Finding Relief: A Smarter, More Supportive Approach to Migraines
What are migraines?
Migraines are “neurovascular” headaches caused by excessive and unbalanced constriction and dilation of blood vessels in the head triggered by “hyper” neural activity. Often, women experience migraine aura because of excessively constricted blood vessels, followed by a surging headache due to excessively dilated blood vessels. Migraines are the most common neurological illness and are most prevalent in adults between 20 and 50 years of age.[1] There may be a genetic, familial predisposition to the development of migraines.
Migraines affect women more than twice as much as men. Any abrupt decline in estrogen makes women more vulnerable to developing migraine headaches[2]. Women are at an increased risk of developing migraines before/during menstruation, during perimenopause, and during post-partum.
The loss of estrogen has been theorized to influence magnesium concentrations, prostaglandin release, oxytocin[3], and serotonin, which influence our pain perception pathways.
Migraine Symptoms
Migraines typically last from 4 to 48 hours. Symptoms may include:
Severe headache
Sensitivity to light, noise, and movement
Vision may be blurry or doubled
May cause nausea and/or vomiting.
Migraine triggers
In addition to hormone changes, many things can trigger migraines, so I recommend keeping a migraine diary to track when migraines occur, along with any preceding factors.
Stress (drives neurotransmitter changes in the brain)
Disorders in serotonin balance impair normal blood vessel dilation (triptan drugs address this directly by affecting serotonin receptors).
Magnesium deficiency (magnesium helps to keep blood vessels appropriately responsive
Inadequate CoQ10, B2 (riboflavin), and other nutrients which are needed for healthy mitochondrial function (mitochondria are the energy-producing factories in our cells)
Environmental factors such as toxins and chemicals
Hormone changes. The loss of estrogen at the end of the menstrual cycle and during perimenopause, menopause, and post-partum has been theorized to influence magnesium concentrations,[4]prostaglandin release,[5] and serotonin (and therefore pain perception) pathways.
Free radicals cause oxidative damage to the cells in our body, including the cells in our brain
Food sensitivities or allergies. Food allergy/sensitivity can trigger a cascade of events that results in a migraine. This dynamic can include histamine-containing and histamine-triggering foods as triggers of migraine headaches. Histamine itself triggers blood vessel dilation.
Keeping a detailed migraine diary is one of the most helpful ways to identify migraine triggers. I’ve had two patients whose migraine triggers were traced back to their morning showers. Both lived in towns that had highly chlorinated water. When you spray super-heated water (like during a shower), you get chloroform. Both patients were breathing chloroform for 10-15 minutes almost every morning. After putting a chlorine filter on their shower head, the headaches disappeared. So, the details matter, which is why, when you experience a migraine, you want to write down everything that you do throughout the day, down to your morning shower.
Conventional Migraine Treatment
Conventional medical treatment for the prevention and treatment of migraines includes:
Non-steroidal anti-inflammatory drugs (NSAIDs) such as naproxen or diclofenac plus a triptan (e.g., sumatriptan such as Imitrex or Treximet), a medication which mimics serotonin (an agonist) and causes mild vasoconstriction. Using for more than 10 days monthly may cause rebound headaches
Beta-blockers (to reduce blood vessel sensitivity to rapid changes in vasodilation)
Gabapentin (to desensitize neural transmissions)
Topiramate (prevents initial triggering vasoconstriction)
Tricyclic antidepressants like amitriptyline (regulating serotonin)
Opioids/narcotics may be prescribed for acute pain
Monoclonal antibody medications are a newer kid on the block. They have been studied and are being used to target the calcitonin gene-related peptide (CGRP) pathway to prevent migraines (they block its action in stimulating the aggressive vasodilation response and then sustaining it via the release of a surge of pro-inflammatory mediators)[6],[7]
General Migraine Recommendations
Stay hydrated
Get high-quality sleep consistently
Reduce/manage stress
Exercise to improve blood flow and support healthy blood vessels
Identify and eliminate dietary triggers (use a journal to track them)
Assess and balance hormones
Eat a real food diet that is rich in nutrients; be sure to practice eating hygiene so that you absorb nutrients
Support histamine breakdown and antihistamine action as needed. Histamine intolerance can result from a poor ability to break down exogenous histamine and/or a poor ability to break down endogenous histamine. Migraine sufferers are more likely to have higher histamine both during headaches and during times without headaches. For more information on histamine intolerance, click here or click here.
Dietary amines (e.g., tyramine) are chemicals that occur naturally, caused by bacteria that break down amino acids. They have been found to trigger migraines in some women. Dietary amines may be found in:
Strong or aged cheeses like cheddar, blue cheese, or gorgonzola
Cured or smoked meats or fish, such as sausage or salami
Beers on tap or home-brewed beer
Some overripe fruits
Certain beans, such as fava or broad beans.
A combination of foods that trigger vasodilation is much more likely to cause a migraine than individual foods (e.g., red wine with cheese and chocolate in the same meal).
Avoid food additives. Food additives can also be common triggers, especially benzoic acid, monosodium glutamate (MSG), and tartrazine (yellow #5).
Supplements that have been studied for migraine prevention and support
Magnesium – Typical starting dose is 250-300mg magnesium daily (glycinate, taurate, malate, or threonate) and adjust as needed
Full-spectrum B-Complex (with extra methylation focus if needed)
CoQ10 (the ubiquinol form, especially for women over 40). Studies show those with migraine have lower CoQ10 levels. Increasing CoQ10 may reduce migraine frequency and severity in those with normal and reduced levels. (Typical dosing is 150mg -200 mg twice daily - Thorne carries one called Thorne CoQ10)
Vitamin B2 (riboflavin) is a key co-factor for multiple enzymes involved in cellular energy generation, especially in the electron transport chain, which affects our mitochondria. Multiple studies have demonstrated the efficacy of high-dose riboflavin in preventing migraines. (Typical dosing is 400-500mg/day -Integrative Therapeutics 400 mg has a formula)
Omega-3 essential fatty acids. Typical dosing is 500-1000mg daily (depending on dietary intake).
Feverfew or Butterbur twice daily. Regular intake of Butterbur reduces migraine incidence and frequency by at least 40% in a dose-dependent fashion (in children too). It has also been shown to reduce prostaglandin synthesis. Typical dosing is 75-100mg twice daily. (It is important to use Petadolex or a similar preparation that has removed alkaloids in butterbur, which can be toxic to the liver. - Pure encapsulations has one)
Ginger – Double-blind, randomized trial showed ginger equal in efficacy to sumatriptan for migraine prevention. ~1/4” slice daily. A combination of ginger and feverfew has been shown to be effective in reducing migraine incidence by 60%.
Vitamin B6 supplementation increases diamine oxidase synthesis (DAO), especially for migraines triggered by histamine intolerance/issues.
5-HTP, a serotonin precursor, has been found to help reduce migraines. Typical dosing is 50-100mg 5-HTP, 2 to 3 times daily, and should be used with caution in patients on SSRIs (anti-depressants).
A supplement of diamine oxidase (DAO) can help to break down histamines in foods. Women have lower levels of diamine oxidase (DAO) than men (except during pregnancy, where it increases up to 500X)[8] (Histamine Block by Seeking Health contains DAO)
For hormonal migraines
Estrogen therapy has been shown to reduce the frequency and intensity of menstrual migraines. The research suggests that using estrogen therapy month over month reduces the frequency and intensity of migraines over time. Women will often find a significant reduction in migraines between months 1 and 2, and then again between months 2 and 3 when used each month consistently.[9] Estrogen therapy may include:
.5 to 2.5 mg of transdermal estrogen therapy cream or for ten days – typically straddling a woman’s period (5-7 days before her period and several days after her period until her estrogen starts to naturally rise, typically between days 3 and 6); alternatively, a woman may use 100 mcg estradiol patch worn ten days per month straddling her period (same as above)[10]
For women using oral contraceptives, extending the monthly course of active pills (24/4 vs 21/7)[11] or using transdermal estrogen during the placebo week to keep estrogen levels adequate many reduce migraine severity and frequency
For women in perimenopause with fluctuating estrogen, estrogen replacement may help to keep estrogen levels consistent with fewer highs and lows, thereby reducing the intensity and frequency of migraines
Important medical disclaimer
The contents of this blog are for informational purposes only and are not a substitute for professional medical advice. None of the recommendations, suggestions, or written information provided is intended to replace a one-on-one relationship with a qualified health care professional. The information presented is not intended to diagnose, treat, cure, or prevent any disease but rather as a sharing of knowledge and information from the research and experience of Jill Chmielewski, RN, BSN. You are encouraged to make your own health care decisions based on your research and partnership with a qualified healthcare professional of your choosing.
References
[1] Rossi, Maria Francesca et al. “Sex and gender differences in migraines: a narrative review.” Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology vol. 43,9 (2022): 5729-5734. doi:10.1007/s10072-022-06178-6
[2] Faubion, Stephanie S et al. “Migraine Throughout the Female Reproductive Life Cycle.” Mayo Clinic proceedings vol. 93,5 (2018): 639-645. doi:10.1016/j.mayocp.2017.11.027
[3] Nappi RE, Tiranini L, Sacco S, De Matteis E, De Icco R, Tassorelli C. Role of Estrogens in Menstrual Migraine. Cells. 2022 Apr 15;11(8):1355. doi: 10.3390/cells11081355. PMID: 35456034; PMCID: PMC9025552.
[4] Li, W et al. “Sex steroid hormones exert biphasic effects on cytosolic magnesium ions in cerebral vascular smooth muscle cells: possible relationships to migraine frequency in premenstrual syndromes and stroke incidence.” Brain research bulletin vol. 54,1 (2001): 83-9. doi:10.1016/s0361-9230(00)00428-7
[5] https://www.tandfonline.com/doi/full/10.1080/14656566.2017.1414182
[6] Sacco, Simona et al. “European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention - 2022 update.” The journal of headache and pain vol. 23,1 67. 11 Jun. 2022, doi:10.1186/s10194-022-01431-x
[7] Ferrari, Michel D et al. “Migraine.” Nature reviews. Disease primers vol. 8,1 2. 13 Jan. 2022, doi:10.1038/s41572-021-00328-4
[8] https://academic.oup.com/humupd/article/14/5/485/812106
[9] Allais, G et al. “Menstrual migraine: a review of current and developing pharmacotherapies for women.” Expert opinion on pharmacotherapy vol. 19,2 (2018): 123-136. doi:10.1080/14656566.2017.1414182
[10] Allais, G et al. “Menstrual migraine: a review of current and developing pharmacotherapies for women.” Expert opinion on pharmacotherapy vol. 19,2 (2018): 123-136. doi:10.1080/14656566.2017.1414182
[11] Maasumi, Kasra et al. “Menstrual Migraine and Treatment Options: Review.” Headache vol. 57,2 (2017): 194-208. doi:10.1111/head.12978