COMMENTARY

A Personalized Approach to Managing Migraine With Complementary and Integrative Medicine

Anna Pace, MD; Niushen Zhang, MD

Disclosures

June 17, 2022

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Anna Pace, MD: Hi, everyone, and welcome. My name is Dr Anna Pace. I'm an assistant professor of neurology at the Icahn School of Medicine at Mount Sinai, and I direct the Headache Medicine Fellowship at Mount Sinai Hospital. Today, I'm lucky enough to be joined by my illustrious colleague, Dr Zhang.

Dr Zhang, would you like to introduce yourself?

Niushen Zhang, MD: Hi, Dr Pace. It's great to be here. I'm Dr Niushen Zhang. I'm a clinical assistant professor of neurology. I'm also the chief of headache medicine at Stanford University. Great to be here.

Pace: Today, we're going to be talking about complementary and integrative medicine for migraine. I think this is a topic that has sparked a lot of interest, especially on the patient side over the last couple of years. Dr Zhang, can you tell me a little bit about what exactly complementary and integrative medicine is?

Zhang: There are actually many definitions of it. What we generally think about are nonpharmaceutical treatment approaches or healthcare practices that may not be part of conventional medicine. The American Board of Integrative Medicine gives a very well-rounded definition of this, in which they say that it's a practice of medicine that focuses on the whole person, and it should be informed by evidence and make use of all of the appropriate treatment approaches that can help our patients achieve optimal health.

The name that we use to describe this field of medicine has changed over time. Initially, it was alternative medicine, then it was called complementary and alternative medicine, or CAM. The most recent term that we use is complementary and integrative medicine.

Pace: Or CIM, for short. I think CIM, based on what you're describing, sounds like it would fit well with headache medicine, in general, when we're thinking about all of the different factors that can potentially contribute to or affect a person's headache frequency. Some of the things that we always think about are lifestyle factors that can affect headaches.

Do you have any data or anything you'd like to talk about in terms of some of the different lifestyle factors that patients can work on when they are looking to try to reduce their headache frequency?

Which Patients Might Benefit From CIM?

Zhang: First, we always want to think about which patients are a best fit for this type of treatment. We think about patients who may not have had adequate responses to their pharmaceutical treatments, who have poor tolerance to these treatments, or maybe some medical contraindication to medications. We also think about people who may be pregnant or lactating or planning pregnancy. These treatments can also be helpful for people who have medication overuse headache or exhibit significant stress and may not have adequate stress coping skills.

Really, the foundation is the lifestyle modifications. The way that I explain it to patients is basically your migraine brain is hypersensitive, especially to change. What it likes is a very regular and predictable schedule for eating, sleeping, and exercise.

Specifically, what we see for exercise is that about 20 minutes a day of aerobic exercise can actually decrease headache frequency and severity. This could be anything from devoted time to walking, hiking, biking, or swimming. Those can all be very helpful.

For sleep, poor sleep quality, including things like insomnia, can affect about 30% of patients with migraine. In our clinic, we always screen for any potential underlying sleep disorders, like sleep apnea. We want to make sure our patients receive appropriate evaluations and treatment for those conditions. What we find most helpful with sleep is just keeping the same bedtime and wake-up time every day, Monday through Sunday.

Of course, we get many questions about food and nutrition. The truth is the evidence is just not strong in this area at this time, for any specific dietary interventions. We always counsel our patients to keep a very regular and consistent meal schedule throughout the day and to avoid skipping meals. Patients also love to ask about food triggers, but the evidence is not strong for what foods must be avoided.

In practice, we find that food triggers are very individual for people. If someone finds that a certain food consistently triggers their migraines, then it would make sense to avoid that food, but in general, we don't encourage people to restrict their diet.

Pace: Exercise and sleep come up often in my clinic as well. Particularly for patients who find that exercise may trigger their attacks or they're hesitant to do any exercise because their attacks are so frequent, I often recommend gentler, low-impact exercises, like yoga, tai chi, or swimming, for example, which I think people find a little bit easier to warm up to or incorporate into their routine.

And really focusing on good sleep hygiene, and even things like trying to wind down before bed and having some type of routine, is really helpful. I have had a number of patients come to me and ask, "Is there anything, like vitamins or herbal supplements, that I can take to try to help prevent my attacks?" There is quite a number of them that have good evidence. What do you usually recommend for your patients?

Strong Evidence for Nutraceuticals and Behavioral Therapies

Zhang: I'm glad you brought that up. There are, I would say, four that are evidence-based and very helpful for our patients. One of them is magnesium. That one has a level B recommendation from the American Academy of Neurology (AAN)/American Headache Society (AHS). We think it helps with calming down neuronal hyperexcitability and preventing cortical spreading depression. Some of the formulations we like are magnesium glycinate, magnesium oxide, and citrate. We do want to watch for any loose stool or diarrhea, because those are some of the common side effects that can potentially happen. The daily dosing is about 200-600 mg/d.

Other than magnesium, we also have vitamin B2 or riboflavin. That also has a level B recommendation, and it's well-tolerated. Some people do get very bright orange or yellow urine when they take it, and the dosing is around 400 mg. There's also coenzyme Q10, which has level C recommendation from AAN/AHS. It plays a role in the electron transport chain and may play an important role in sustaining mitochondrial energy stores. It's also very well-tolerated, and the daily dosing is about 300 mg.

The last one we have is something called feverfew, which is a type of chrysanthemum. This also has a level B recommendation. We think this may have some anti-inflammatory properties. Some people do get gastrointestinal (GI) side effects with that, so you do have to watch out. We don't recommend this one during pregnancy because it can cause early contractions and potentially miscarriage. The daily dosing for that is 50-300 mg.

Pace: It's great that there are so many different nutraceutical options for migraine prevention. I personally find the combination of magnesium and riboflavin to be a good one that I tend to start with. I think nutraceuticals come up quite often. I have many patients who ask me about them. Are there any patients, in particular, whom you think would benefit most from nutraceuticals?

Zhang: Similar to what we talked about before, many of our patients just don't tolerate some of the pharmaceutical treatments that we have, so this would be a good option to start with. One thing I always ask my patients to keep in mind is that the improvement can be gradual with these supplements. Really, like any preventive treatment, you want to give it up to 3 months before someone may see maximum benefit.

Pace: Agreed. I think it's hard sometimes to wait that long, but when they do, it really can help. Another type of CIM treatment that has really great evidence in migraine prevention includes the behavioral therapies, which brings to mind things like cognitive-behavioral therapy. I'm curious what your thoughts are about those and whether or not you recommend patients to utilize them?

Zhang: I think those are terrific options. Honestly, I think one of the challenges for providers is how to broach this topic without making your patients feel like you're dismissing their experience as psychiatric or psychological. I think one way to approach this is to help your patients understand that the contributors to their headaches are usually partial and additive, and that things like stress, anxiety, and mood disorders can have a significant impact on their headaches.

That's why it's really important that we find effective ways to address those. What's great is that now we have the highest level of evidence showing that specific biobehavioral treatments, such as cognitive-behavioral therapy, biofeedback, and relaxation training, are all effective preventive treatments for migraine.

Pace: As far as I understand, it sounds like patients who have migraine and who may also have anxiety and depression may benefit from these. Do you ever see patients who don't have a history of anxiety or depression utilize any of these therapies and find them helpful just for migraine?

Zhang: Absolutely. I would say relaxation training and also biofeedback. These are great because you can not only use them as a preventive treatment — things that you practice on a daily basis for prevention — but also reach for them as acute treatment tools when you feel that migraine escalating or the onset of migraine.

Pace: I think that sounds great, and I agree. I find that sometimes broaching this topic with patients can be a bit challenging because on the one hand, you want to be able to validate their experience, but at the same time help to target some of the potential mood components of their presentation or the anxiety that comes with having a migraine attack with aura, which I see very commonly and I'm sure you probably do as well. Using things like relaxation therapy in the moment during an aura, I think, can be incredibly useful.

One of the other things that I always get asked about is acupuncture and whether or not there is evidence for that in terms of its efficacy in helping with migraine prevention. I seem to get that question from many of my pregnant patients. Do you have any experience recommending acupuncture to patients? What do you think about the data for that?

Acupuncture and Yoga: More To Learn

Zhang: We are very data-driven and we want to provide evidence-based treatments for our patients. Acupuncture has pretty good evidence for its use as a preventive treatment in episodic migraine. There's still sparse evidence for using it to treat chronic migraine or to use it as an acute treatment.

When it comes to treating episodic migraine with acupuncture, there's an excellent 2016 Cochrane review that nicely summarizes the evidence for acupuncture for this treatment. They looked at 22 trials with almost 5000 patients and found that acupuncture is slightly more effective than sham in reducing frequency of headaches and at least similarly effective as some of our standard prophylactic medications.

Pace: That's great. As far as I know about the data, it seems like it would be a good option in addition to, perhaps, the traditional therapies that we are using, like oral medications. Similarly, yoga also comes up in the same conversation — whether yoga can be useful. Again, many of my pregnant patients ask this question. Do you ever recommend yoga to patients?

Zhang: With yoga, I think there's still much we have to learn about in terms of how it helps our patients with migraine. At this time, we just don't have that much robust evidence for that.

There was a randomized clinical trial published in Neurology in 2020 that looked at the effect of yoga as an add-on therapy for episodic migraine. They had two groups. One was a medical therapy group, and the other underwent medical therapy for migraine treatment, as well as yoga. They had the yoga group practice a predesigned yoga intervention 3 days per week for 1 month with an instructor at a center. This was followed by, I think, 5 days per week for 2 months at home. They looked at over 100 patients for this study.

In the end, when they compared the medical therapy group with the yoga group, the yoga group showed a significant decrease in headache frequency, intensity, and some of the migraine disability scores. The conclusion was that yoga, as an add-on therapy for episodic migraine, may be superior to medical therapy alone. I think this is a very promising beginning in terms of the research, and I really hope that we get more studies like this done in the future.

Pace: Yes. I think it illustrates an important concept that I think many of us ascribe to, in that it's really important to think about the patient, what their lifestyle is like, and what they feel comfortable with in terms of a treatment regimen and how important it is to really create an individualized plan for them.

I personally use, often, a combination of pharmacologic treatment and nonpharmacologic treatments, so the fact that that study showed that yoga was great in addition to traditional migraine therapy hammers that point home for me, in terms of using even some of the other therapies that we've talked about in addition to our traditional oral or injectable therapies for migraine. Would you agree?

Zhang: I totally agree, Dr Pace. I think some of the most helpful treatment plans that we develop for our patients are those that integrate both pharmacologic tools and the nonpharmacologic tools that we have. Part of why I love headache medicine is that we actually get to personalize these treatments for our patients.

Pace: I completely agree. I think that's a good place for us to end. We thank you all very much for joining us.

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