Headache Treatment


Tuesday, May 25, 2010

Headache Wellness- What's After the Pills?

After remission has occurred with headache, it becomes important to begin preparing for the time when medications will not be needed. Here are some suggestions that we often implement as our patients feel better, but they may be helpful for some patients who may not need medical care. Some suggestions on what you can do yourself:

1) Break bad habits.

Avoid caffeine completely for five days each week- or, twenty days each month on average. It is important that you don't merely "cut down" on these days- you must stop completely, to allow your body to recover from even a mild caffeine addiction. In severe cases medical treatment of the underlying headache may be needed before attempting caffeine withdrawal.

Break other dietary habits- sugar and carbohydrate cravings are common. Read a book about sugar addiction like "Sugar Busters". If you crave a food or type of food, or you have headaches when you miss meals, read about dysglycemia, hypoglycemia, and the relationship between these problems and future risk of heart disease and diabetes and other health problems. We often recommend a "celiac diet" trial off wheat for two to four weeks for metabolic symptoms (headache, fatigue, food cravings). It may be worthwhile to have blood tests for celiac antibodies and a genetic test for celiac disease as a practical matter, since a wheat-free diet is difficult to follow for many long-term; however, even if tests are negative, a trial off wheat would be a likely first test.

Stop tobacco products.

Get plenty of rest each night. If you need a product for pain and rest, and you are not allergic to aspirin, a good choice would be Doan's Pills PM (with diphenhydramine), a magnesium salicylate and antihistamine combination that we have found to be unlikely to cause rebound headaches and appears better tolerated than aspirin.

Avoid taking combination painkillers like BCs, Excedrin Migraine, and tylenol products more than two days each week to avoid "medication overuse headache".

Try stopping any birth control pill.

Try substituting digestive enzymes (available at health food stores) for chronic use of antacids for "reflux". Read a book about reflux (for example, the book "Why Stomach Acid is Good for You").

2) Get regular exercise.

For patients with headache, swimming is an ideal exercise- the pool is cooling and heat stress is not a problem; and there is no risk of neck injury. Patients with migraine are more likely to develop an acquired dystonia- persistent neck pain after minor strain, such as lifting weights over the head. So, swimming is the ideal exercise. For many, however, there is a "hair problem"- too hard to get to the gym and clean up afterward!

If you are short on time, a regular program of Pilates, which takes only three minutes twice daily, can be remarkably effective in toning core muscles and strengthening upper back posture. We find that most of the benefit occurs in very little time. Get a tape and pick out some of your favorites to do at home.

3) Consider taking selected vitamins and minerals.

Magnesium glycinate: our preferred form of magnesium. Magnesium is is short supply in our diet due to intensive farming practices, and there is additional evidence that people with migraine have lowered magnesium levels. Additionally, magnesium can be effective for constipation, palpitations, anxiety, and sleep disturbance. The glycinate in this form is an amino acid that itself has a stress-relieving effect. Take the dose recommended on the bottle. Magnesium can be increased to two or three times daily doses when renal function is normal- the dose can be increased until diarrhea occurs, then slightly decreased ("subdiarrheal doses").

Vitamin E 1000 I.U. "Mixed Tocopherols" or"Natural Vitamin E". The addition of "tocotrienals" adds expense and uncertain benefit. When reviewing the very poor quality literature on Vitamin E, look at whether the study was done on dl-apha tocopherol, or d- alpha tocopherol. If the study doesn't specify, it is certain that the study was of poor quality. Recent work on Vitamin E suggests it functions in many ways unrelated to that of an "antioxidant". For patients with headache, especially menstrual migraine, Vitamin E has a slight anticoagulant effect which corrects the tendency of migraine patients to clot. In patients with an identified clotting disorder, vitamin E is strongly recommended. May interact with some medications such as Coumadin.

Vitamin C- helpful for patients with constipation, vitamin C may be increased to 2000 mg taken three times daily, or more, as limited by diarrhea. The literature on vitamin C is full of controversy. However, we find it most helpful for constipation, and possibly for headache itself.

Vitamin D- preferred dose is 5000 mg daily. Vitamin D is made in the range of 50,000 units/day when sunbathing; it's synthesized in the skin, and helps turn over UV-damaged skin cells to prevent skin cancer, and also reduces inflammation. Importantly, excess is absorbed into the body where it plays a significant role as an antiinflammatory agent and immune modulator protective against many cancers, heart disease, and influenza and other infections. In my experience an adequate vitamin D level protects against the inflammatory changes associated with chronic migraine. Patients who weigh more than 200 pounds, have had gastric bypass surgery, or cholecystectomy, may need far more. It's a good idea to have levels measured at baseline, and again at three months. Toxicity concerns are essentially nonexistent below 10,000 units/day, and probably much higher doses are safe with monitoring of blood levels occasioally. Optimum blood levels are between 50 and 100 ng/ml. Note, however, that the FDA has not approved supplementation in this range. I feel strongly that this will change soon. A good place to read about Vitamin D is at:

Niacin and B Complex- these are respiratory enzyme co-factors. B vitamins may possibly be helpful in migraine by assisting the metabolic deficit that accompanies the condition, and which may explain the common problem of fatigue in patients with migraine. Blood tests for CO2 and Lactate may be helpful in identifying an underlying respiratory defect. Niacin can be taken over the counter; you should consider at least occasional liver function tests. We prefer the use of prescription Niaspan 500 mg, to increase to two every night after one month, as easier to titrate. If you take niacin over the counter, do not use "no flush" niacin. Read about and familiarize yourself with the "flushing" reaction (which will almost always resolve with time and can be prevented by taking with aspirin, ibuprofen, or an antihistamine). Niacin in doses ranging up to 6 grams daily in divided doses has reported benefits for anxiety and there have been 14 studies (not well controlled) on the benefit of niacin for headache. In patients with headache who also have cardiovascular risk factors and have been recommended to take a statin (Lipitor, etc.) we recommend a trial of niacin first, as potentially benefiting headache as well. Vitamin B2 taken at 400 mg daily for two to three months has been reported to be beneficial in preventing migraine.

For neurological consultation and assistance with wellness planning, contact our office at