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Natural Strategies to Help Headache Sufferers

Natural Strategies to Help Headache Sufferers. Kathi J Kemper, MD, MPH Wake Forest University Health Sciences. Disclaimer. I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:

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Natural Strategies to Help Headache Sufferers

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  1. Natural Strategies to Help Headache Sufferers Kathi J Kemper, MD, MPH Wake Forest University Health Sciences

  2. Disclaimer • I have the following financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity:         American Academy of Pediatrics, “Mental Health, Naturally “ Author. Royalties anticipated. • The presentation will include no description of any proprietary items for screening, diagnosis, or treatments. • I do not intend to discuss an unapproved or investigative use of a commercial product in my presentation.

  3. Objectives By the end of this session, participants will be able to • Advise patients to keep a headache diary and use MYMOPs to track symptoms at follow up visits • Counsel patients on dietary modifications to prevent headaches • Discuss the effectiveness of stress management practices in preventing headaches • Use evidence-based resources (See AAP Section for Complementary and Integrative Medicine; join the listserv – tsalus@aap.org; see * www.wfubmc.edu/cim - Pediatric Second Opinion Clinic pages on Action plans, symptom diaries)

  4. Headache • Third most common pain complaint • 90% Migraine or Tension-Type Headache • 10% other : cervicogenic, myofascial pain, sinus, TMJ, eye, head trauma, tumor, hemorrhage, infection, pseudotumor, vasculitis

  5. * RISK FACTORS: CDH • Anxiety, depression, stress • Sleep apnea • Chronic illness • Obesity • Family history • Medication overuse

  6. *Consider CT if • Early morning wakening with HA and nausea (can also be sinuses) • Worse with Valsalva • Sudden change in mood, mental status or neurologic function (not classic aura) • HA with cancer or other systemic illness • Sudden, severe (worst in life) HA • Papilledema

  7. Headache: CAM Use • 32% -> 40% used CAM in the previous 12 months. • Chiropractic ~ 14 –> 21%% • Relaxation ~ 8 % • Acupuncture ~ 8% -> 17% • Massage ~ ->17% Eisenberg, et al, JAMA 1998 Rossi et al. Headache 46:622-631, 2006

  8. CAM has become conventional(offered at UNC HA Clinic) • Biofeedback (thermal, muscular, HRV) • Hypnotherapy/Guided Imagery • Osteopathy • Acupuncture • Mindfulness Meditation • Herbal and DS counseling

  9. Chronic Pain Basics • Track symptoms • Promote healthy lifestyle

  10. Track Symptoms • Headache Diary http://www.wfubmc.edu/Center-for-Integrative-Medicine/Specialty-Services/Pediatric-Second-Opinion-Clinic.htm • MYMOP (Measure Yourself Medical Outcome Profile) http://sites.pcmd.ac.uk/mymop/files/MYMOP_questionnaire_initial_form.pdf http://sites.pcmd.ac.uk/mymop/files/MYMOP_questionnaire_follow-up_form.pdf

  11. AVOID TRIGGERS • Non-modifiable: genetics, gender, weather • Semi-modifiable: air pollution (including tobacco smoke, CO, SO2, NO2), menses • Modifiable - Lack of sleep • Missing meals • Allergens • Foods – tyramine containing, nuts, cheese, smoked fish, artificial sweeteners, nitrate preservatives, MSG, caffeine withdrawal • Stress – physical, psychological !!USE A HEADACHE DIARY!!

  12. Integrative Medicine Specialty Care Primary care and safe interventions (supplements; biofeedback) Fundamentals (nutrition; stress management) Communication & Counseling Skills

  13. Fundamentals – 4H Relationships Food Fitness Manage Stress Environment

  14. Lifestyle Treatment Choices • Avoid triggers! • Nutrition and supplements; don’t skip meals • Exercise/sleep • Environment • Stress management

  15. Avoid Food Allergens • Clinical trial of 43 patients • Allergy skin testing • 69% responded to diet modification (p<0.005) • People with IgE-specific food allergy benefit more from the elimination diet than people with negative skin tests. Mansfield L et al.. Ann Allergy, 2004

  16. Elimination Diet? • 88 children with migraines • Trigger foods identified by reintroduction in 40 of the children • 93% improved by eliminating trigger foods Malox and Trier. Nutrition, 2003

  17. Dietary Supplements • Vitamin B2 • Magnesium • Fatty acids/fish oil • CoQ10 • Melatonin • Detailed references at end of handout

  18. Supplements: Vitamin B2 • 200 mg BID with meals for 3 months -> 68% reduction in migraine attacks in RCTs (P<0.001) • Side effect: yellow urine Schoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007

  19. Supplements: Magnesium • 1 gram iv acutely or 300 – 500 mg daily po to prevent • Good dietary sources: soy beans, black beans, tofu, seeds, nuts, whole grains, shellfish Mauskop. Headache, 2002; Pfaffenrath. Cephalgia, 1996 Mazzotta. Cephalgia, 1999; Wang, Headache, 2003 Peikert. Cephalgia, 1996; Facchinetti F, Headache, 1991

  20. *Current Use of Mg++ Supplements • 500 mg/day K+ Mg++ aspartate or gluconate • Avoid combining with Fe, Ca, Zn • May cause diarrhea • May take months to benefit Mann, Doug et al. “Migraine and Tension-Type Headache.” Integrative Medicine. Ed. David Rackel MD. Philadelphia: Sanders, 2006 143-156.

  21. Phospholipid Bilayer

  22. Omega-6 Fatty Acids Omega-3 Fatty Acids Linoleic Acid (18:2n-6) a-Linolenic Acid (18:3n-3) ∆-6 Desaturase (GLA)γ -Linolenic Acid (18:3n-6) Stearidonic Acid (18:4n-3) Elongase (DHGLA) Dihomo-γ-Linolenic Acid (20:3n-6) Eicosatetraenoic Acid (20:4n-3) ∆-5 Desaturase Eicosanoids (AA)Arachidonic Acid (20:4n-6) (EPA) Eicosapentaenoic Acid (20:5n-3) Elongase 24:5n-3 Eicosanoids Leukotriene 5-series Prostaglandins E3 Thromboxanes A3 ∆-6 Desaturase Eicosanoids Leukotriene 4-series Prostaglandins E2 Thromboxanes A2 24:6n-3 β-Oxidation (DHA) Docosahexaenoic Acid (22:6n-3)

  23. Fatty acids: Omega 3s • Open studies -- it helps reduce headaches; RCTs – mixed results; • Supplements –free from mercury, dioxins, PCBs; palatable • See our handout: • http://www.wfubmc.edu/Center-for-Integrative-Medicine/Patient-Resources/Dietary-Supplements.htm Harel. J Adolesc Health, 2002 Pradalier. Cephalgia, 2001 Puel. Br J Nutr, 2004

  24. Coenzyme Q-10 • Open label, 150 mg qd X 3 months; 62% had > 50% reduction in number of HA days • Hershey Pediatric study • Measured CoQ10 in 1550 patients (avg age 13 years) • 33% with levels below reference range, given 1-3 mg/kg-d CoQ10 • Follow up 3+ months later: a) signif increase in CoQ10 level; Signif decrease in HA disability (P<0.001) • No side effects; except pain in pocketbook Rozen and Silberstein, Cephalalgia 22: 137-141, 2002 Hershey AD. Headache, 2007

  25. Melatonin • Mechanisms • Potentiates GABA; Modulates Ca entry in to vascular smooth muscle cells • Modulates 5HT2 receptor – like B- blockers; inhibits the synthesis of pg E2 - inflammation mediator • Effective preventive for cluster HA and HA associated with delayed sleep-phase syndrome • Dosing 6-12 mg one hour hs • Few side effects • ConsumerLab reviews show consistent quality Rozen. Headache, 2006 Vogler. CNS Drugs, 2006 Rozen, Neurology, 2003 Miano. Neurol Sci, 2008

  26. Stress management • Stress is common • Stress triggers/worsens pain • Reducing stress helps 50% - 70% of headache sufferers • Managing stress: • Biofeedback • Hypnosis

  27. Mind-Body Medicine

  28. Home Biofeedback Peripheral Temperature Heart Rate Variability Skin Conductance

  29. Biofeedback Use of electronic equipment to measure and feed back information about physiologic functions—which are then modulated in desirable direction Goal-balancing ANS (& CNS) activity “video-games for your body” kid-friendly 2007 meta-analysis showed > 50 controlled trials of BF for HA; EFFECTIVE! Strong treatment effect that persists for over 12 months after training Allen Pediatr Ann, 2004 Kaushik R. Complement Ther Health Med, 2005 Trautman. Cephalgia, 2006 Nestoriuc. Pain, 2007

  30. Hypnosis/Guided Imagery Hypnosis: An altered state of awareness usually involving relaxation during which the participant can give himself suggestions for desired changes to which he is more likely to respond that in his usual state of awareness. Guided Imagery involves using the imagination to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization.

  31. Hypnosis – Prevention • Meta-analysis – strong evidence of benefits for tension HA (Hammond. Int J Clin Exp Hypnosis, 2007) • Better than wait-listed controls for migraine prevention (Melis. Headache, 1991) • Superior to propranolol or placebo in juvenile classic migraine prevention (next slide)

  32. Hypnosis : Headache • Children 6 to 12 years with classic migraine • RXT: propanolol vs. placebo for 3 months each • Then hypnosis training • FU 6 months more • Placebo period 13.3 HA/ 3 mos • Propanolol: 14.9 HA/3 mos • Hypnosis: 5.8 HA/3 mos • P<0.05 hypnosis superior Olness. Pediatrics. 1987 Hammond: Int J Clin Exp Hypn. 2007

  33. Contraindications to Hypnosis Ignoring underlying disorder Used for fun or entertainment The problem is more effectively treated with another modality (e.g. medication) Patient is psychotic, acutely depressed Patient (child) does not want to engage in hypnosis (but parent wants them to)

  34. Mind-Body: Autogenic Training • Form of hypnosis • Repeat phrases • My hands and arms are heavy and warm • My legs and feet are heavy and warm • My heartbeat is calm and regular • My breathing is easy and free • My forehead is cool • My belly is relaxed • Reduces need for headache medication • Reduces frequency of migraine attacks Zsombok. Headache, 2003 Juhasz. Headache, 2007

  35. Resources • Web • www.aap.org/sections/CHIM • www.wfubmc.edu/cim • Articles • Kemper KJ, Breuner CC. Complementary, Holistic, and Integrative Medicine: Headaches. Pediatrics in Review. 2010;31(2):87 • Partap S. Fisher PG. Managing Chronic Daily Headaches. Contemporary Pediatrics, 2010;April: 30-39 • Books • Be the Boss of Your Body” Series • www.freespirit.com • “Home Computer Biofeedback Fun • www.wilddivine.com • www.heartmath.com

  36. Suggested Practice Changes • Give patients headache diaries to identify triggers • Use symptom diary to track progress (MYMOP) • Refer patients for allergy testing • Consider recommending B2, magnesium, fish oil, melatonin, or coQ10 to selected patients • Start recommending stress management practices such as biofeedback or hypnosis • Join the AAP SOCIM (tsalus@aap.org or www.aap.org/sections/chim/

  37. Detailed Information and Additional Resources

  38. *Diet and Migraine • Regularization of meals • Normalize blood sugar (glycemic index) • Elimination Diet 1: Caffeine, cheese, nuts, chocolate, shellfish, onions, aspartame, wine, beer, dairy, processed meats • Elimination Diet 2: Lamb and rice – add back • Reduction in omega-6 fatty acids – red meats • Increase in omega-3 fatty acid intake-fish oil

  39. Changing Fatty Acid Intake:Omega 6: Omega 3 • Prehistoric ~ 1900 ~ 2000 • 1:1 4:1 25:1 n-6 fats n-3 fats

  40. * Magnesium - mechanism • Ionized magnesium levels low in 50% of MHA patients • Migraines associated with platelet aggregation, serotonin release • Magnesium reduces platelet aggregation • Magnesium decreases the affinity of serotonin for vascular receptor sites • Magnesium acts as an NMDA receptor (glutamate receptor) antagonist • NMDA receptors & pain transmission • Inhibits one type of neuronal spreading depression in experimental models * OPTIONAL SLIDE – for participant reference

  41. * Consequences of Reduced Mg++ • Vasoconstriction of scalp arteries • Reduced affinity of serotonin receptors • Lower threshold for activation of N-methyl- d-aspartate receptors • Enhanced platelet aggregation and serotonin release

  42. Petasites hybridus Root Extract • Large, 3arm, dose-finding RCT (Lipton, Neurology, 2004) • Reduced frequency by more than 50% in 68% of those with highest doses. • Few dropouts. • Two other confirmatory studies, one in children.

  43. * Trials with Mg++ Supplements • An infusion of 1.0 g of magnesium sulfate in 40 patients with acute migraine • 52% responded to therapy • 86% of the responders had low serum ionized Mg++ levels • 16% of the non-responders had low serum ionized Mg++ levels. Mauskop A. Alternative therapies in headache – Is there a role? Medical Clinics of North America 85(4): 1077-84; 2001.

  44. * Trials with Mg++ Supplements • Four trials with oral magnesium supplementation • Three of the four showed efficacy • The one negative trial used a poorly absorbed magnesium salt which resulted in diarrhea

  45. Herbs In Migraine • Feverfew – yes for prevention if you can get British and use it daily • Valerian –to help with sleep • Petasites (Butterbur) – yes for prevention if you can get quality product

  46. * Feverfew • Feverfew (Tanacetum parthenium) • 270 adult migraine patients • 70% reduction in intensity and frequency of migraine • Other trials have not been as promising but all show benefit of feverfew > placebo • Variability in quality of products! Murphy J et al.. Lancet 1988. Ernst E et al.. Public Health Nutrition .2000.

  47. Follow- up in 4-6 weeks. Ask patient to bring chart and say you plan to be proud of them (build expectation of success) and will ask them what they’d like to do for next step (involve them in problem solving). Do it! Follow Up

  48. *Feverfew • Significant reduction in frequency, not in duration • No head to head studies with other modalities • Dosing: 125mg/day of the dried leaf standardized to a minimum 0.2% parthenolide • Maximum effect after 4-6 weeks • Adverse effects: Aphthous ulcers and gastrointestinal side effects in 5-15% • Avoid abrupt cessation: agitation & increased HA • Contraindicated during pregnancy

  49. Valerian • Used for sleep, anxiety • 150-300 mg of dried root hs or tid • Few side effects • Avoid prolonged use – rebound headache • Used during headache • Smells very bad

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