News from science - other treatments than traditional medicine

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The researchers suggest that it is important for doctors to remember that patients don´t always tell that they go to alternative treatment. The doctors guess that the patients prefer the alternative treatments because there are fewer side-effects than from doctors´ prescribed medicine.

S. von Peter, W. Ting, S. Scrivani, E. Korkin, H. Okvat, M. Gros, C. Oz and C. Balmaceda, 2002. Survey on the use of complementary and alternative medicine among patients with headache syndromes. Cephalalgia 22, 395-400.

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The 44 studied people received 18 lessons about exercise, a lecture about food migraine, two hours of relaxing therapy and one hour about how migraine can be improved with life-style changes. After both 6 weeks and three months, the study group had much less migraine than the control group. Their attacks were shorter, they had fewer of them and they were less painful. Generally, the study group were much better than the controls who hadn´t altered their migraine patterns.

The scientists nonetheless advise against concluding that treatment can be effective for everyone. The studied people were highly motivated and had themselves chosen to follow the ´course´ to get better.

Unfortunately the scientists did not mention whether any of the study group had had to go through a ´cold turkey´, i.e. stopped overusing medicine and thereby showed a reduction the number of migraine days. But the conclusion is clear - it is much cheaper to treat chronic migraineurs in this way than with traditional prescription medicine.

M. Lemstra, B. Stewart and W. P. Olszynski, 2002. Effectiveness of multidisciplinary intervention in the treatment of migraine: a randomized clinical trial. Headache 42, 845-854.

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Both before and after the acupuncture, the flashing lights caused increased blood flow through the brains of those patients who had no benefit fom the acupuncture, but those who did benefit reacted less to the flashing light after treatment with the needles. Six out of ten migraineurs benefited from the acupuncture. Of the 4 who didn´t benefit, 2 actually became worse.

M. Bäcker, M. Hammes, D. Sander, D. Funke, M. Deppe, T. R. Tölle og G. J. Dobos, 2004. Changes of cerebrovascular response to visual stimulation in migraineurs after repetetive sessions of somatosensory stimulation/acupuncture): a pilot study. Headache 44, 95 - 101.

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A team of German scientists has carried out a study to get some idea about how the results found in laboratory experiments using acupuncture against migraine (RCT) can be compared with the results collected by the clinical system - i.e. from patients who have received acupuncture, not as an experiment, but as a real part of their treatment against migraine.

The scientists discovered that patients in the first (RCT) group who had had their number of migraine attacks reduced by at least 50% after 12 weeks had an average reduction of 54%. 24 weeks after their treatment, they still had a reduction of 44%.

The patients who received RCT treatment were substantially better off than patients on the waiting list who had not received acupuncture.

The surprise was that the results showed that treatment using non-penetrating acupuncture was just as effective as real acupuncture. The reduction in the number of attacks was just as great as in those who received treatment by approved migraine medicine and much larger than normally seen in placebo groups (control groups who do not receive effective treatment) in such studies.

The scientists concluded that non-penetrating acupuncture can be just as effective a preventive treatment against migraine as real acupuncture and that where the needles are applied is of little importance (2).

(1). O. Ekholm, M. Kjøller, M. Davidsen, U. Hesse, L. Eriksen, A. Illemann Christensen and M. Grønbæk, 2006. Sundhed og sygelighed i Danmark 2005 & udviklingen siden 1987. Statens Institut for Folkesundhed. 305 s.

(2). K. Lindea, A. Strenga, A. Hoppea, W. Weidenhammera, S. Wagenpfeilb and D. Melcharta, 2007. Randomized trial vs. observational study of acupuncture for migraine found that patient characteristics differed but outcomes were similar. Journal of Clinical Epidemiology 60, 280-287.

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Canadian Journal of Neurological Sciences 1999, 26, 33-36.

The Danish Headache Center in Glostrup practices biofeedback

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In cell cultures (in which the nerves cells swim around in nutrient-rich liquid in the laboratory) it can be shown that botox reduces the amount of CGRP (a chemical that is produced by nerves during a migreaine attack). It is not yet known whether this also happens after treatment with botox against e.g. migraine (2).

(1) B. Guyuron, K. Rose, J. S. kriegler og T. Tucker, 2004. Hourglass deformity after botulinum toxin type A injection. Headache 44, 262-264. (2) P. L. Durham, R. Cady og R. Cady, 2004. Regulation of CGRP secretion from trigeminal nerve cells by botulinum toxin type A: implications for migraine therapy. Headache 44, 35 - 43.

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The study was terminated after 4 months.

J. A. Smuts, S. Schultz and A. Barnard, 2004. Mechanism of action of Botulinum toxin type A in migraine prevention: a pilot study. Headache 44, 801-805.

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Before the year 2000, doctors used Botox as an ´anti-wrinkle´ treatment and injected small amounts of Botox into the muscles of the forehead around some of the worst wrinkles there as an alternative to plastic surgery. Botox paralyses the muscles that ´make´ wrinkles, so the skin around the injection becomes smooth. It has been found, quite unexpectedly, that many patients´ migraine became substantially better after receiving an injection of Botox (1).

Botox worked on about a half of the treated migraineurs who improved (fewer attacks and less strong attacks) after the injections. The effect lasted about 2–4 months and started after only a few hours, which means that Botox could be used as a treatment of acute migraine (2).

The effect of Botox has naturally been compared with the effect on the muscles that cause wrinkles in the forehead. It was found that 21 out of 22 patients who had had a substantial improvement from Botox and who wanted a continuing effect also had an improvement after surgical removal of the muscles involved. 10 of the patients had a substantial improvement and the remaining 11(who were more strongly affected by migraine) had some improvement after the operation (3).

There has also, of course, been speculation about side-effects. The doctors assert that at most 5% of treated patients will experience side-effects e.g. in that the body does not react to repeated injections (4).

Many reports in the scientific journals (including those mentioned here) are not ´controlled´ studies (5), i.e. they report the observed effects but no equivalent injections of a placebo were made into control persons equivalent to the treated patients. There is therefore still reason to be a little careful before recommending Botox as the answer to migraineurs prayers.

In addition, the treatment is expensive and has to be repeated every few months. There are also reports that repeated treatments give a more permanent effect.

(1) S. Silberstein, N. Mathew, J. Saper and S. Jenkins, 2000. Botulinum toxin type A as a migraine preventive treatment. For the BOTOX Migraine Clinical Research Group. Headache 40, 445-50.

(2) W. J. Binder, M. F. Brin, A. Blitzer, L. D. Schoenrock and J. M. Pogoda, 2000. Botulinum toxin type A (BOTOX) for treatment of migraine headaches: an open-label study. Otolaryngol Head Neck Surg 123, 669-76.

(3) B. Guyuron, T. Tucker and J. Davis, 2002. Surgical treatment of migraine headaches. Plast Reconstr Surg 109, 2183-9.

(4) A. W. Klein, 2001. Complications and adverse reactions with the use of botulinum toxin. Semin Cutan Med Surg 20, 109-20.

(5) S. Evers, A. Rahmann, J. Vollmer-Haase and I. W. Husstedt, 2002. Treatment of headache with botulinum toxin A--a review according to evidence-based medicine criteria. Cephalalgia 22, 699-710.

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S. J. Tepper, M. R. Bigal, F. D. Sheftell and A. M. Rapoport, 2004. Botulinum neurotoxin type A in preventive treatment of refractory headache: a review of 100 consecutive cases. Headache 44, 794-800.

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Reuters 31. December 1996.

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C. Lisotto, E. Maggioni, F. Mainardi and G. Zanchin, 2000. Caffeine efficacy in hypnic headache syndrome. Cephalalgia 20, 332.

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13 out of 23 migraineurs who completed the programme for 8 weeks found a reduction to half of the number of attacks from before the study.

R. Nicholson, J. Nash and F. Andrasik, 2005. A self-adminstered behavioural intervention using tailored messages for migraine. Headache 45, 1124-1139.

Uploaded 21-10-2006

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The researchers measured the content of endorphins (the body’s own pain relief chemical) before the exercise programme and during the programme period. All patients had fewer migraine attacks and the attacks were less severe and lasted a shorter time. The greatest effect of the exercise programme was seen in patients who had a low content of endorphins in their blood before they began exercising.

E. Køseoglu, A. Akboyraz, A. Soyuer and A. Ø. Ersoy, 2003. Aerobic exercise and plasma beta endorphin levels in migrainous headache without aura. Cephalalgia 23, 972-976.

Uploaded 02-03-2005

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Green vegetables, red bell peppers, leeks, avocados and dried beans all contain folate. We also get it from bread and other grain products (2). We get folic acid from vitamin pills that is converted to folate in the body.

Finally, the poor conversion of folate because of this fault gives an increase of homocystein in the blood and a consequent increased risk of narrowing of the coronary artery (3).

So there are extra good reasons for eating lots of vegetables if you are a migraineur.

(1) A. Oterino, N. Valle, J. Pascual, Y. Bravo, P. Muñoz, J. Castillo, C. Ruiz-Alegría, P. Sánchez-Velasco, F. Leyva-Cobián and C. Cid, 2005. Thymidylate synthase promoter tandem repeat and MTHFD1 R653Q polymorphisms modulate the risk for migraine conferred by the MTHFR T677 allele. Molecular Brain Research 139, 163-168.

(2) http://www.altomkost.dk/madtildig/Hvad_er_der_i_maden/Vitaminer_og_mineraler/Folat/forside.htm

(3) D. Girelli, N. Martinelli, F. Pizzolo, S. Friso, O. Olivieri, C. Stranieri, E. Trabetti, G. Faccini, E. Tinazzi, P. F. Pignatti and R. Corrocher, 2003. The Interaction between MTHFR 677 C-T Genotype and Folate Status Is a Determinant of Coronary Atherosclerosis Risk. The American Society for Nutritional Sciences J. Nutr. 133, 1281-1285.

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T. Abe, H. Kim, K. Shimazu, N. Araki, D. Furuyra, C. Takano, T. Shimazu and A. Uemura, 2000. Efficacy of magnesium infusion therapy for migraine attacks. Cephalalgia 20, 343.

18-12-2004

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On the other hand, there were some side effects. 26 of the total of 30 people who took part in the experiment reported burning sensations in their face and neck and that they sweated.

The authors recommend that more work needs to be done to develop a medicine that uses MgSO4 as a treatment against migraine. We must just wait and see.

S. Demirkaya, O. Vural. B. Dora and M. A. Topcuoglu, 2001. Efficacy of intravenous magnesium sulphate in the treatment of acute migraine attacks. Headache 41, 171 – 177.

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J. A. Astin and E. Ernst, 2002. The effectiveness of spinal manipulation for the treatment of headache disorders; a systematic review of randomized clinical trials Cehpalalgia 22, 617-623.

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G. Bronfort, N. Nilsson, M. Haas, R. Evans, C. H. Goldsmith, W. J. J. Assendelft and L. M. Bouter, 2005. Non-invasive physical treatments for chronic/recurrent headache. The Cochrane Database of Systematic Reviews 2005 Issue 4.

http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001878/frame.html

21-10-2006 Botox works best if you have had migraine for only a few years Injections of Botox reduce the number of migraine attacks for some months. But not all migraineurs benefit from the treatment. 74 migraineurs were treated with Botox and were asked about its effect. A clear connection was found between the effect of Botox and the number of years the patient had suffered migraine. 4 out of 5 migraineurs got less migraine from Botox injections if they had had migraine for 20 years or less. Botox helped only a half of those who had had migraine for 30 years or more. The study did not show whether this effect was because migraineurs with attacks for more than 30 years were older than those who had had migraine for a shorter time, nor whether there was a connection with what medicines the migraineurs had used.

E. J. Eross, J. P. Gladstone, S. Lewis, R. Rogers and D. W. Dodick, 2005. Duration of migraine is a predictor for response to botulimun toxin type A. Headache 45, 308-314.

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32 patients with and without aura took 3 mg melatonin just before bed-time for 3 months. 25 of them reported that they had only half as many, or even fewer, attacks compared with before the treatment and 8 of them had no attacks at all in the period after the trial. This promising effect started after as little as a month´s treatment (2).

(1) B. Claustrat, J. Brun, C. Chiquet, G. Chazot and F. Borson-Chazot. 2004. Melatonin secretion is supersensitive to light in migraine. Cephalalgia 24, 128-33.

(2) L. Barclay, 2004. Melatonin Decreases Migraine Frequency and Intensity. Neurology 63, 757.

Uploaded 06-04-2006

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80% of the women who had had chronic headache were a lot better after treatment. A lot better meant that they had half as many (or fewer) days of headache. Men and women with episodic headache did not show any real benefit of the treatment.

P. Torelli, R. Jensen and J. Olesen, 2004. Physiotherapy for tension-type headache: a controlled study. Cephalalgia 24, 29-36.

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P. S. Sandor, L. Di Clemente, G. Coppola, U. Saenger, A. Fumal, D. Magis, L. Seidel, R. M. Agosti and J. Schoenen, 2005. Efficacy of coenzyme Q10 in migraine prophylaxis: a randomized controlled trial. Neurology 64, 713-5.

*Q10 is an anti-oxidant found in e.g. meat, offal and oily fish.

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The people studied had 2 - 8 attacks per month and kept a diary about their attacks for 4 weeks before the treatment started and for 6 months after start of treatment.

Before treatment, the patients had an average of 4 attacks per month and after both 2 and 6 months treatment the average had fallen to only 2 attacks per month. Their use of medicine was reduced by 35%. It was their use of triptans especially was reduced, while their use of painkillers was still the same as before treatment.

The treatment didn´t vary much the intensity and frequency of their attacks.

The study was not a blind test - i.e. the patients knew what they were treated with so it is possible that there could have been a significant placebo effect in the results. Other earlier studies have shown the same effect.

C. Boehnke, U. Reuter, U. Flach, S. Schuh-Hofer, K. M. Einhäupl and G. Arnold, 2004. High-dose riboflavin treatment is efficacious in migraine prophylaxis: an open study in a tertiary care centre. European Journal of Neurology 11, 475.

The Danish Migraine Association comments: Riboflavin is a vitamin also known as B2. It is found in milk and other animal proteins. The recommended daily dose (in food) is in the range 1-2 mg riboflavin per day. We get that from milk, eggs, nuts, spinach, broccoli and meat.

Uploaded 30-10-2005

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All patients with symptoms other than acute headache who attended a Spanish neurological clinic during a 2 year period (2000-2002) were scanned. There were 1876 patients altogether, of whom a half had migraine. Only 22 patients (equivalent to 1.2%) had changes in their brains that could be seen on the scans. The clinic´s patients had a little more brain damage (0.6%) than 1000 people from the general population used used as a control group. There was, as expected, a slight tendency for older people and people with ´headache of unknown origin´ to have more lesions than younger people and people with tension headache and migraine.

So there was no generally significant over-representation of lesions in the brains of migraine and headache patients.

A. P. Sempere, J. Porta-Etessam, V. Medrano, I. Garcia-Morales, L. Concepcion, A. Ramos, I. Florencio, F. Bermejo and C. Botella, 2005. Neuroimaging in the evaluation of patients with non-acute headache. Cephalaliga 25, 30-35.

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The patients in the study received spectacles with coloured glass which should reduce the glare and reflections from things around them. The colour of the glass was decided by how susceptible the patient was to strong light.

21 patients used the glasses for 6 weeks and afterwards tried glasses with a slightly different colour. 2 patients were decidedly better with the glasses they had chosen themselves, compared with using glasses with the altered colour, while one person was worse. The others found no difference between the ´correct´ spectacles and the altered ones.

No comparison was made with clear spectacles or none at all, but the effect of the specific colour is small.

A. J. Wilkins, R. Patel, A. Adjamian and B. J. W. Evans, 2002. Tinted spectacles and visually sensitive migraine. Cephalalgia 22, 711-719.

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The yoga group learned yoga positions, breathing and relaxation exercises and meditation, which they carried out for one hour per day and 5 days per week. They also learned a so-called 'cleaning' process (kriya) that they carried out once a week and stretching exercises for the neck, shoulders and back, and strength training.

The self-help group learned about types of migraine, what triggers migraine and medicine -induced migraine and received written material about these subjects. They were also asked to keep a migraine diary.

All participants filled out various questionnaires before and after the three months.

Those who learned yoga had fewer days with migraine, less pain during the attacks, shorter attacks, used less medicine and had less tendency for depression than before they started the yoga. These parameters also improved in the self-help group after 3 months compared with before the start.

The scientists point out that the yoga group received more attention from the scientists than the self-help group and this may have influenced the results.

P. J. John, N. Sharma, C. M. Sharma and A. Kankane, 2007. Effectiveness of yoga therapy in the treatment of migraine without aura: a randomized controlled trial. Headache 47, 654-661.

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F. Sheftell, A. Rapoport, R. Weeks, B. Walker, I. Gammerman og S. Baskin, 2000: Montelukast in the prophylaxis of migraine: a potential role for leukotriene modifiers. Headache 40, 158-163.

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That doesn´t sound like much, but could it tbe the beginning of the development of a completely new medicine to treat migraine attacks?

The BIBN treatment did not alter the changes in diameter of the middle cranial artery that was caused by CGRP, but prevented the blood vessels outside the skull enlarging because of the CGRP injection.

K. A. Petersen, L. H. Lassen, S. Birk, L. Lesko and J. Olesen, 2005. BIBN4096BS antagonizes human alpha-calcitonin gene related peptide-induced headache and extracerebral artery dilatation. Clin Pharmacol Ther. 77, 202-13.

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M. Cutrer and M. A. Moskowitz, 1996 in Headache. 36 (579-585) and K.Taylor and J. Goldstein 1996 in Headache 36, 514-5.

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