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Review Article
Address correspondence to
Dr Alexander Mauskop,
New York Headache Center,
30 East 76th Street, New York,
NY 10021, drmauskop@
nyheadache.com.
Relationship Disclosure:
Dr Mauskop has served as a
speaker for Allergan, Inc.;
GlaxoSmithKline; and
Zogenix, Inc.
Unlabeled Use of
Products/Investigational
Use Disclosure: Dr Mauskop
reports no disclosure.
* 2012, American Academy of
Neurology.
Nonmedication,
Alternative, and
Complementary
Treatments for
Migraine
Alexander Mauskop, MD, FAAN
ABSTRACT
Purpose of Review: The efficacy of some nonpharmacologic therapies appears to
approach that of most drugs used for the prevention of migraine and tension-type
headaches. These therapies often carry a very low risk of serious side effects and
frequently are much less expensive than pharmacologic therapies. Considering this
combination of efficacy, minimal side effects, and cost savings, medications should
generally not be prescribed alone but rather in combination with nonpharmacologic
therapies.
Recent Findings: In addition to the established nonpharmacologic therapies, such
as biofeedback, relaxation training, butterbur, riboflavin, magnesium, and coenzyme Q10 (CoQ10) supplementation, recent data provide support for the use of
aerobic exercise and acupuncture. Discovery of the high incidence of the C677T
mutation of the methylenetetrahydrofolate reductase gene, MTHFR, and attendant
elevation of homocysteine levels in patients with migraine with aura led to a trial of
cyanocobalamin, folate, and pyridoxine in these patients. This trial showed that
taking these three supplements resulted in a reduction of homocysteine levels and
improvement of migraines.
Summary: Therapies proven (to various degrees) to be effective for migraine include
aerobic exercise; biofeedback; other forms of relaxation training; cognitive therapies;
acupuncture; and supplementation with magnesium, CoQ10, riboflavin, butterbur, feverfew, and cyanocobalamin with folate and pyridoxine.
Continuum Lifelong Learning Neurol 2012;18(4):796–806.
PSYCHOLOGICAL APPROACHES
Extensive literature indicates that pain
patients with an internal locus of control have lower levels of anxiety, depression, and disability than those who
believe that they have no control over
their condition because external factors
are dominant. This locus of control is
modifiable and can be shifted.1 Patients
can learn that they are not entirely at
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the mercy of genetic factors, weather,
or unpredictable behavior of people
around them that causes their headaches. They can use self-management
techniques including biofeedback,
avoid triggers when possible, try alternative and pharmacologic therapies, and
become aware of other options such as
acupuncture. The knowledge that they
have these options, even without trying
August 2012
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a
TABLE 4-1 Acceptance Commitment Therapy
1. The limits of control (short- and long-term costs and benefits), focus on
experience (body scan)
2. Values (what you care about, how you want to live your life)
3. Cognitive defusion (observing thoughts without trying to evaluate or
change them)
4. Mindfulness (being in the moment)
5. Committed action (road map connecting values, goals, actions, obstacles,
and strategies)
6. Review and continued action in support of values
7. Moving forward
a
Modified from Wetherell JL, et al, Pain.3 Reproduced with permission of the International Association for the Study of Pain (IASP). www.sciencedirect.com/science/article/pii/
S0304395911003393.
all of them, can give them a sense of
control over their headaches. Changing
the outlook from powerless to empowered will often result in a reduction of
headaches. Another psychological factor is known as catastrophizing. Examples of catastrophizing are ‘‘I will never
get better,’’ ‘‘My husband will leave me,’’
and ‘‘I am a total failure.’’ Independent
of anxiety, depression, and physical
symptoms, this negative view of life
circumstances can lead to impaired functioning and lower quality of life in patients with migraine.2 Psychological
approaches found to be effective in patients with pain are cognitive-behavioral
therapy (CBT) and acceptance and commitment therapy (ACT).3 Table 4-1 and
Table 4-23 explain the steps used in
CBT and ACT sessions.
Biofeedback has been proven to provide long-term benefits in the treatment
of both migraine4 and tension-type headaches,5 although self-administered progressive relaxation training might also
be effective. Biofeedback involves learning to control bodily functions that
normally are not under our conscious
a
TABLE 4-2 Cognitive-Behavioral Therapy
1. Three-component cognitive-behavioral therapy model (thoughts, feelings,
behaviors), pain monitoring
2. Relaxation training (diaphragmatic breathing, progressive muscle
relaxation, guided imagery)
3. Pain-fatigue cycle, activity pacing, and pleasant-event scheduling
4. Identifying and challenging negative thoughts (activity, belief,
consequences, dispute model)
5. Problem-solving skills training and assertive communication
6. Review and practice
7. Relapse prevention
a
Modified from Wetherell JL, et al, Pain.3 Reproduced with permission of the International Association for the Study of Pain (IASP). www.sciencedirect.com/science/article/pii/
S0304395911003393.
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797
Alternative Treatments
KEY POINTS
h Forty minutes of aerobic
exercise performed
3 times a week is
effective for preventing
headaches.
h Frequent isometric neck
exercise can relieve
cervicogenic headaches
and improve migraine
headaches in patients
with associated neck
pain or muscle spasm.
control, such as skin temperature and
muscle tension. Neurofeedback is a
variant of biofeedback and involves
learning how to alter one’s own EEG
patterns. This ability requires first learning to achieve a state of deep relaxation. The most important factor in
achieving success with biofeedback is
regular daily practice. The usual course
of biofeedback consists of 10 weekly
sessions, but some patients may require fewer sessions, particularly children and those who are diligent about
their daily practice and are skilled at
imagery. Any form of meditation done
on a daily basis (I recommend starting
with 20 minutes of daily practice) is
also likely to provide significant benefits.6 Patients with disabling headaches
should be referred to a psychologist for
CBT or ACT. Among other benefits,
CBT or ACT can help shift a patient
from an external locus of control to an
internal locus of control, which improves outcomes.
Biofeedback is a simple technique
that has been proven to relieve migraine and tension-type headaches,
and the benefits have been shown to
persist for up to 5 years.7 Self-taught
progressive relaxation is equally effective if the patient is motivated and
practices daily.
PHYSICAL METHODS
Aerobic exercise is proven to be effective for the prevention of migraine
headaches. A study of 46,648 Swedes8
showed that ‘‘In the cross-sectional
analyses, low physical activity was associated with higher prevalence of migraine and non-migraine headache. In
both headache groups, there was a
strong linear trend (PG.001) of higher
prevalence of ‘low physical activity’
with increasing headache frequency.’’
A follow-up study9 compared aerobic
exercise (40 minutes 3 times a week)
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with topiramate and relaxation training
and found these three treatments to
be equally effective. Only topiramate
caused side effects, which occurred in
33% of patients.
Neck pain is a more frequent accompanying symptom than nausea during
a migraine attack.10 Some patients feel
that their migraines are triggered by
neck pain, although it is possible that
neck pain is just an early sign of an
impending migraine. Isometric neck
exercise can be effective in the treatment of cervicogenic headaches and
migraines accompanied by neck pain,
whether triggered by or associated
with neck muscle spasm. The goal of
the exercises is to strengthen neck muscles, which will render them more resilient and less likely to return to spasm.
A simple 1-minute exercise (Figure 4-1)11
needs to be repeated 10 or more times
throughout the day. To do this exercise, sustained pressure is exerted with
one’s hand on one side of the head,
then the other side, then the forehead,
and, finally, the occiput for 10 to 15
seconds in each direction, while the
head remains stationary in a neutral
position. Patients can be advised to set
an hourly alarm. Along with the neck
exercise, patients can also scan their
body for areas of muscle tension and
perform some breathing and relaxation
exercises. Improvement can be expected after about 2 weeks of diligent
exercise, but if exercise is discontinued,
muscles will weaken and neck pain and
headaches may recur (Case 4-1).
DIETARY INTERVENTIONS
Caffeine can be a major trigger in transforming episodic migraines into more
frequent or even chronic headaches. It
insidiously increases attacks but at first
may be an effective adjuvant analgesic.
Over time, as with opioid analgesics,
patients develop tolerance and physical
August 2012
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FIGURE 4-1
Isometric neck exercise.
Reprinted with permission from Mauskop A, Brill MA, Dell.11
Case 4-1
A 29-year-old woman was very concerned about her headaches, which
began after a long airplane ride 2 weeks ago. She had never before had
headaches. The pain was constant and mostly involved the right side
of her head. She felt numbness and a pins-and-needles sensation over the
right occipital area. She was afraid that this was a sign of an impending
stroke and was eager to have an MRI of her brain. She had no nausea,
photophobia, phonophobia, or any other neurologic symptoms but
admitted to having neck pain. She had not tried any medications
because she did not want to mask her symptoms. She was in good health,
exercised regularly, refrained from abusing alcohol, and drank only one
cup of coffee daily. At work she spent hours on the phone and cradled
the receiver on her shoulder. Her physical examination was normal,
except for diminished sensation over the right occipital area and
tenderness of suboccipital and neck muscles.
She had cervicogenic headaches with an element of occipital neuralgia
caused by muscle spasm, which in turn was triggered by sleeping in an
awkward position on the airplane. She agreed to delay an MRI scan for
2 weeks and see whether treatment stopped her headaches. She no longer
cradled the phone receiver on her shoulder, she performed isometric
neck exercises 10 times a day, and she took naproxen 500 mg 2 times a
day as needed. Within 2 weeks she had complete relief of her headaches
and continued her neck exercises to prevent recurrence.
Comment. This case describes a woman who has cervicogenic headaches
with symptoms of an occipital neuralgia. Isometric neck exercise and
ergonomic adjustment can be very effective for the treatment of
cervicogenic headaches. Some patients may also require biofeedback or
relaxation training since stress, which can cause tension in neck muscles,
is a frequent contributing factor.
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799
Alternative Treatments
KEY POINTS
h Caffeine is a major
contributor in the
transformation of
headaches from
episodic to chronic.
Daily consumption of
as little as two cups of
coffee or caffeine drinks
plus analgesic products
containing caffeine can
worsen headaches.
h Reactive hypoglycemia is
common in patients with
migraine. Adherence to
regular mealtimes, small
frequent meals, and
avoidance of foods with
high glycemic index can
significantly improve
migraine headaches.
h Serum magnesium
levels are unreliable for
predicting brain
magnesium levels; the
commercially available
red blood cell
magnesium levels are
more indicative of the
true magnesium status
but are not entirely
accurate. Magnesium
levels in the lower half
of the normal range
should be considered
deficient. Serum levels
are helpful only when
they are low.
h Clinical symptoms of
magnesium deficiency,
in addition to
headaches, are leg
muscle cramps; feeling
cold or having cold
extremities; and, in
women, premenstrual
syndrome symptoms.
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dependence. It is not the caffeine use
but the withdrawal that causes headaches. Patients may not recognize how
much caffeine they consume; two cups
of coffee with breakfast, one to two
cans of caffeine-containing soft drinks,
and a few caffeine-containing analgesics may not seem to them to be excessive. Also, some large coffee chains
market 12-oz cups containing as much
as 240 mg of caffeine and 16-oz cups
with 320 mg of caffeine. Regular consumption of as little as two to three
cups of coffee is sufficient to trigger a
withdrawal headache in patients prone
to headaches.
A small number of my patients have
reported improvement in headaches
and general well-being after elimination
of gluten from their diets, even in the
absence of celiac disease. Gluten sensitivity may be a different and milder
form of allergy to gluten. It is thought
to be a result of the expression of an
innate immunity and its marker, tolllike receptor (TLR). TLR was found to
be elevated in gluten-sensitive patients
but not in those with celiac disease or
healthy controls. Some patients with
known celiac disease note improvements in headache when their disease
is better controlled, but this varies.
Many patients get headaches when
they skip a meal. A meal high in simple
carbohydrates can also bring on a headache, probably because many patients
with migraine have reactive hypoglycemia.12 More frequent and smaller meals
daily, often with complex carbohydrates,
can be helpful.
Tyramine-rich foods, such as chocolate, cheese, and other products of
fermentation, as well as alcohol, aspartame, and nitrites can trigger migraine
in some susceptible individuals. Keeping a food diary can be helpful. Several
free smartphone applications for tracking headaches and various potential
triggers are available.
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MAGNESIUM
Magnesium deficiency is well documented in some patients with migraine.
Studies of serum ionized magnesium,13,14 whole-brain NMR spectroscopy,15 intracellular levels in various
types of cells,16,17 and magnesium loading18 have consistently shown that patients with migraine and cluster headache
frequently have a magnesium deficiency. Only 1% of body magnesium is
present in the serum; therefore, a
serum magnesium level correlates
poorly with the true magnesium status
of the brain. Serum levels are only
useful when the value is below normal.
Red blood cell magnesium level is a
commercially available test that is
somewhat more accurate, and if the
value is at the lower end of the normal
range, a magnesium deficiency might
be present. The normal range is
4.0 mg/dL to 6.4 mg/dL, and when the
patient’s value is below 5.0 mg/dL,
magnesium supplementation might
be beneficial. Clinical symptoms other
than headaches are also useful in assessing a potential magnesium deficiency. Symptoms include muscle
twitching or leg or foot muscle cramps
(often nocturnal); fatigue; cold extremities or cold intolerance; insomnia;
palpitations; and, in women, premenstrual syndrome symptoms (bloating,
breast tenderness, irritability).
Several double-blind, placebocontrolled (DBPC) studies of magnesium
supplementation have been conducted.
Of the two largest studies (each with
more than 80 patients), one was positive19 and one was negative.20 The active
treatment in the negative study caused
diarrhea in 45% of patients, indicating
that the magnesium salt used in the study
(magnesium-L-aspartate-hydrochloride
trihydrate) was not absorbed. The positive study used a different magnesium
salt (trimagnesium dicitrate), which
caused diarrhea in only 18% of patients.
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Another positive but smaller DBPC study
of supplementation with magnesium
pyrrolidone carboxylic acid21 showed a
reduction in the number of days with
headache in women with menstrual
migraines as well as improvement in
premenstrual syndrome symptoms
(measured by Menstrual Distress Questionnaire scores). A DBPC pediatric study
of magnesium oxide for the prevention
of frequent migrainous headaches22 was
negative for the primary outcome measure of migraine frequency, but was
positive for secondary measures of headache days and headache severity.
In practice, when magnesium deficiency is suspected, 400 mg of magnesium oxide or chelated magnesium
(eg, magnesium gluconate, glycinate,
aspartate) can be taken daily with food.
Magnesium and other supplements
often have to be taken for 1 month or
more before any benefits are noticed.
These are inexpensive supplements
but they may be poorly absorbed and
cause diarrhea. The slow-release form
of magnesium lactate is more expen-
FIGURE 4-2
sive but may have better bioavailability
and tolerability. If a dosage of 400 mg
is tolerated but not beneficial, it can be
increased to 400 mg 2 or 3 times a day.
Renal disease is the only contraindication, since it is accompanied by reduced magnesium excretion.
IV infusion of magnesium has been
shown to relieve acute migraine in
86% of patients with low serum ionized magnesium levels and in only 16%
of those with normal levels, as seen
in Figure 4-2.14 In that study half of the
40 patients had low ionized magnesium levels. Another study demonstrated that an infusion of magnesium
aborted migraines with aura but not
those without aura.23 Infusions can be
administered to patients during a severe attack of migraine headache or
prolonged aura to treat the attack. A
study of IV infusion of magnesium
sulfate in patients with cluster headaches showed that the 40% of patients
who had low serum ionized magnesium levels had a good response to
the infusion, while those with normal
KEY POINT
h Oral magnesium
supplements can cause
diarrhea or fail to be
absorbed. If magnesium
deficiency is suspected
or if serum or red blood
cell magnesium levels
are low, an IV infusion
of 1 g of magnesium
sulfate can be
beneficial. Parenteral
treatment of migraine
should begin with a
magnesium infusion.
Serum IMg2+ levels and means in patients with migraine (A) and cluster headache
(B) prior to magnesium infusion.
Reprinted with permission from Mauskop A, et al, Clin Sci.14 B the Biochemical Society. www.clinsci.org/cs/089/
cs0890633.htm.
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Alternative Treatments
levels did not respond.24 I infuse
patients who are intolerant to or who
do not benefit from oral magnesium
in the presence of symptoms of
deficiency or low red blood cell serum
levels. Serum levels are useful only
when they are low. Infusions are
simple and safe, considering that only
1 g of magnesium sulfate is used. The
patient is infused in a recumbent
position because of possible orthostasis from vasodilation; the patient
should remain in a recumbent position until the sensation of warmth
subsides. One gram of magnesium sulfate (available as a 50% solution) is di-
luted with normal saline, filling a 10 mL
syringe, and is administered during a
5-minute period by slow push using a
butterfly needle. If the sensation of
heat is too intense, causing nausea and
dizziness, the infusion rate is reduced.
If a patient comes to an emergency department, physicians may consider using
magnesium infusion as a first-line therapy (Case 4-2).
COENZYME Q10
Deficiency of CoQ10, a mitochondrial
cofactor, was found in 33% of children
with migraines.25 Supplementation with
Case 4-2
A 39-year-old woman had been experiencing menstrual migraine since
puberty. Her headaches started the day before her period and lasted
3 days, during which she was incapacitated by pain, nausea, and vomiting.
On review of organ systems she reported frequent leg muscle cramps
and coldness of extremities, both of which worsened during her periods.
Sumatriptan injections and prochlorperazine suppositories provided
partial relief but did not restore her to normal functioning because of the
residual pain, fatigue, and drowsiness. She had tried propranolol but
developed dizziness without relief of headaches. Topiramate caused
cognitive impairment. Mini-prophylaxis (taking a prophylactic agent for
1 week, starting 2 days before her period) with naproxen and frovatriptan
was ineffective. Continuous contraception stopped her periods for only
2 months and then her period broke through and was accompanied by a
severe migraine. Dexamethasone 8 mg daily for the 3 days of headache
provided sufficient relief to allow her to go to work, but she still had a
mild headache and nausea and functioned near 50% of her capacity.
Oral magnesium supplementation provided no help, but an injection
of 1 g of magnesium sulfate during an attack produced dramatic relief
without any side effects. She tried increasing the dose of oral magnesium
but developed diarrhea. Chelated and slow-release forms of magnesium
were better tolerated but also did not prevent her menstrual migraine.
The patient went on to receive monthly premenstrual infusions of 1 g of
magnesium sulfate with complete prevention of her migraine attacks.
When she traveled and was unable to receive her infusion, severe
headache returned.
Comment. Magnesium deficiency is common in patients with migraine,
but it is often not detectable by measuring serum levels. In patients
with other clinical symptoms of magnesium deficiency, a therapeutic
trial with an oral magnesium supplement is indicated. If a patient with
frequent and severe migraines does not tolerate or respond to oral
magnesium, an IV infusion may be highly effective.
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CoQ10 significantly reduced disability
and headache frequency. A DBPC trial
of 42 adults using 100 mg of CoQ10
3 times a day was also positive.26 The
only side effects that patients are likely
to experience are insomnia or dyspepsia if CoQ10 is taken at night. A doseranging study of CoQ10 in Parkinson
disease established that only the highest dose, 1200 mg/d, was effective. It is
possible that a dose higher than 300
mg/d, usually recommended for
migraine, may be even more beneficial.
However, in the absence of any data
and because of the relatively high cost,
I recommend that migraine patients take
300 mg daily.
RIBOFLAVIN
Riboflavin, or vitamin B2, is another mitochondrial cofactor involved in energy
generation that has been shown to be
effective in the prophylaxis of migraine
headaches. A single DBPC study was
conducted in 55 patients using 400 mg
of riboflavin daily for 3 months.27 While
the results were positive, a significant
difference between riboflavin and placebo was noted only in the third month.
Therefore, when using riboflavin for migraine prophylaxis, patients should be
advised to take it for at least 3 months.
Understandably, patients are reluctant
to wait that long to see whether the
treatment is successful, and this is a
reason to use a combination of riboflavin with magnesium, CoQ10, and at
times herbal supplements. Riboflavin is
considered probably effective (Level B),
according to the updated evidencebased guideline on the prevention of
episodic migraines.28 Summaries of
these guidelines can be found in Appendix C and Appendix D.
BUTTERBUR
Butterbur (Petasites hybridus) is a common plant that was shown to be efContinuum Lifelong Learning Neurol 2012;18(4):796–806
fective for the prevention of migraine
headaches in a DBPC three-arm study
that involved 245 patients.29 A daily
dose of 150 mg of butterbur was significantly more effective than placebo,
whereas 100 mg was not. However,
butterbur is a toxic plant with teratogenic, carcinogenic, and hepatotoxic
properties. The recently updated guideline28 considers butterbur effective
(Level A) for the prevention of episodic
migraine headaches.
FEVERFEW
Feverfew (Tanacetum parthenium) is
a safe plant that can be ingested raw or
in any form a patient desires. Most patients opt for a processed and encapsulated formulation, but the amount
of active ingredients (parthenolides) in
these products varies widely. The best
DBPC study used standardized extract
in 170 patients and showed statistically
significant improvement.30 This extract
is considered probably effective (Level
B) in the updated guideline,28 but it is
not available in the United States. Feverfew products that are available may
not be of the same quality and consistency because they lack the regulation of the nutraceutical industry.
KEY POINTS
h Supplementation with
300 mg of CoQ10
can be effective for
preventing migraines in
adults and adolescents.
It should be
administered in the
morning because if
taken at night it can
cause insomnia.
h Daily intake of 400 mg
of riboflavin can prevent
migraine headaches,
although in some
patients the benefit
may appear only after
3 months.
h Butterbur and feverfew
can be effective for the
prevention of migraine
headaches in some
patients. Pregnant
women, however,
should not take these
herbal preparations.
Butterbur is associated
with several serious
potential risks.
FOLIC ACID, VITAMIN B12, AND
VITAMIN B6
Variant C677T of the methylenetetrahydrofolate reductase gene, MTHFR, has
been implicated as a genetic risk factor in the susceptibility to migraine with
aura. The C677T polymorphism reduces
enzymatic capability and causes elevated
homocysteine levels. It is speculated that
disruption of neurovascular endothelium by elevated homocysteine levels is
a possible trigger for migraine with aura.
It is also possible that this is the cause of
white matter lesions and strokes seen in
patients having migraine with aura.
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Alternative Treatments
KEY POINTS
h Patients with migraine
with aura should have
their homocysteine
level checked. If it is
high, supplementation
with folic acid,
cyanocobalamin, and
pyridoxine may reduce
the homocysteine level
and migraine disability.
h Acupuncture can be
effective for some
patients with migraine
and tension-type
headaches, although
it can be a
time-consuming
and expensive
treatment.
804
In a DBPC study, 52 patients experiencing migraines with aura were administered either placebo or 2 mg of
folic acid, 400 Hg of cyanocobalamin
(vitamin B12), and 25 mg of pyridoxine
(vitamin B6).31 Vitamin supplementation
reduced homocysteine by 39% compared with baseline, a reduction that
was significantly greater than in the placebo group. Vitamin supplementation
also significantly reduced migraine disability, headache frequency, and pain
severity. It seems reasonable to check
homocysteine level in all patients with
migraine with aura.32
ACUPUNCTURE
Definitive proof is lacking to show
that acupuncture relieves headaches;
however, the available evidence from
randomized controlled trials strongly
suggests that acupuncture produces a
benefit extending beyond the placebo
effect. A difficulty of conducting blinded
trials is that insertion of a needle produces a strong placebo effect, and acupuncture is performed differently in
different regions. Placing needles into
nonacupuncture spots appears to be
as effective. However, acupuncture may
sometimes be as effective as prophylactic drugs while causing significantly
fewer side effects. The largest study of
acupuncture, conducted in Germany,
enrolled 15,056 patients, of whom
11,874 were treated with acupuncture
in addition to standard care and the
remaining 3182 were randomized to
acupuncture or control groups (standard care alone, no acupuncture).33,34
The group of 11,874 patients and those
randomized to acupuncture showed a
45% reduction in headache days per
month over the course of 6 months
compared to the control group. The
study groups included patients with
migraine, tension-type headache, and a
combination of both, and did not dif-
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ferentiate between the headache types
when reporting the results.
Acupuncture is widely practiced in
Germany, and one study addressed
the efficacy of this treatment when performed by different specialists. The study
revealed that acupuncture was equally
effective when performed by all specialists, with the exception of orthopedic
surgeons, whose results were inferior.
OXYGEN
Oxygen is an excellent abortive treatment for about 70% to 80% of patients
with cluster headache.35,36 It is crucial
to use oxygen under high flow (10 L to
12 L per minute) through a nonrebreathing mask (10 Lpm concentrators
are available). Patients with cluster
headache require a large tank of 100%
oxygen or a 10-Lpm concentrator. Complete relief is often achieved within 5
to 15 minutes, particularly when the
treatment is initiated early in the attack. This treatment is practical for attacks that occur at home, although
some patients have a tank of oxygen at
home and another at work. Oxygen is
devoid of side effects, and the only hazard is an explosion from an open flame.
Patients who smoke should be warned
about this risk. Oxygen is ineffective
for other types of headaches.
CAPSAICIN
Application of capsaicin into the nostril on the side of cluster headache
attacks has been the subject of several
small studies. One study was doubleblind37 whereas another compared
instillation of capsaicin into the ipsilateral versus the contralateral nostril.38 In
both studies capsaicin was applied for
7 days. In the double-blind study capsaicin was applied twice daily into the
ipsilateral nostril, and in the second
study it was applied once a day. Both
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studies were positive, but because of
small sample size the results are suggestive rather than conclusive.
SUMMARY
While every patient requires an individual approach, these recommendations
are applicable to most patients with
migraine. Planning regular sleep schedules, regular meals, avoidance of high
simple-carbohydrate foods, adequate
hydration, restriction and consistency
of caffeine intake, regular aerobic exercise, and biofeedback or meditation are
reasonable. Many patients also benefit
from taking magnesium, CoQ10, riboflavin, butterbur, or feverfew. Patients
having migraine with aura and also an
elevated homocysteine level should be
treated with cyanocobalamin, folic acid,
and pyridoxine. Isometric neck exercise
strengthens neck muscles and may improve cervicogenic and migraine headaches. Acupuncture is an option for the
prevention of headaches. Oxygen can
be effective for aborting cluster headache attacks, while intranasal capsaicin
might shorten the cluster period. It is
important to write down these options
for patients to take home as most people will have difficulty remembering
them. It is best not to preprint this list,
as patients are much more likely to follow advice when it appears to be specifically tailored to and discussed with them.
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