Migraines: The science, causes and treatment options.

The third most common disorder in the world, migraines are estimated to affect at least 38 million individuals in the U.S. although some sources state that the actual figure may be closer to 50 million patients – including both adults and children.1 Given its prevalence and often debilitating symptoms that can make doing even simple tasks quite impossible, it’s important to understand more about this health condition, its triggers and options for natural and conventional therapies. Migraines may be chronic (characterized by 15 or more headache days per month) or episodic (0 to 14 headache days per month).

Some basic facts.
 
A migraine is a type of headache that causes an intense throbbing sensation, usually in one area of the head. It may be accompanied by nausea, vomiting, sensitivity to sound or light, blurry or other vision problems, and many other symptoms. There are numerous triggers as varied as the symptoms and different from one person to another that include sleep deprivation, stress, certain foods or food additives (e.g. monosodium glutamate), changes in barometric pressure, hormonal fluctuations during menses or perimenopause as well as multiple other factors.  

Just a few of the facts cited by the American Migraine Foundation:
▪ 1 in 4 households has a family member with migraine.
▪ Fewer than 5% of sufferers have been seen by a health care provider, received an accurate diagnosis and obtained appropriate treatment.
▪ More than 90% of affected individuals will miss work, school, social or other activities due to the severity of symptoms.
▪ Children with one parent who has migraine have a 50% chance of developing the disorder; if both parents are affected, that number increases to 75%.2

The science behind the causes.

Researchers believe that migraine is the result of fundamental neurological abnormalities caused by genetic mutations at work in the brain. New models are aiding scientists in studying the basic science involved in the biological cascade, genetic components and mechanisms of migraine. Understanding the causes of migraine as well as the events that affect them will give researchers the opportunity to develop and test medications that could be more targeted to preventing or interrupting attacks entirely.

While older theories about the causes of migraines suggested that symptoms were possibly due to fluctuations in blood flow to the brain, we now realize that changes in blood flow and blood vessels don't initiate the pain, but may contribute to it. We know too that triptans, which are commonly used as abortive treatments, work more on our brain’s serotonin levels rather than on vasoconstriction although this mechanism may still play a role; and high levels of oxidative stress are also involved. But, there is much we still need to understand about this widespread condition…and the variations in how each patient is affected and by what factors most definitely contributes to the complexity of identifying appropriate protocols.

Changes in the brain itself cause migraine. The associated pain starts with abnormal activation of the trigeminovascular system (TGVS), which consists of small sensory neurons that originate from trigeminal ganglion and upper cervical dorsal nerve roots (in the neck area). There are projections of this sensory system throughout the brain and found in the thalamus, the limbic system (which explains the emotional response to pain), the sensory cortex and subcortical areas such as the midbrain, cerebellum and reticular formation.  

The trigeminal nerve or fifth cranial nerve innervates or supplies nerves to the meninges, cerebral blood vessels, and other areas of the head via three branches: the ophthalmic; maxillary; and mandibular. The trigeminal nerve (the fifth cranial nerve or the CN V) is responsible for sensation in the face and motor functions such as biting and chewing.

Activation of the TGVS causes release of various neuropeptides at the meninges that can induce neurogenic inflammation including:
▪ Calcitonin
▪ Substance P
▪ CGRP (calcitonin gene-related peptide): CGRP is a 37-amino acid sensory neurotransmitter that is widely distributed throughout both the central and the peripheral nervous system.
▪ Neurokinin A, the most abundant neuropeptide in the trigeminal nerve system.

CGRP plays a key role in several mechanisms of migraine pathology and pain perception, including vasodilation, neurogenic inflammation, mast cell degranulation, sensory signalling activation and peripheral sensitization.

The cortical spreading depression theory is also thought to be involved in migraine formation. This involves a slow-moving wave of depolarization that starts in the base of the cerebral cortex and spreads over the cortex into the thalamus, into the brain stem and then into the sensory cortex. This mechanism may cause pain to immolate from there, but we know that the trigeminal nerve branches also activate the thalamus, which has wide projections throughout the body. All of this results in cortical depolarization and is associated with the local release of a chemical called CGRP by perivascular nerves. Consequent neurogenic inflammation contributes to sustained activation of the meningeal nociceptors and the TGVS.  

In 2018, the FDA approved three new migraine medications -- erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) -- which are in a class of drugs called monoclonal antibodies. They are "targeted" therapies that seek out and interfere with CGRP, the protein previously mentioned that inflames nerve endings and is involved in the development of migraines. For that reason, the drugs are also known as CGRP antagonists or CGRP inhibitors. They block and neutralize CGRP for weeks at a time and are given as an injection, typically just once per month.  These medications offer additional therapies to other options for patients whose symptoms do not initially abate with one medication or another.

Can a natural approach provide symptomatic relief?

There are several ways to support your overall health that have been helpful in treating migraine symptoms. As always, you should consult your physician before making any changes to your current treatment plan, adding supplements or starting a new exercise program.  

Some basic tenets of a natural approach include:
Diet. Eat a healthy, balanced diet with whole (vs. processed) foods. Choose non-GMO and organic products when possible and avoid identified migraine food triggers that may be different from one person to the next. Limit or avoid gluten, dairy and sugar, all of which are very inflammatory foods and can cause problems in many conditions.
Exercise! If you know that your seasonal allergies cause your migraines to flare, choose indoor activities like yoga or Pilates to avoid exacerbating symptoms.  
Regular sleep, preferably 7 to 8 hours nightly, is crucial.
Consider supplements like vitamins A, E, C and D as well as selenium, resveratrol, alpha lipoic acid, P5P, EcG, NAC, VIt D ,  Co Q 10 (100mg three times a day) and feverfew as well as gut-healing probiotics.
Note that vitamin B complex and magnesium (600 mg/day) are also thought to be helpful in preventing migraines, as permitted based on your particular health.
Reduce stress. We can’t emphasize this enough and while we also know it’s easier said than done, consider relaxation techniques like breath work, getting out in nature and away from your devices and practicing meditation and mindfulness when possible.
Lower your toxic load; that means eliminating your exposure to chemicals, toxins, pesticide-treated food and talking to your doctor about possible infectious triggers in your environment.
Acupuncture  
Biofeedback
Essential Oils: l
▪ Peppermint – Acts as a natural analgesic as well as other uses.
▪ Lavender – Acts as an anti-inflammatory and dilates blood vessels.
▪ Thyme and rosemary – these essential oils contain carvacrol that acts much like an anti-inflammatory such as ibuprofen, but without any side effects.
▪ Ginger tea – Ginger has been used as a medicine for thousands of years and contains more than 200 powerful, healing substances in its oils giving it the ability to reduce inflammation, calm muscle contractions, and soothe nausea.

It’s important to remember that obtaining maximum relief may involve multi-treatment models that integrate both conventional and functional medicine. We know that each patient is unique and as such our whole body neurological evaluation is designed to identify the root cause of your condition and pursue migraine pain relief specific to your health, any other existing conditions and individual lifestyle factors.

In hope and healing,
Dr. Suzanne Gazda

References:

1 https://americanmigrainefoundation.org/resource-library/facts-about-migraine/
 
2 https://migraineresearchfoundation.org/about-migraine/migraine-facts/