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CAM You can Use: Preventing Headaches

CAM You can Use: Preventing Headaches. Kathi J Kemper, MD, MPH General Pediatrics, Integrative Medicine 2 nd Opinion Clinic (Monday mornings) kkemper@wfubmc.edu 716-9640. Disclaimer.

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CAM You can Use: Preventing Headaches

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  1. CAM You can Use: Preventing Headaches Kathi J Kemper, MD, MPH General Pediatrics, Integrative Medicine 2nd Opinion Clinic (Monday mornings) kkemper@wfubmc.edu 716-9640

  2. Disclaimer • I have no conflicts of interest to report regarding this presentation; I published a CME article on this topic with MedScape for which my institution received payment • The presentation includes no description of any proprietary items for screening, diagnosis, or treatments

  3. Objectives By the end of this session, participants will be able to • Counsel patients on dietary modifications to prevent headaches • Discuss the scientific evidence about the effectiveness of stress management practices in preventing headaches • Find evidence-based resources about the effectiveness of acupuncture in preventing headaches (See AAP Section for Complementary and Integrative Medicine; join the listserv) • NOT focused on diagnosis or medications

  4. Headache • Common! (in teens, > 4 HA in past month by 6% males; 14% females) (Linet. JAMA, 1989) • 90% Migraine or Tension-Type Headache • 10% other : sinusitis, eye, trauma, ice cream, cervicogenic, myofascial pain, TMJ, hemorrhage, infection, pseudotumor, vasculitis, tumor,

  5. CAM Use for Tension-Type HA • 40% used CAM • 60% did not tell MD (how many MD’s asked?) • Types of CAM • Chiropractic 21% • Acupuncture 17% • Massage 17% Rossi et al. Headache 46:622-631, 2006 * CAM – Complementary or Alternative Medicine, somewhat outdated and useless term

  6. CAM at UNC for Headache • Biofeedback (thermal, muscular, heart rate variability, autonomic) • Hypnotherapy • Osteopathy • Acupuncture • Mindfulness Meditation • Herbal and supplement counseling

  7. Prevention options Bioenergetic Patient-Centered Care Biomechanical Biochemical LIFESTYLE

  8. Prevention/health promotion lifestyle • Avoid triggers! • Nutrition and supplements • Exercise/sleep • Environment • Stress management

  9. Lifestyle – 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 !!KEEP A HEADACHE DIARY!!

  10. Diet: 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 benefited more from the elimination diet than people with negative skin tests. Mansfield L et al.. Ann Allergy, 2004

  11. 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, fast food • Increase in omega-3 fatty acid intake-fish oil

  12. Dietary Supplements • B vitamins • Minerals: calcium, magnesium • Fatty acids/fish oil • CoQ10 • Melatonin

  13. Supplements: B vitamins • B2 • Migraine sufferers suspected of having a mitochondrial defect -> impaired O2 utilization • Riboflavin (B2) is the precursor to key molecules in the electron transport chain in the mitochondria • 200 mg BID with meals for 3 months -> 68% reduction in migraine attacks in RCT (next slide) • Side effect: yellow urine Schoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007 • B6 essential in converting tryp to serotonin • More than 100 mg daily -> nausea, abd pain, sleepiness, lower B12 levels; >1000 mg daily -> sensory neuropathy

  14. * High Dose Riboflavin vs. Placebo Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis: a randomized controlled trial. Neurology 50(2): 466-70; 1998.

  15. Supplements: Minerals • Calcium for PMS-related migraines • 44% of boys and 58% of girls 6-11 insuff • 64% of boys and 87% of girls 12-19 insuff • Ensure 1200- 1500 mg daily Thys-Jacobs. J Am Coll Nutr, 2000 • Magnesium (1 gram iv acutely) or 300 – 500 mg daily po to prevent (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

  16. * 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

  17. * 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

  18. * 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.

  19. * 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

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

  21. 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)

  22. Phospholipid Bilayer

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

  24. Why EFA Imbalance in US? • Diet is high in Omega-6 and low in Omega-3 (previously 1:1 ratio, now 20:1) • Hydrogenated oils • Enzyme cofactor deficiency (B-3, B-6, Biotin, C, Zinc, Magnesium) • Genetic polymorphism (biochemical individuality) • Hyperinsulinism from high glycemic load diet (increase DGLA to AA) • Increased stress -> increased demands.

  25. Fatty acids: Omega 3s • Popular approach to decreasing inflammation • Open studies suggest it helps reduce headaches; doses 1-3 grams daily • RCTs – mixed results; olive oil may not be a placebo! • Supplements – generally free from mercury, dioxins, PCBs; palatable Harel. J Adolesc Health, 2002 Pradalier. Cephalgia, 2001 Puel. Br J Nutr, 2004

  26. Coenzyme Q-10 • Open label, 150 mg qd - for 3 months • 62% had > 50% reduction in number of HA days • Migraine Days: 7.34 -> 2.95/mo • Frequency: 4.85 -> 2.81/month • No side effects; except pain in pocketbook Rozen and Silberstein, Cephalalgia 22: 137-141, 2002

  27. Melatonin and Headache • Mechanism • Potentiates GABA; Modulates Ca entry in to vascular smooth muscle cells • Modulates 5HT2 receptor – like B- blockers; Inhibits the synthesis of prostaglandin E2 - inflammation mediator • Melatonin low and out of phase in menstrual migraine, chronic daily headache, migraine, status and cluster HA • Effective preventive for cluster HA and HA associated with delayed sleep-phase syndrome

  28. Melatonin: Sleep phase delay or cluster HA • Corrects delayed sleep-phase syndrome • An alternative to benzodiazepines • Dosing 6-12 mg one hour before bed • Few side effects • ConsumerLab reviews show consistent quality Rozen. Headache, 2006 Vogler. CNS Drugs, 2006 Rozen, Neurology, 2003 Pringsheim. Headache, 2002 Miano. Neurol Sci, 2008 – PEDIATRIC STUDY

  29. Lifestyle: Stress management • Stress is common • Stress triggers/worsens pain • Managing stress: exercise, sleep, nutrition, mind/emotion/body/spirit • Biofeedback • Hypnosis • Reducing stress helps 50% - 70% of headache sufferers

  30. The Many Forms of Mind-Body Medicine

  31. Stress and Physiological Activation High Arousal/High Energy SYMPATHETIC Low Arousal/Low Energy PARASYMPATHETIC Institute of HeartMath

  32. Biofeedback-What and why? 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

  33. *Biofeedback - Example • Blanchard - 116 patients with migraine • Assigned to either thermal biofeedback, thermal biofeedback with relaxation training, or pseudomeditation, headache monitoring • Six month follow-up • 51% of the subjects in the thermal biofeedback groups improved in frequency compared to 5% and 22% for the monitoring and pseudomeditation groups Blanchard E et al.. J Consult Clin Psychol; 1990.

  34. Biofeedback Modalities Home or Office Use Peripheral Temperature Heart Rate Variability Surface EMG Skin Conductance

  35. *Biofeedback-Temperature Theory-the more relaxed, the lower sympathetic nervous system activity, the more peripheral blood flow, hands and feet warm up Resources Dermatherm Bands Sharn, Incorporated www.sharn.com BioDots www.futurehealth.org www.cliving.org Digital Temp Portable Units www.Bio-medical.com www.thoughttechnology.com

  36. *Heart Rate Variability(HRV) 2 1.5 76 BPM 83 BPM 70 BPM m Volts 1 .793 sec. .726 sec. .859 sec. 0.5 0 -0.5 0 1 2 2.5 seconds of heart beat data

  37. Hypnosis/Guided Imagery Hypnosis: An altered state of awareness usually but not always involving relaxation during which the participant can give himself/herself suggestions for desired changes to which he/she is more likely to respond that in their usual state of awareness. Guided Imagery: A technique that involves using the imagination and mental images to promote relaxation, changes in attitude or behavior, and encourages physical healing. AKA- visualization.

  38. Children Enjoy It To teach self hypnosis for a specific purpose (such as reduction of pain or elimination of a habit) involves helping young children focus on their natural thinking styles. Kids move in and out of altered states and imaginary activities all the time. Think IMAGINARY PLAY! The child is in control. We serve as the teacher or coach. Offer choices and options. The child can use this skill when he or she chooses. Ask that parents not remind the child to practice self hypnosis; it’s up to the child/adolescent

  39. 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)

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

  41. * Hypnosis Misconceptions Patient is under control of the hypnotherapist Patient is unaware of surroundings and/or activities around him/her Patients defenses are impaired (there is improved access to subconscious material) Symptoms are masked Patient can be forced to do things they would not normally do

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

  43. 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

  44. Massage for Migraines • Massage improves blood flow and decreases inflammation, relaxes muscles, reduces stress, provides tangible social support • Can combine with physical therapies such as ice, heat; aromas (peppermint) • RCT for migraines showed significantly decreased frequency and improved sleep Lawler SP. Ann Behav Med, 2006 Pieovesan. Arq Neuropsiquiatr, 2007

  45. Chiropractic • Commonly used • Older studies support use of chiropractic in migraine; frequency and severity were reduced • Little other evidence supporting use in headache of different types Tuchin. Australas Chiropr Osteopathy, 1997 Parker. Aust NZ J Med, 1978

  46. Osteopathy - Headache • Five of six studies showed positive results for tension, cervicogenic and post-traumatic HA • No studies specifically for migraine • No control groups or long term results • Two of 6 studies: results comparable to TCA Hoyt. J Am Osteopath Assoc, 1979 Fernandez-de-las-Penas. J Orthop Sports Phys Ther, 2006 Bronfort. J Manipulative Phys Ther, 2001

  47. Acupuncture for Chronic Daily Headache – UNC study • RCT of usual medical care (UMC) vs UMC + acupuncture • Medical care alone: no change • Medical care +acupuncture • Improvement in headache impact (function) • Improvement in general mental health domains (SF-36) • 3.7 times >likely to report reduced suffering Coeytaux R. Headache, 2005 Gottschling. Pain, 2008 – PEDIATRIC STUDY LASER ACUP. Witt. Cephalgia, 2008 – COST EFFECTIVENESS

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