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This transcript has been edited for readability.
Anna Tempo, MD: Hello, everybody, and welcome. My title is Dr Anna Tempo. I am an assistant professor of neurology on the Icahn College of Medication at Mount Sinai, and I direct the Headache Medication Fellowship at Mount Sinai Hospital. At this time, I am fortunate sufficient to be joined by my illustrious colleague, Dr Zhang.
Dr Zhang, would you wish to introduce your self?
Niushen Zhang, MD: Hello, Dr Tempo. It is nice to be right here. I am Dr Niushen Zhang. I am a medical assistant professor of neurology. I am additionally the chief of headache drugs at Stanford College. Nice to be right here.
Tempo: At this time, we will be speaking about complementary and integrative drugs for migraine. I feel it is a subject that has sparked a variety of curiosity, particularly on the affected person aspect over the past couple of years. Dr Zhang, are you able to inform me somewhat bit about what precisely complementary and integrative drugs is?
Zhang: There are literally many definitions of it. What we typically take into consideration are nonpharmaceutical remedy approaches or healthcare practices that will not be a part of standard drugs. The American Board of Integrative Medication provides a really well-rounded definition of this, by which they are saying that it is a apply of drugs that focuses on the entire particular person, and it needs to be knowledgeable by proof and make use of the entire acceptable remedy approaches that may assist our sufferers obtain optimum well being.
The title that we use to explain this area of drugs has modified over time. Initially, it was various drugs, then it was referred to as complementary and various drugs, or CAM. The newest time period that we use is complementary and integrative drugs.
Tempo: Or CIM, for brief. I feel CIM, based mostly on what you are describing, feels like it might match nicely with headache drugs, generally, once we’re occupied with the entire various factors that may doubtlessly contribute to or have an effect on an individual’s headache frequency. Among the issues that we all the time take into consideration are way of life components that may have an effect on complications.
Do you’ve any information or something you would like to speak about when it comes to a number of the completely different way of life components that sufferers can work on after they need to attempt to cut back their headache frequency?
Which Sufferers Would possibly Profit From CIM?
Zhang: First, we all the time need to take into consideration which sufferers are a greatest match for this kind of remedy. We take into consideration sufferers who could not have had ample responses to their pharmaceutical remedies, who’ve poor tolerance to those remedies, or possibly some medical contraindication to drugs. We additionally take into consideration individuals who could also be pregnant or lactating or planning being pregnant. These remedies may also be useful for individuals who have medicine overuse headache or exhibit important stress and should not have ample stress coping abilities.
Actually, the muse is the way of life modifications. The best way that I clarify it to sufferers is mainly your migraine mind is hypersensitive, particularly to vary. What it likes is a really common and predictable schedule for consuming, sleeping, and train.
Particularly, what we see for train is that about 20 minutes a day of cardio train can truly lower headache frequency and severity. This may very well be something from devoted time to strolling, mountaineering, biking, or swimming. These can all be very useful.
For sleep, poor sleep high quality, together with issues like insomnia, can have an effect on about 30% of sufferers with migraine. In our clinic, we all the time display screen for any potential underlying sleep problems, like sleep apnea. We need to be sure that our sufferers obtain acceptable evaluations and remedy for these circumstances. What we discover most useful with sleep is simply retaining the identical bedtime and wake-up time daily, Monday by means of Sunday.
After all, we get many questions on meals and vitamin. The reality is the proof is simply not robust on this space at the moment, for any particular dietary interventions. We all the time counsel our sufferers to maintain a really common and constant meal schedule all through the day and to keep away from skipping meals. Sufferers additionally like to ask about meals triggers, however the proof just isn’t robust for what meals have to be averted.
In apply, we discover that meals triggers are very particular person for folks. If somebody finds {that a} sure meals persistently triggers their migraines, then it might make sense to keep away from that meals, however generally, we do not encourage folks to limit their food regimen.
Tempo: Train and sleep come up typically in my clinic as nicely. Notably for sufferers who discover that train could set off their assaults or they’re hesitant to do any train as a result of their assaults are so frequent, I typically suggest gentler, low-impact workout routines, like yoga, tai chi, or swimming, for instance, which I feel folks discover somewhat bit simpler to heat as much as or incorporate into their routine.
And actually specializing in good sleep hygiene, and even issues like attempting to wind down earlier than mattress and having some kind of routine, is actually useful. I’ve had numerous sufferers come to me and ask, “Is there something, like nutritional vitamins or natural dietary supplements, that I can take to attempt to assist stop my assaults?” There’s fairly numerous them which have good proof. What do you normally suggest in your sufferers?
Sturdy Proof for Nutraceuticals and Behavioral Therapies
Zhang: I am glad you introduced that up. There are, I might say, 4 which might be evidence-based and really useful for our sufferers. Certainly one of them is magnesium. That one has a stage B advice from the American Academy of Neurology (AAN)/American Headache Society (AHS). We predict it helps with calming down neuronal hyperexcitability and stopping cortical spreading melancholy. Among the formulations we like are magnesium glycinate, magnesium oxide, and citrate. We do need to look ahead to any free stool or diarrhea, as a result of these are a number of the widespread uncomfortable side effects that may doubtlessly occur. The day by day dosing is about 200-600 mg/d.
Apart from magnesium, we even have vitamin B2 or riboflavin. That additionally has a stage B advice, and it is well-tolerated. Some folks do get very vivid orange or yellow urine after they take it, and the dosing is round 400 mg. There’s additionally coenzyme Q10, which has stage C advice from AAN/AHS. It performs a job within the electron transport chain and should play an necessary function in sustaining mitochondrial vitality shops. It is also very well-tolerated, and the day by day dosing is about 300 mg.
The final one we’ve got is one thing referred to as feverfew, which is a kind of chrysanthemum. This additionally has a stage B advice. We predict this may occasionally have some anti-inflammatory properties. Some folks do get gastrointestinal (GI) uncomfortable side effects with that, so that you do must be careful. We do not suggest this one throughout being pregnant as a result of it will probably trigger early contractions and doubtlessly miscarriage. The day by day dosing for that’s 50-300 mg.
Tempo: It is nice that there are such a lot of completely different nutraceutical choices for migraine prevention. I personally discover the mixture of magnesium and riboflavin to be a very good one which I have a tendency to begin with. I feel nutraceuticals come up very often. I’ve many sufferers who ask me about them. Are there any sufferers, specifically, whom you assume would profit most from nutraceuticals?
Zhang: Just like what we talked about earlier than, a lot of our sufferers simply do not tolerate a number of the pharmaceutical remedies that we’ve got, so this may be a very good choice to begin with. One factor I all the time ask my sufferers to remember is that the advance will be gradual with these dietary supplements. Actually, like all preventive remedy, you need to give it as much as 3 months earlier than somebody might even see most profit.
Tempo: Agreed. I feel it is arduous typically to attend that lengthy, however after they do, it actually may also help. One other kind of CIM remedy that has actually nice proof in migraine prevention contains the behavioral therapies, which brings to thoughts issues like cognitive-behavioral remedy. I am curious what your ideas are about these and whether or not or not you suggest sufferers to make the most of them?
Zhang: I feel these are terrific choices. Actually, I feel one of many challenges for suppliers is tips on how to broach this subject with out making your sufferers really feel such as you’re dismissing their expertise as psychiatric or psychological. I feel one strategy to method that is to assist your sufferers perceive that the contributors to their complications are normally partial and additive, and that issues like stress, anxiousness, and temper problems can have a big influence on their complications.
That is why it is actually necessary that we discover efficient methods to deal with these. What’s nice is that now we’ve got the best stage of proof exhibiting that particular biobehavioral remedies, reminiscent of cognitive-behavioral remedy, biofeedback, and rest coaching, are all efficient preventive remedies for migraine.
Tempo: So far as I perceive, it feels like sufferers who’ve migraine and who may additionally have anxiousness and melancholy could profit from these. Do you ever see sufferers who do not have a historical past of tension or melancholy make the most of any of those therapies and discover them useful only for migraine?
Zhang: Completely. I might say rest coaching and likewise biofeedback. These are nice as a result of you can’t solely use them as a preventive remedy — issues that you simply apply every day for prevention — but additionally attain for them as acute remedy instruments once you really feel that migraine escalating or the onset of migraine.
Tempo: I feel that sounds nice, and I agree. I discover that typically broaching this subject with sufferers generally is a bit difficult as a result of on the one hand, you need to have the ability to validate their expertise, however on the identical time assist to focus on a number of the potential temper elements of their presentation or the anxiousness that comes with having a migraine assault with aura, which I see very generally and I am positive you most likely do as nicely. Utilizing issues like rest remedy within the second throughout an aura, I feel, will be extremely helpful.
One of many different issues that I all the time get requested about is acupuncture and whether or not or not there’s proof for that when it comes to its efficacy in serving to with migraine prevention. I appear to get that query from a lot of my pregnant sufferers. Do you’ve any expertise recommending acupuncture to sufferers? What do you concentrate on the info for that?
Acupuncture and Yoga: Extra To Study
Zhang: We’re very data-driven and we need to present evidence-based remedies for our sufferers. Acupuncture has fairly good proof for its use as a preventive remedy in episodic migraine. There’s nonetheless sparse proof for utilizing it to deal with continual migraine or to make use of it as an acute remedy.
In terms of treating episodic migraine with acupuncture, there’s a superb 2016 Cochrane overview that properly summarizes the proof for acupuncture for this remedy. They checked out 22 trials with nearly 5000 sufferers and located that acupuncture is barely simpler than sham in lowering frequency of complications and at the very least equally efficient as a few of our customary prophylactic drugs.
Tempo: That is nice. So far as I do know concerning the information, it looks like it might be a very good choice along with, maybe, the normal therapies that we’re utilizing, like oral drugs. Equally, yoga additionally comes up in the identical dialog — whether or not yoga will be helpful. Once more, a lot of my pregnant sufferers ask this query. Do you ever suggest yoga to sufferers?
Zhang: With yoga, I feel there’s nonetheless a lot we’ve got to study when it comes to the way it helps our sufferers with migraine. Presently, we simply do not have that a lot sturdy proof for that.
There was a randomized medical trial printed in Neurology in 2020 that appeared on the impact of yoga as an add-on remedy for episodic migraine. That they had two teams. One was a medical remedy group, and the opposite underwent medical remedy for migraine remedy, in addition to yoga. That they had the yoga group apply a predesigned yoga intervention 3 days per week for 1 month with an teacher at a middle. This was adopted by, I feel, 5 days per week for two months at residence. They checked out over 100 sufferers for this examine.
In the long run, after they in contrast the medical remedy group with the yoga group, the yoga group confirmed a big lower in headache frequency, depth, and a number of the migraine incapacity scores. The conclusion was that yoga, as an add-on remedy for episodic migraine, could also be superior to medical remedy alone. I feel it is a very promising starting when it comes to the analysis, and I actually hope that we get extra research like this achieved sooner or later.
Tempo: Sure. I feel it illustrates an necessary idea that I feel many people ascribe to, in that it is actually necessary to consider the affected person, what their way of life is like, and what they really feel snug with when it comes to a remedy routine and the way necessary it’s to actually create an individualized plan for them.
I personally use, typically, a mix of pharmacologic remedy and nonpharmacologic remedies, so the truth that that examine confirmed that yoga was nice along with conventional migraine remedy hammers that time residence for me, when it comes to utilizing even a number of the different therapies that we have talked about along with our conventional oral or injectable therapies for migraine. Would you agree?
Zhang: I completely agree, Dr Tempo. I feel a number of the most useful remedy plans that we develop for our sufferers are those who combine each pharmacologic instruments and the nonpharmacologic instruments that we’ve got. A part of why I like headache drugs is that we truly get to personalize these remedies for our sufferers.
Tempo: I utterly agree. I feel that is a very good place for us to finish. We thanks all very a lot for becoming a member of us.
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