This transcript has been edited for clarity.
Anna Pace, MD: Hello, every person, and welcome. My name is Dr Anna Pace. I am an assistant professor of neurology at the Icahn Faculty of Medication at Mount Sinai, and I immediate the Headache Drugs Fellowship at Mount Sinai Healthcare facility. Today, I’m blessed plenty of to be joined by my illustrious colleague, Dr Zhang.
Dr Zhang, would you like to introduce your self?
Niushen Zhang, MD: Hi, Dr Rate. It is really great to be right here. I am Dr Niushen Zhang. I am a medical assistant professor of neurology. I’m also the main of headache medicine at Stanford College. Wonderful to be listed here.
Pace: Nowadays, we’re going to be chatting about complementary and integrative drugs for migraine. I assume this is a matter that has sparked a ton of fascination, primarily on the affected individual facet above the past few of a long time. Dr Zhang, can you notify me a small little bit about what accurately complementary and integrative drugs is?
Zhang: There are essentially many definitions of it. What we generally believe about are nonpharmaceutical procedure strategies or health care methods that may well not be aspect of typical medication. The American Board of Integrative Drugs offers a very effectively-rounded definition of this, in which they say that it truly is a apply of drugs that focuses on the total man or woman, and it ought to be informed by evidence and make use of all of the appropriate procedure strategies that can help our clients realize best well being.
The name that we use to describe this subject of medicine has modified above time. In the beginning, it was choice drugs, then it was named complementary and alternate medicine, or CAM. The most latest phrase that we use is complementary and integrative medicine.
Rate: Or CIM, for quick. I believe CIM, based on what you are describing, appears like it would in shape properly with headache medication, in general, when we’re considering about all of the distinct components that can possibly add to or impact a person’s headache frequency. Some of the factors that we generally assume about are lifestyle variables that can have an affect on headaches.
Do you have any data or anything you’d like to converse about in terms of some of the distinct way of living things that clients can get the job done on when they are on the lookout to try to reduce their headache frequency?
Which Patients Could possibly Advantage From CIM?
Zhang: Initially, we constantly want to believe about which individuals are a best fit for this kind of cure. We think about clients who could not have experienced adequate responses to their pharmaceutical treatment options, who have weak tolerance to these remedies, or it’s possible some professional medical contraindication to medicines. We also feel about men and women who could be pregnant or lactating or setting up pregnancy. These treatments can also be helpful for persons who have medication overuse headache or show considerable anxiety and might not have adequate strain coping skills.
Definitely, the foundation is the life-style modifications. The way that I clarify it to patients is basically your migraine brain is hypersensitive, specifically to alter. What it likes is a really standard and predictable timetable for ingesting, sleeping, and physical exercise.
Specifically, what we see for exercise is that about 20 minutes a working day of cardio training can truly minimize headache frequency and severity. This could be nearly anything from devoted time to walking, hiking, biking, or swimming. All those can all be extremely valuable.
For snooze, lousy slumber excellent, which include items like sleeplessness, can influence about 30% of sufferers with migraine. In our clinic, we often screen for any possible underlying snooze problems, like sleep apnea. We want to make absolutely sure our people obtain ideal evaluations and procedure for all those circumstances. What we come across most beneficial with snooze is just trying to keep the exact bedtime and wake-up time each individual working day, Monday by way of Sunday.
Of course, we get quite a few issues about food items and nutrition. The real truth is the evidence is just not strong in this space at this time, for any certain nutritional interventions. We usually counsel our clients to keep a very normal and consistent meal timetable in the course of the working day and to prevent skipping meals. Clients also like to talk to about meals triggers, but the proof is not robust for what foods ought to be averted.
In follow, we locate that food items triggers are really unique for persons. If someone finds that a certain food items continually triggers their migraines, then it would make sense to keep away from that food stuff, but in typical, we never encourage men and women to restrict their diet program.
Rate: Training and rest come up generally in my clinic as well. Especially for clients who discover that workout may well bring about their assaults or they are hesitant to do any exercise for the reason that their attacks are so recurrent, I generally propose gentler, low-impression exercises, like yoga, tai chi, or swimming, for case in point, which I feel individuals discover a small little bit simpler to warm up to or include into their schedule.
And genuinely concentrating on very good slumber hygiene, and even items like attempting to wind down in advance of mattress and acquiring some kind of plan, is seriously helpful. I have had a range of clients occur to me and ask, “Is there something, like nutritional vitamins or natural supplements, that I can consider to try out to assistance prevent my attacks?” There is pretty a variety of them that have good evidence. What do you ordinarily recommend for your people?
Powerful Evidence for Nutraceuticals and Behavioral Therapies
Zhang: I am happy you introduced that up. There are, I would say, 4 that are proof-based and incredibly useful for our clients. One of them is magnesium. That just one has a degree B recommendation from the American Academy of Neurology (AAN)/American Headache Culture (AHS). We think it assists with calming down neuronal hyperexcitability and avoiding cortical spreading despair. Some of the formulations we like are magnesium glycinate, magnesium oxide, and citrate. We do want to view for any loose stool or diarrhea, mainly because those are some of the widespread aspect results that can perhaps take place. The day by day dosing is about 200-600 mg/d.
Other than magnesium, we also have vitamin B2 or riboflavin. That also has a stage B suggestion, and it can be nicely-tolerated. Some men and women do get really vivid orange or yellow urine when they choose it, and the dosing is close to 400 mg. You will find also coenzyme Q10, which has level C suggestion from AAN/AHS. It performs a role in the electron transportation chain and may perhaps engage in an crucial position in sustaining mitochondrial energy outlets. It truly is also quite perfectly-tolerated, and the day by day dosing is about 300 mg.
The final 1 we have is a thing termed feverfew, which is a form of chrysanthemum. This also has a stage B advice. We believe this could have some anti-inflammatory attributes. Some people today do get gastrointestinal (GI) side results with that, so you do have to look at out. We do not recommend this 1 through pregnancy simply because it can trigger early contractions and likely miscarriage. The daily dosing for that is 50-300 mg.
Pace: It can be terrific that there are so many distinct nutraceutical possibilities for migraine avoidance. I personally come across the mix of magnesium and riboflavin to be a fantastic a single that I are likely to get started with. I feel nutraceuticals come up fairly typically. I have numerous sufferers who check with me about them. Are there any individuals, in individual, whom you believe would profit most from nutraceuticals?
Zhang: Comparable to what we talked about before, several of our patients just do not tolerate some of the pharmaceutical remedies that we have, so this would be a very good option to commence with. 1 thing I often check with my sufferers to preserve in intellect is that the enhancement can be gradual with these health supplements. Actually, like any preventive therapy, you want to give it up to 3 months right before a person may perhaps see greatest benefit.
Rate: Agreed. I think it can be challenging in some cases to wait that prolonged, but when they do, it truly can help. A different sort of CIM cure that has definitely terrific proof in migraine prevention consists of the behavioral therapies, which provides to brain matters like cognitive-behavioral treatment. I am curious what your views are about all those and regardless of whether or not you suggest people to employ them?
Zhang: I imagine people are fantastic selections. Actually, I feel a person of the problems for companies is how to broach this matter without having generating your people sense like you happen to be dismissing their practical experience as psychiatric or psychological. I consider one way to solution this is to assistance your clients fully grasp that the contributors to their head aches are generally partial and additive, and that items like stress, panic, and mood ailments can have a sizeable effect on their problems.
Which is why it can be seriously significant that we come across helpful approaches to handle those people. What is great is that now we have the best amount of evidence showing that precise biobehavioral therapies, this kind of as cognitive-behavioral treatment, biofeedback, and rest training, are all helpful preventive treatment plans for migraine.
Pace: As considerably as I realize, it sounds like sufferers who have migraine and who could also have anxiousness and depression may possibly profit from these. Do you at any time see patients who will not have a background of nervousness or melancholy benefit from any of these therapies and come across them handy just for migraine?
Zhang: Absolutely. I would say peace instruction and also biofeedback. These are good since you can not only use them as a preventive remedy — things that you exercise on a every day basis for avoidance — but also access for them as acute treatment applications when you come to feel that migraine escalating or the onset of migraine.
Tempo: I feel that seems great, and I concur. I discover that at times broaching this subject with patients can be a little bit hard because on the a single hand, you want to be able to validate their encounter, but at the same time aid to target some of the potential mood factors of their presentation or the nervousness that comes with acquiring a migraine attack with aura, which I see really normally and I’m certain you probably do as well. Making use of factors like relaxation therapy in the instant through an aura, I consider, can be extremely valuable.
1 of the other issues that I generally get requested about is acupuncture and no matter whether or not there is proof for that in phrases of its efficacy in supporting with migraine prevention. I seem to get that dilemma from quite a few of my expecting clients. Do you have any knowledge recommending acupuncture to individuals? What do you feel about the facts for that?
Acupuncture and Yoga: Much more To Discover
Zhang: We are incredibly knowledge-driven and we want to give proof-primarily based therapies for our clients. Acupuncture has fairly great proof for its use as a preventive treatment in episodic migraine. There is nevertheless sparse evidence for using it to handle continual migraine or to use it as an acute treatment method.
When it arrives to managing episodic migraine with acupuncture, there is certainly an superb 2016 Cochrane evaluate that properly summarizes the proof for acupuncture for this therapy. They looked at 22 trials with pretty much 5000 individuals and found that acupuncture is a little much more successful than sham in minimizing frequency of complications and at the very least in the same way successful as some of our normal prophylactic medications.
Tempo: That is wonderful. As far as I know about the data, it would seem like it would be a great solution in addition to, probably, the standard therapies that we are utilizing, like oral prescription drugs. Likewise, yoga also will come up in the very same dialogue — no matter whether yoga can be valuable. Yet again, a lot of of my pregnant clients question this dilemma. Do you ever endorse yoga to individuals?
Zhang: With yoga, I think there’s still much we have to find out about in phrases of how it allows our clients with migraine. At this time, we just never have that much robust proof for that.
There was a randomized clinical trial published in Neurology in 2020 that appeared at the effect of yoga as an add-on therapy for episodic migraine. They had two teams. One particular was a medical therapy team, and the other underwent medical therapy for migraine treatment method, as well as yoga. They experienced the yoga group apply a predesigned yoga intervention 3 days for every 7 days for 1 month with an teacher at a centre. This was followed by, I think, 5 days for every week for 2 months at dwelling. They looked at around 100 sufferers for this review.
In the stop, when they when compared the health care remedy team with the yoga group, the yoga group confirmed a substantial reduce in headache frequency, depth, and some of the migraine disability scores. The conclusion was that yoga, as an increase-on therapy for episodic migraine, may perhaps be exceptional to health care remedy on your own. I imagine this is a quite promising commencing in terms of the investigate, and I seriously hope that we get additional studies like this performed in the future.
Tempo: Certainly. I assume it illustrates an essential thought that I imagine lots of of us ascribe to, in that it is really definitely crucial to imagine about the affected individual, what their life-style is like, and what they truly feel relaxed with in terms of a remedy regimen and how important it is to genuinely produce an individualized program for them.
I individually use, generally, a mixture of pharmacologic remedy and nonpharmacologic treatment options, so the truth that that research showed that yoga was great in addition to regular migraine remedy hammers that issue house for me, in conditions of working with even some of the other therapies that we have talked about in addition to our traditional oral or injectable therapies for migraine. Would you concur?
Zhang: I fully agree, Dr Speed. I believe some of the most beneficial remedy options that we acquire for our sufferers are those that combine equally pharmacologic instruments and the nonpharmacologic applications that we have. Section of why I really like headache medication is that we essentially get to personalize these treatments for our individuals.
Speed: I fully agree. I feel that’s a superior area for us to close. We thank you all incredibly much for signing up for us.