal with this complex underlying set of dysfunctions. Taking this broader approach is surely sensible, rather than just living with the migraine syndrome and depending on inadequate control of the episodes, as well as the potential for drug rebound headache syndromes.

Research has also revealed that the most common direct cause of migraine headache is temporal arteritis, which is inflammation of the small cerebral extracranial arteries under the temple, although the extent of this condition is usually mild and episodic, and a host of other contributing causes may participate, triggering the neuronal hyperexcitation and spreading cortical depression. These inflamed arteries are often running with superficial nerves, which are irritated, leading to the migraine episodes. The occipital nerve is another focus of research, and may be inflamed or compressed, often with myofascial contracture and syndrome underlying, triggering the blood vessel spasm. The prodrome, or aura, that precedes a classic migraine results from cranial vasoconstriction, and both temporal arteritis and occipital vasoconstriction, as well as myofascial contracture at the neck, base of the skull, and scalp, may contribute. This aura typically develops over 10-30 minutes and varies in intensity and manifestation, with the patient potentially experiencing light flashes, anxiety, numbness and tingling, dizziness, slight confusion, sensitivity to light and sound, nausea, and a throbbing headache in the classic syndrome. Each patient must be assessed individually to determine the underlying causes, and a treatment protocol must address a number of these factors.

Classification of migraine in standard medicine includes the classic migraine with aura, the common migraine without an aura, menstrual migraines, hemiplegic migraines (one-sided temporal headaches, sometimes with balance problems, dizziness and vertigo), opthalmoplegic migraines (pain in the eye orbit, sometimes with double vision, droopy eyelid, or other visual disturbance), basilar artery migraine (intracranial and involving the main brain artery), benign exertional migraine, and status migrainous (severe prolonged migraines requiring hospitalization, and often preceded by anxiety and depression). Vestibular migraine is a newer classification that is still poorly understood, but involves vestibular symptoms such as vertigo, imbalance and head-movement intolerance, as well as photophobia and phonophobia, although patients with these migraine symptoms are not necessarily experiencing vestibular migraine, and there is no definitive test for vestibular migraine. This type of headache could involve neuro-anatomical pathway abnormalities and this new classification is used to justify new technologies with laser which are not yet evidence-based. Each type of migraine will require differences in the treatment protocol, and integration of conservative treatment protocols first is sensible to avoid potential adverse effects and rebound migraine syndrome. The complexity of this differential assessment shows the patient that they must allow the Complementary Care physician some time to properly assess and determine the individualized course of therapy. There is no magic acupuncture point and magic herb with a one-size-fits-all effect, and successful clinical trials in China show that short courses of individualized treatment, with frequent treatments, are most successful. Standard treatment in China utilize 5 treatments per week for 4 weeks, with repetition of the course if needed. Integration of proven protocols with herbal and nutrient medicine over longer periods of time are also needed for the best outcomes.

What are the types of pharmaceutical approaches to migraine and how can Complementary Medicine have success with these same approaches?

In the recent past, almost all migraine patients were given a drug that selectively inhibited serotonin receptors to stop the hyper-reaction of vasodilation in the brain with migraine episodes. This treatment failed for most patients, just like the prior treatments with various pain relievers, but continues to be the treatment prescription in almost all migraine syndromes. Medical doctors started to use medications that were meant for other pathologies when patients reported decreases in migraine frequency with the use of the drugs. Today, a variety of drugs are tried, Beta-blocking and calcium channel-blocking hypertension medications, synthetic estrogens, anti-seizure drugs such as topiramate, benzodiazepines, drugs for depression, anticholinergic drugs, etc. Patients today are starting to look at the side effects and risks of these medications a little more closely and looking either for alternatives, ways to decrease frequency of use of drugs, or ways to decrease side effects and risks with Complementary and Integrative Medicine (CIM). The failure of pharmacological treatment for a great percentage of patients is well known.

Some of these medications used for migraine therapy were not created to treat migraine, and present considerable risk and side effect problems. Topomax, or topiromate, is a widely prescribed migraine medication today. It is an antiseizure medication, and the exact mechanism of action is still unclear. In February of 2008, the FDA issued warnings that clinical studies showed an alarming association with mental changes with chronic use that included inexplicable ideas of suicide and suicidal attempts. Warnings of cognitive dysfunction, mood disorder, somnolence, fatigue, neuropathy, dizziness, onset of glaucoma, metabolic acidosis and kidney stones had already been of concern, as well as adverse effects on liver function. Clinical incidence of these nervous system problems occurred in up to 30 percent of study participants. It is surmised that this drug may act on a variety of systems, antagonizing glutamate receptors, enhancing GABA activity, and blocking sodium channels in neural cells, much like the benzodiazapine anti-depressants. If this antiseizure medication is used, it is sensible for the patient to increase the dose slowly, try to address the whole pathology with CIM/TCM and then try to taper the drug to achieve a state of mild frequency and intensity of episodic symptoms without need for chronic use of this problematic drug.

In 2008, experts in migraine treatment from the Drexel University College of Medicine and the University of North Carolina (Pertlin, Calhoun, Siegel, Mathew) published a recommendation in the medical journal Headache (2008; 48:805-19) that stated the "a clinic-based study by Oates et al found that 69 percent of headache patients were on one or more medication that was not intended for headache prevention", and proposed a more rational combination therapy for refractory migraine (resistant to standard therapy). The reason cited for this broad pharmaceutical approach to migraine prevention was the broad array of cofactors and comorbidities associated with migraine syndromes, such as anxiety, depression, bipolar disorder, asthma, cardiovascular disease, stroke, epilepsy, and medication overuse. Studies of chronic migraine patients cited the high percentage of patients who no longer received adequate reduction in migraine frequency and duration from therapy with just one drug, even when their prescribing physicians switched the type of drug from one class of drugs to another. Proposed guidelines called for multi-drug treatment regimens for these patients, but cited the array of serious and common adverse side effects for the proposed drugs. These recommendations have been adopted since 2008 and have resulted in many more migraine patients on a multi-drug regimen. What is overlooked is the diminished quality of life and numerous adverse side effects of these treatment protocols, and the potential for Complementary and Integrative Medicine (CIM/TCM) to supply safer treatment protocols to prevent both a diminished quality of life and the syndrome of refractory rebound headaches that has now alarmed experts around the world.

TCM/CIM provides not only safer treatment protocols and more time to encourage diet and lifestyle modifications to decrease migraine frequency and intensity, but also provides treatment for the array of cofactors and comorbidities that are worsening the migraine syndrome, all in the same treatment. This holistic approach to migraine care is sorely needed and stubbornly resisted in standard medicine, but the need for this approach is obvious.

In recent years, many M.D.s are resorting to botox treatment for migraines, especially serious migraines not helped by pharmaceutical therapy, but controversy has again risen with this therapy in 2010. The New York Times reported that the company that makes botox, Allergen, agreed to settle an FDA suit for improper kickbacks to prescribers and improper marketing techniques for $600 million, rather than face the publicity of a trial for these criminal allegations (NY Times Sept. 9, 2010, Business). The Times reports that many neurologists stated that standard pharmaceutical treatment for severe migraine does not improve very many patients' overall condition, and botox seems to have a significant effect. In some studies, though, botox did not perform significantly better than placebo injections, and in a second Allergan study to support migraine botox therapy, patients with at least 15 days of migraine headaches per month were helped by reducing these headaches by 2.3 fewer days of suffering per month over placebo injections. Dr. David M. Simpson, a professor of neurology at Mt. Sinai School of Medicine questions whether the botox injections helped only with a placebo effect, and Dr. Sidney M. Wolfe, the director of public health research at the group Public Citizen, stated that a small benefit that might be due to placebo effect may not be worth the risk and expense. The cost of these treatments was $4000 to $8000 per year, and Dr. Wolfe stated that perhaps acupuncture needling could be a much less expensive alternative. In any case, integrating acupuncture and herbal/nutrient medicine into the botox protocol would seen a smart move.

Many patients wonder what botox really is. Botulinum toxin is a protein neurotoxin produce by the bacteria Clostridium botulinum. Botulinum toxin is highly toxic systemically, but targeted injection into muscles has been shown to be safe, as long as the toxin is broken down locally. Unfortunately, a number of cases of the botox migrating through the body and causing respiratory failure and death following treatment have occurred. Canadian authorities have also issued a warning that botox may spread to other parts of the body and cause muscle weakness, difficulty swallowing, pneumonia, breathing problems and speech disorders. Nevertheless, the use of botox in cosmetic treatment to smooth skin, and now to treat migraines is very common now. Studies in 2010 have also found that emotional expression and cognition may also be affected by botox injections (Havas et al), and concerns of more widespread use, especially by unqualified practitioners, has been voiced. Patients looking for a more conservative approach are trying Complementary Medicine first.