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migraines

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By Leah S. Dunaief

Leah Dunaief

A local physician had a remarkable result. In clinical practice, he was treating a patient with severe migraines. The patient, 60 years old, had been experiencing migraines for 12 years. Recently they increased in frequency, and he was enduring six to eight debilitating headaches per month, each lasting more than 72 hours.  This equates to 18-24 headache days each month.

For those of us who suffer migraines, we know this must have been horrible. A migraine is not just a bad headache. It is as if a drill were unremittingly penetrating one spot in the head, all the while accompanied by nausea, vomiting and an inability to tolerate light. The aftermath is to feel hung over and unsteady. Migraines steal hours and days from the lives of the afflicted. 

The patient had tried various traditional medications, like zolmitriptan and topiramate to no avail. He also avoided possible migraine triggers like aged cheese, caffeine and red wine without success.

The internist, who specializes in lifestyle medicine, put him on a plant-based, high nutrient diet that he created of essentially low inflammatory foods every day. Hence he named it the LIFE diet, and its centerpiece is composed primarily of dark leafy greens, frozen blueberries, a banana and soy milk in a smoothie. These high fiber ingredients, when reinforced with flax seed meal, and a little pomegranate juice, can be made into a 32-ounce drink by a sturdy electric blender. The diet is further reinforced by eating more nutrient-dense veggies, like spinach, kale, arugula and romaine lettuce, for example, at subsequent meals in the day. These foods are thought to reduce chronic inflammation in the body.

The LIFE diet also limits dairy and red meat, whole grains, starchy vegetables and oils, according to reporter Sarah Jacoby, who interviewed the doctor for “Today” last Thursday, Nov. 18.

The results of the new regimen were dramatic. After two months, the patient was experiencing one headache per month. After three months, the headaches were gone. The patient suffered no further migraines. This result has lasted more than seven years so far.

At this point, the local physician, teaming up with his brother, who is a medical researcher, wrote up the study and sent it to the highly prestigious British Medical Journal or BMJ that publishes medical case studies deemed important. Delighted when it was accepted for publication, the doctor, who is a passionate believer in the healing power of dark green leafy vegetables, was further pleased when he learned that BMJ, considering the study valuable enough, had sent out a press release to publications all over the world with a summary.

The response was overwhelming, a testament to the need for a remedy to a universal malady. As of this writing, more than 40 news outlets across the globe, including UPI and WebMD, have picked up the story, from Europe to the Middle East to Asia and Australia, translating it into a dozen different languages.

“I think this (case report) is a tremendous start in the treatment of migraine headaches,” added the local physician. “This is kind of revolutionary to have the ability to say, ‘Not only does it work, but it works in the worst case scenarios. And it works in a short period of time.’”  He has seen similar results in other of his patients.

Dr. Charles Flippen, professor of neurology at the David Geffen School of Medicine at UCLA, agreed, stating that the change the patient experienced was, “rather impressive,” especially how long the effect has lasted. He added, “Now a large sample is necessary to draw conclusions about the benefits of diet change on migraines or chronic migraines,” as quoted by Sarah Jacoby for “Today.” 

Dr. Dawn Buse, clinical professor in the department of neurology at Albert Einstein College of Medicine in New York said, “There have been some recent studies suggesting that major dietary changes can reduce migraine symptoms,” according to “Today.”

“Even though we don’t know the exact mechanism for migraine, the concept of an inflammatory process as part of the underlying physiology of chronic pain has been around for decades,” explained Flippen. “So the idea that you have a diet that reduces the production of pro-inflammatory substances would fit nicely with our current understanding of migraine … It’s not purely magic that it worked.”

For the doctor, whose work has now circled the globe, the satisfaction is enormous. “I went into medicine to help people. It’s beyond gratifying that I may be helping people to take their lives back by reversing disease with the LIFE diet,” he concluded.  

And the name of the local internist who authored the study that has gone viral: my son and our own columnist, David Dunaief, MD.

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By Melissa Arnold

Just about everyone knows the throbbing discomfort of a headache, whether it comes after a long day of work, too little sleep or an oncoming cold. It’s also likely that you’ve heard someone say they have a migraine when the pain becomes severe.

But the truth is that migraine is more than just a bad headache, and the term has taken on a variety of meanings, not all of them accurate.

According to the American Migraine Foundation, migraine is an incurable brain disease that affects approximately 40 million people in the United States — that’s 1 in 4 households. In the majority of those cases, at least one close relative has migraines as well, but it’s still uncertain what causes the disease. 

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Migraine can come with a wide range of neurological symptoms that differ from person to person and day to day. These symptoms exist on a spectrum from sporadic to chronic, mild to incapacitating, and some people can even experience trouble speaking, weakness and numbness in ways that mimic a stroke.

“Migraine is more than just pain. While the pain is often moderate to severe, one sided and throbbing, there are other characteristics,” said headache specialist Dr. Noah Rosen, director of the Northwell Headache Center in Great Neck. 

“The individual must also have either sensitivity to light and noise or nausea to meet the full definition. This can worsen with movement, and many people also develop associated skin or hair sensitivity. Many people may also experience changes in mood, energy level and appetite. About 20% of migraine patients may also have aura with their migraines, which is a brief, fully reversible neurological deficit. Auras can cause visual changes, sensation changes and sometimes weakness.”

For Cat Charrett-Dykes, migraines have been a regular part of her life since she was 13 years old. She would see sparkles and spots and go through bouts of nausea and vomiting, all while feeling like a knife was stabbing through her head. At school, she had trouble reading and finding the right words. “I felt like Dorothy in ‘The Wizard of Oz.’ Some of my siblings also had migraine occasionally, but not to the same degree,” said Charrett-Dykes, who lives in Holtsville. 

The attacks were relatively easy to tame until after the birth of her first child. Then, as is common, her migraines became more severe and frequent. She saw countless healthcare providers, who couldn’t agree on a diagnosis: They suggested she had anxiety, allergies, epilepsy. One even asked if her ponytail was too tight.

Unfortunately, getting a proper diagnosis and care can be a problem in the migraine community. The World Health Organization reports that more than half of all people with migraine haven’t seen a doctor for their condition in at least a year. Many more have never been formally diagnosed. While seeing a neurologist can be useful, not all neurologists are experts in headache disorders.

“Only about 700 people in the country are certified headache specialists, and the field of headache medicine is not yet formally recognized by the federal government, so there are limits on the field’s growth despite how common the condition is,” Rosen explained. “During my time as a resident physician I was seeing severely disabled patients with headache disorders end up in the emergency room, yet I had almost no education in that area, in part because of how underserved the condition is. It is often ignored, stigmatized and mistreated.”

Charrett-Dykes waited decades to find someone who understood her. 

“It wasn’t until 2003 that I was finally diagnosed. As soon as the physician’s assistant walked into the room, he took one look at me and turned off the lights,” she recalled. “No one had ever done that before. He said, ‘You have migraines, don’t you? I know that face. My wife has migraines, too.’ It was such a relief.”

Still, a diagnosis is only the beginning of the migraine journey. Treatment is focused on identifying the person’s unique triggers — perhaps certain foods, scents, strenuous activity, or an irregular schedule — along with the precise combination of medications and other options to help ease their symptoms. There is no magic bullet, and finding treatment that helps can be challenging. 

“Trigger identification and avoidance is a great thing to try, but not always possible.  Raising the ‘threshold’ required to set off a migraine can be done with pharmacological or non-pharmacological approaches,” Rosen said. “Of the medications that are available now, some are preventive and some are acute (or abortive). The preventive treatments help avoid getting the headache in the first place. Healthy habits like regulating sleep, diet, hydration and stress can reduce frequency, as can some vitamin supplements, complementary practices like acupuncture, biofeedback, mindfulness and regular cardiovascular exercise.”  

Nancy Harris Bonk

The process of trial and error is exhausting for many people with migraine, including Nancy Harris-Bonk of Albany, who’s tried countless doctors and medications since her first migraine attack as a young teen. At one point, she was taking the highest dose of oxycodone allowed under a doctor’s care and still having 25 or more migraine days each month.

“I just wasn’t recovering, so I went online and started looking for answers,” said Bonk, whose episodic migraines turned chronic after a fall left her with a traumatic brain injury. “I was able to make contact with someone else who had migraine attacks, and it opened a door for me. I learned that I wasn’t alone and that there were treatment options. It made me want to help educate others about migraine disease and how to live with it.”

Downstate, Charrett-Dykes had similar goals. She founded Chronic Migraine Awareness, Inc. (CMA) in 2009, a simple chat group that later grew into a multifaceted nonprofit connecting people with resources, specialists, and one another. CMA’s main Facebook group now has 12,000 members around the world, with several smaller groups for specific demographics and topics. They also provide care packages for people with migraine, support caregivers, and lead advocacy efforts.

Bonk eventually qualified for Social Security Disability Insurance, freeing her up to focus on her well-being while acting as a resource for others. She still has about 15 migraine days a month, but medication changes and a knowledgeable healthcare team have made life a lot more manageable, she said. She serves on the board of CMA and works with the National Headache Foundation’s Patient Leadership Council; the Coalition for Headache and Migraine Patients (CHAMP); and Migraine.com.

“Learning all you can about migraine disease, knowing what it is and what it isn’t, can make a big difference when it comes to seeking care and advocating for yourself,” Bonk said. “Forming connections with others who have similar experiences is important so we know we’re not alone. This disease can leave us feeling isolated, frustrated and overwhelmed … talking with others who are going through a similar journey is validating and a great comfort. ”

While each of these organizations has a unique focus, they all share a desire to increase knowledge and awareness of migraine disease.

“The pain of migraine is not like other pain and should not be treated like that. It needs to be discussed and not just treated,” Rosen said. “The stigma of people with migraine having a low pain tolerance is also nonsense. I have been impressed on a daily basis by the strength, resilience and resourcefulness of these patients.”

June is Migraine and Headache Awareness Month. To learn more, visit www.migraine.com. To connect with others, visit CMA’s website at www.chronicmigraineawareness.org. The Northwell Headache Center has several locations on Long Island and telehealth appointments are available. For information, call 516-325-7000 or visit www.northwell.edu/neurosciences/our-centers/headache-center.

Trying to avoid triggers for migraines can be worse than navigating a minefield. Stock photo

By David Dunaief, M.D.

Migraines are a debilitating disorder. Symptoms typically include nausea, photophobia and phonophobia — sensitivity to light and to sound, respectively. The corresponding headache usually is unilateral and has a throbbing or pulsating feeling.

Migraines typically last anywhere from four to 72 hours, which is hard to imagine. Then, there is a postdrome recovery period, when the symptoms of fatigue can dog a patient for 24 hours after the original symptoms subside. Migraines are among the top reasons patients see a neurologist (1).

According to the American Migraine Foundation, there are approximately 36 million migraineurs, the medical community’s term for migraine sufferers. This has increased from 23.6 million in 1989. Women are three times more likely to be affected than men (2), and the most common age range for migraine attacks is 30 to 50 (3), although I have seen them in patients who are older.

What causes a migraine?

The theory was once simple: It was caused by vasodilation (enlargement) of the blood vessels. However, this may only be a symptom, and there are now other theories, such as inflammation of the meninges (membrane coverings of the brain and spinal cord). As one author commented, “Migraine continues to be an elephant in the room of medicine: massively common and a heavy burden on patients and their healthcare providers, yet the recipient of relatively little attention for research, education, and clinical resources” (4). There are many potential triggers for migraines, and trying to avoid them all can be worse than navigating a minefield. Triggers include stress, hormones, alcohol, caffeine, diet, exercise, weather, odor, etc. (5).

Focusing on prevention

There are many problems with treating acute migraine attacks beyond the obvious patient suffering. Eventually, patients may increase tolerance to drugs, needing more and more medication until they reach the maximum allowed. There are also rebound migraines that occur from using medication too frequently — more than 10 days in the month — including with acetaminophen (Tylenol) and NSAIDs (6). There are several options for preventive paradigms, some of which include medication, supplements, alternative therapies and dietary approaches.

Medication’s role

There are several classes of medications that act as a prophylaxis for episodic (less than 15 days per month) migraines. These include blood pressure and anti-seizure medications, botulinum toxin (botox) and antidepressants (7).

Blood pressure control itself reduces the occurrence of headaches (8). The data is strongest for beta blockers. Propranolol, a beta blocker, has shown significant results as a prophylaxis in a meta-analysis (group of studies) involving 58 studies where propranolol was compared to placebo or compared to other drugs (9). However, it showed only short-term effects. Also, there were a substantial number of dropouts from the studies.

Topiramate, an anti-seizure medication, showed a significant effect compared to placebo in reducing migraine frequency (10). In a randomized control trial (RCT) that lasted six months, there was a dose-response curve; the higher the dose, the greater the effect of the drug as a prophylaxis. However, drugs come with side effects: fatigue, nausea, numbness and tingling. The highest recommended dose is 100 mg because of side effects. As a result, almost one-third or 30 percent of patients cease therapy at the 200-mg dose because of side effects (11).

Botulinum toxin type A injection has not been shown to be beneficial for preventive treatment of episodic migraines but has been approved for use as a prophylaxis in chronic (greater than 15 days per month) migraines. However propranolol, mentioned already, has shown better results with fewer adverse reactions (12).

Alternative approaches

Butterbur, an herb from the butterbur (Petasites hybridus) root, was beneficial in a four-month RCT for the prevention of migraine (13). The 150-mg dose, given in two 75-mg increments, reduced the frequency of migraine attacks by almost twofold compared to placebo. This herb was well tolerated, with burping the most frequent side effect. Only Petasites’ commercial form should be ingested; the plant contains pyrrolizidine alkaloids, which may be a carcinogen and seriously damage the liver.

Feverfew, another herb, but this time the leaves are used for medicinal purposes, unfortunately, had mixed prophylaxis results. In a meta-analysis, study authors concluded that feverfew was not more beneficial than placebo (9). And, the most significant caveat with herbal medications is that their safety is not regulated by the FDA nor by any officially sanctioned regulatory body.

What about supplements?

High-dose riboflavin, also known as vitamin B2, may be an effective preventive measure. In a small RCT, 400 mg of riboflavin decreased the frequency of migraine attacks significantly more than placebo (14). The number of days patients had migraines also decreased. The side effects were mild for both placebo and riboflavin. Thus, this has potential as a prophylaxis, though the trial, like most of those mentioned above, was relatively short.

How about diet and exercise?

From my experience and those of other physicians, such as Dr. Joel Fuhrman and Dr. Neal Bernard, nutrient-dense foods are potentially important in substantially reducing the risk of migraine recurrence. I have seen many patients, both in my practice and in the three years I worked with Dr. Fuhrman, do much better, if not recover. There are a number of foods that are unlikely to cause migraine and reduce their occurrence, such as cooked green, orange and yellow vegetables, some fruits — though not citrus fruits — certain nuts, beans and brown rice. The number of foods can be expanded over time.

Interestingly, endogenous (from within the body) and exogenous (from outside the body, such as preservatives) toxins cause high levels of free fatty acids and blood lipids that are triggers for migraine (15). Higher fat diets and high levels of animal protein have been associated with more migraines. In addition, obesity may increase the frequency and severity of migraines (16).

Also, there was a small randomized controlled trial that showed exercise with 40 minutes of cycling three times a week may be comparable to medication for migraine prevention (17). Thus, there are several options for preventing migraines. The most well studied are medications; however, the most effective may be dietary changes and exercise, which don’t precipitate the rebound migraines that medication overuse may cause. And the herb butterbur may be an option as well.

References: (1) uptodate.com Sept. 2011. (2) Headache. 2001;41(7):646. (3) Medscape.com. (4) Annals of Neurology 2009;65(5):491. (5) Cephalalgia. 2007;27(5):394. (6) Headache. 2006;46 Suppl 4:S202. (7) uptodate.com. (8) Circulation. 2005;112(15):2301. (9) Cochrane Database Syst Rev. 2004. (10) JAMA. 2004;291(8):965-973. (11) CMAJ. 2010;182(7):E269. (12) Prescrire Int. 2011;20(122):287-290. (13) Neurology. 2004;63(12):2240. (14) Neurology. 1998;50(2):466-470. (15) J Women’s Health Gend Based Med. 1999;8(5):623-630. (16) Obes Rev. 2011;12(5):e362-371. (17) Cephalalgia. 2011;31(14):1428-1438.

Dr. Dunaief is a speaker, author and local lifestyle medicine physician focusing on the integration of medicine, nutrition, fitness and stress management. For further information, visit www.medicalcompassmd.com or consult your personal physician.