NOVEMBER 2004 MEETING NOTES
TOPIC: “EFFECTIVE NUTRITION FOR HEADACHE PAIN MANAGEMENT“
The East Bay Headache Support Group meeting on November 9, 2004 featured Robin Polokoff, PhD, as its guest speaker. We met in the Hanson Room at John Muir Medical Center with 21 in attendance.
Dr. Robin Polokoff obtained her PhD in Nutrition and Biochemistry at North Carolina State University in 1979 where her studies were on dietary fat absorption and metabolism. She then went on to a postdoctoral research associateship at the University of Wisconsin, studying the effects of dietary fluoride. Then she accepted a research associate position at the Eleanor Roosevelt Cancer Institute examining the links between cholesterol and cancer. Dr. Polokoff became an assistant professor, first at the University of Colorado Medical Center and later in the Nutrition Department at Drexel University in Philadelphia. Subsequently, she entered the private sector for nutritional research working first for Schering Plough in New Jersey and later for Berlex Biosciences in San Pablo, California. For the past several years Dr. Polokoff has operated a private nutritional counseling practice in Walnut Creek.
Dr. Polokoff began her presentation by polling the audience members as to how many suffer pain each day from headaches, how many take prescription medicines, and how many take OTC (over-the-counter) pain relievers. Most people in the room raised their hands in response to her questions.
She said that her talk would be about alternative modalities for headache pain management, including diet, nutritional supplements, and herbs; and stated that hopefully we can learn that besides pain relievers (pharmaceuticals) there are more natural alternatives that can help prevent or abate headache pain.
The different types of headaches were presented: Cluster, Tension and Migraine.
Cluster Headache: A sudden, severe pain on side of head, around the eye. Attacks are spaced close together, perhaps 1-2 times per day for several weeks. There are an estimated one million sufferers in the US today. Cluster headaches occur most often in men between 20-40 years old. Like migraine, pain is related to an inflammatory process resulting from interaction between nerve and blood vessels in the covering of the brain. They can be triggered by smoking, alcohol consumption, and nasal congestion.
Tension Headache: Associated with muscle tension from shoulder and back of neck to top of head—feels like a tight band around the head/neck. Tension is the most common form of headache—78% of adults will have a tension headache at some time. Causes are unknown, but likely due to chemical and neuronal imbalances in the brain and may be related to muscle tightening in back of neck and/or scalp. Tension headaches can be triggered by stress, anxiety, poor posture, overeating or drinking.
Migraine Headache. Three stages include:
1. Prodrome—early signs/symptoms. 70-80% of migraine sufferers experience a prodrome. Subtle symptoms include: fatigue, yawning, nausea, irritability, muscle aches and pains, head pain, changes in sensory perception, food craving (for sweet), thirst.
2. Aura—only 15% experience it. Flashing lights/streaks. Numbness/tingling in fingers.
3. Headache—throbbing vascular pain. Besides throbbing head pain, symptoms can include depression, drowsiness, weakness, nausea, sensitivity to senses, sensory loss. Migraine affects 28 million Americans (13% of the population-1 in every 4 U.S. households has a migraine sufferer), and is more prevalent in women. Typically appears in teens and continues into adulthood. Peaks between ages 35-45. Becomes less frequent and milder with age. Runs in families—if both parents have migraines, 75-80% probability of children having them; if only 1 parent, then a 50% probability of passing it on to the next generation.
Migraine mechanism of action: Caused by successive vasoconstriction, vasodilatation and inflammation in the brain. Nerve cells aren’t stable in migraineurs. Synapse = membranes between 2 nerve cells. At synapses nerve cells communicate by transmission of chemical neurotransmitters (serotonin, norepinephrine). Nerve cells in pain control system of brain get unstable and can’t control neurochemical levels. When triggered beyond threshold, neurotransmitter levels in this unstable area fall (migraine generator). This activates a nerve (trigeminal nerve) which carries sensation from front of head and face to receptors on walls of blood vessels on side and base of brain and scalp (the meninges). Activation of nerve causes chemicals to be released from nerve ending into blood vessels causing inflammation, swelling, dilation of blood vessel and pain. Mediator is serotonin (stored in platelets). As episode starts, stress chemicals induce the release of serotonin. Serotonin causes increased cerebral constriction producing aura and increased sensitivity to pain. Serotonin then quickly metabolizes and level goes down—causing vasodilatation, reflex increase in blood flow and irritation/pressure of surrounding nerves, i.e., more throbbing pain.
Dr. Polokoff stated that migraine is an inflammatory process. The meningeal blood vessel becomes swollen. She then stressed that it is important that you take your migraine abortive medication during the prodrome phase—don’t wait for the headache pain to come on.
Migraine Triggers—Defined as “something inside or outside the body that can activate processes that cause migraines in people prone to condition.” Keep a headache diary to help determine your triggers. Triggers can include:
1. Stress/anxiety—from work deadlines, financial issues, family pressures, etc. Let down stress.
2. Changes in barometric pressure. 51% of migraine sufferers are sensitive to weather changes. Can include extreme heat/cold or wet/dry air.
3. Hunger—skipping meals or fasting.
4. Fatigue or oversleeping.
5. Alcohol—especially red wine.
6. Caffeine (decaffeinated coffee, and herbal teas, are OK).
7. Nicotine.
8. Certain foods.
9. Bright lights—office lighting, flashing lights or screens.
10. Loud noises.
11. Specific odors or chemical fumes (air pollution).
12. Physical exertion (over exertion—especially in heat).
13. Head trauma.
14. Hormonal changes (especially estrogen in women—HRT or birth control).
15. Medication.
16. High altitude and jet lag.
Appearance of ability of triggers to induce headache seems to vary because of threshold. As trigger level rises above threshold, migraine mechanism gets activated.
What to do when you get a headache?
Aim of treatment is to: prevent migraine (reduce/prevent triggers), calm the unstable nerve cells (triptans do this), relieve/reduce inflammation of blood vessels (use anti-inflammatories, calcium channel blockers, beta blockers).
Treatment Options (may help to reduce/relieve headache pain):
1. Acupuncture (preventive) can reduce frequency and need for medications. About 70% of humans respond to acupuncture.
2 . Acupressure with massage may help decrease pain.
3. Biofeedback—not as effective for migraine headache. Techniques include deep breathing exercises, meditation and visualization.
4. Chiropractic/physical therapy—relief through massage, spinal manipulation and periodic adjustments of joints and soft tissue. A controlled trial yielded mixed results, but small trials indicate chiropractic/physical therapy may be preventive. HOWEVER, lots of complications, especially from neck manipulation. Yoga and other stretching/relaxation techniques may be helpful.
5. Aromatherapy – helps alleviate milder headaches, i.e., tension. One drop Peppermint, lavender, chamomile or eucalyptus oil into one teaspoon almond oil – rub into skin or add 4-7 drops of oil into bath and steep. Peppermint raises pain threshold, has relaxing effect (2 different studies showed positive effects). Eucalyptus = calming and relaxing effects and improves cognitive performance.
6. Exercise – no scientific trials, but offers relief from stress. Have sex (more intense the orgasm, more intense the relief)-you could get about an hour’s relief from the headache. During exercise the brain releases endorphins, hormones which relieve pain and produce euphoria.
Diet
Of many environmental triggers, foods/beverages are more common. Early studies suggest that 30-40% of migraine sufferers benefit by avoiding certain foods. Results of 4 double blind studies support the role of food in precipitating migraines. However, food sensitivities vary:
1. From person to person
2. Amount of food consumed, and
3. Time of pain onset. Some triggers are immediate, others are delayed (up to a day or two).
Keep a food diary. Foods that can trigger headaches:
1. Amines-Tyramine–found mainly in foods/beverages. Undergone bacterial decomposition. Cause blood vessels to constrict and then expand. 20-25% of people reduce headaches by eliminating tyramine from their diets.
Foods to avoid:
--Ripened cheese (Swiss, stilton, blue, Colby, gouda, cheddar, brie, camembert, mozzarella, parmesan, provolone).
--Ripened bananas/avocadoes.
--Chocolate (-PEA-causes dilation) (white chocolate is OK).
--Oranges and citrus.
--Alcohol (brandy, red wine, rum, sherry) (scotch, whiskey and beer are ˝ as potent) (white wine, gin and vodka are the least).
--Fresh (less than one day old) yeast breads/products – especially in cluster headache sufferers.
--Sour cream and cultured dairy products (yogurt, buttermilk).
--Nuts.
--Aged meat, fish.
--Liver, wild game.
Dr. Polokoff told her audience to “keep in mind that young and fresh is best (except for yeast breads).
2. MSG (also known as hydrolyzed vegetable protein, natural flavor/seasoning, autolyzed yeast, sodium caseinate, and calcium caseinate). MSG is a flavor enhancer added to processed/packaged foods. Chinese food – soy sauce – causes headaches in 10-25% of general population. Headaches occur fast (15-30 minutes) after easting. Commonly found in soups, bouillons, flavored salty snacks, croutons, bread crumbs, gravies, ready-to-eat meals, processed meats, low-fat/low-calorie foods.
3. Nitrites–preserve/cure meats (lunch meat, bacon, hot dog, sausage, salami, bologna, pepperoni).
4. Caffeine–double edge sword. If used occasionally, can constrict blood vessels and help abort migraine—effects take 30 minutes and last 3-5 hours. Caffeine is often included in pain relievers to improve efficacy and absorption of medications, but if it is used on a daily basis (2-5 cups per day), a person can develop caffeine rebound headaches. Dr. Polokoff suggested that if you’re a coffee drinker, don’t bother taking medications that include caffeine. And better yet, wean your-self from caffeine. Then you’ll be able to use caffeine when you need it
5. Aspartame (Nutrasweet, Equal). (Dr. Polokoff said that Splenda seems to be OK)
6. Certain vegetables, especially onions.
7. Pickled/fermented/marinated foods (sauerkraut, pickles, dark vinegar). (Clear vinegar is OK)
8. Beans (broad beans, lima, fava and snow peas).
9. Certain fruits (figs, raisins, papayas).
10. Salted, dried fish (herring, cod, pickled herring).
To remove offending foods, keep a headache diary. Remove all suspect trigger foods from diet. When headaches stabilize, add back one food at a time until symptoms reappear. Dr. Polokoff added that if you have an inflammatory reaction to dairy/gluten products, it could be a food sensitivity and you should see a nutritionist.
What foods can you eat?
1. Dairy – American cheese, Velveeta, cottage cheese, cream cheese, ricotta, pot, farmer, fresh, milk. Limit yogurt to ˝ cup per day. Eggs.
2. Snacks – sunflower, pumpkin seeds.
3. Condiments – white vinegar, ketchup, mustard, mayonnaise.
4. Fruits - kiwi, apple, most berries, cherries, grapes, melons, peaches, pears (organic dried fruits without sulfites).
5. Veggies – leeks, shallots, spring onions, all fresh, frozen, dried, canned vegetables except beans, chili peppers, olives. Limit tomatoes and onions to ˝ cup per day.
6. Breads and cereals – all breads one day old or store bought. All cereals without dried fruit or artificial sweeteners.
7. Soups: homemade (no beans, cheese, onion, tomato).
8. Dessert: all cakes, cookies, candies and pies without prohibited ingredients, gelatin, sherbet, sorbet.
9. Meat/seafood – all fresh beef, poultry, fish or pork. Tuna and other canned seafood packed in water.
What about vitamins and minerals? Dr. Polokoff stressed that it is important that we all take multi-vitamins and multi-mineral supplements every day. She said that packaged foods and even fresh vegetables and fruits are nutrient-deficient. Multiple dosing through the day is better than taking your vitamins and minerals once per day.
Vitamins
1. Take B vitamins. Important for proper functioning of nervous system. Helps body deal with stress. Aids in metabolism of carbohydrates (helps prevent hypoglycemia). Research points to B6 25 mg 3 times per day in preventing headaches. Riboflavin (B2) also effective prophylactic (increases cellular energy/efficiency). Randomized study (1998) showed 400 mg (more than 200 times the RDA (recommended daily allowance) riboflavin taken daily for 3 months effectively reduced migraine frequency by 2/3. Once migraine free, gradually taper down to 100 mg per day.
Dr. Polokoff then recommended that headache sufferers should take B vitamins in the following amounts per day:
B2: 100-400 mg
B3: 100 mg
B6: 100 mg
2. Antioxidants-prevent oxidation of cell membranes – prevent cell damage – to maintain cell integrity).
- Vitamin C: Dr. Polokoff recommended 1000 mg per day
- Vitamin A or beta carotene: 10,000 IU per day.
- Vitamin E: 400 IU per day.
All have demonstrated benefits in treating migraine.
3. Folic Acid-for neural tube development. In one study intravenous injection of 15 mg folic acid achieved total relief of acute migraine within one hour in 60 subjects, with great improvement in another 30%. Dr. Polokoff recommended taking 1 mg folic acid per day.
4. Choline–important in nerve cell membranes as part of spingomyelin. Blood levels low in people who suffer from migraines, and headaches improve with supplements. Found in all fatty foods. Dr. Polokoff suggested we get choline from a good diet.
Minerals
1. Iron–Helps transport oxygen to tissues. Iron deficiency can increase headache by reducing the blood’s ability to carry oxygen. Any ferrous salt is good, but ferrous sulphate is the most common. Take 20 mg per day.
2. Magnesium—used with great success to prevent/treat migraines and cluster headaches. Several studies have shown that migraineurs have low levels of intracellular magnesium. Effective in preventing migraine because it helps maintain cerebral blood vessel tone. Several studies have shown magnesium (400-600 mg per day) reduces headache frequency and length of attack, especially with menstrual migraine. One study showed intravenous magnesium sulfate (1 gm) to 40 patients produces very good, sustained relief of migraine attack in 53% of subjects. For oral, take magnesium glycinate/citrate. Don’t take more than 1000 mg daily because too much results in diarrhea. She recommended taking 400 mg per day.
3. Calcium-along with magnesium, helps to calm muscles and relax blood vessels. Study showed women who take 200 mg calcium daily have fewer headaches (especially during menstrual periods). 1000 mg per day recommended for migraine prevention. When taking supplements, take 2 times as much calcium as magnesium, best is carbonate/glucinate.
Supplements and Herbs:
Supplements
1. Omega-3 fatty acids (fish oils-EPA and DHA). Reduce pain of migraine because they are powerful anti-inflammatory agents. In one study they reduced intensity and frequency of migraine EPA (300 mg 3 times per day) and DHA (200 mg 3 times per day) for 12 weeks, then 2 times per day. Found in cold water fish--salmon, tuna, halibut, mackerel.
2. Omega 6 Fatty (gamma linolenic or GLA and ALA) may be effective in migraine prevention. 1997 – GLA and ALA administered to 168 patients over 6 months and 86% experienced reduction in severity, frequency and duration of migraine. Oral dose of 500 mg 2-4 times per day. Found in safflower, sunflower, soybean and especially evening primrose oil. In one study both omega 3 and 6 FA improved headaches occurrence in 85% of trial with 6 months usage (preventative).
3. AA, Tryptophan and PHE-a
TRP—essential aa-precursor of serotonin.
PHE—blocks enzymes in CNS which break down endorphins. Can be effective pain reliever.
4. 5-HTP--a derivative of aa-tryptophan and serotonin precursor. Demonstrated to increase pain tolerance and may boost brain serotonin levels. When used long-term is effective in prevention and reducing intensity, frequency and duration of migraine. Recommended dose is 200 mg 3 times per day.
5. SAM-e (well known in use for arthritis). Helps regulate hormone and neurotransmitter levels. Can provide as much pain relief to naproxen (Aleve/Naprosyn). Dosage for migraine 400 mg 4 times per day. Begin with 200 mg 2 times daily and gradually increase over 3 weeks to dose.
Herbs
1. Ginkgo biloba (40-60 mg 3 times per day) can affect cerebral blood flow.
2. Feverfew (member of the daisy family)-inhibits prostaglandin production and serotonin secretion so less blood vessel contraction. Used as a preventative agent. In five different studies feverfew was shown to be effective as migraine preventer, but results were not always compelling (2 of 5 trials showed no effect, other 3 detected advantages but were some flaws in studies). Yet in successful studies, 70% experienced decline of frequency or severity of headache. Eat one fresh leaf per day or make tea or take capsules. Dose is 125 mg capsule 3 times per day (don’t use if taking anticoagulants). Also, if you have hay fever or are allergic to ragweed, don’t take feverfew.
3. White willow bark and Meadowsweet bark-contains salicin, related to aspirin. Like feverfew, inhibits prostaglandin production. Drink as tea infusion.
4. Capsaicin (from chili peppers)-this is what makes chilies “hot.” Relieves pain by temporarily blocking pain signal pathways and can also trigger endorphin release. Used mostly by cluster headache sufferers. Comes in nasal spray form.
5. Butterbur (Petadolex)-anti-inflammatory agent, used for 20 years in Germany. In double blind studies was shown to be 77% effective as migraine preventative agent. Very expensive. Dose is 50 mg two times daily.
6. Ginger-used especially for nausea accompanying migraine. Helps reduce pain and inflammation and acts as a digestive aid, soothing/relaxing GI tract. Dose is 1000-2000 mg daily (500 mg 4 times per day).
7. Sedative/calming herbs-Valerian, chamomile, passion flower, lavender, kava kava. Good for tension headaches. Calming herbs. Drink as tea infusion or use oils topically on forehead or in bath. Dose is valerian 150-300 mg per day, kava kava 100 mg 3 times per day.
What to do to prevent headaches?
Over-the-counter and prescribed drugs may help in occasional severe migraine attacks, but they may not be the desirable answer to avoiding repetitive bouts of migraine. Rather a more natural approach can be taken.
1. Raising the migraine threshold. Makes it more difficult to get a migraine no matter what the activating circumstance/trigger. Relaxation and stress reduction techniques can prevent accumulation tension that lowers threshold for migraine.
2. Avoiding migraine triggers. Maintain a diet low in refined sugar, MSG, aspartame, caffeine, alcohol, chocolate, cheese, citrus and nitrate-containing foods; and high in fiber. Eat small but frequent meals (don’t skip) to keep blood sugar stable. Stick to a regular sleep routine. Exercise regularly. Quit smoking. Switch from fluorescent lighting to incandescent. Note that triggers are cumulative. There are dietary triggers and triggers you can’t control. Assume you’re sensitive to everything.
3. Take a daily multivitamin/multi-mineral supplement. And supplement with extra riboflavin B2, Omega 3 and Omega 6 FFA, magnesium and calcium.
Protocol to seeing a nutritionist:
Keep a headache diary.
Note your food triggers (foods eaten 24-48 hours before onset of headache).
Keep list of environmental triggers.
Go on an elimination diet for 4-6 weeks, and then slowly add back one food at a time.
The intention of the East Bay Headache Support Group is to provide information and resources for the headache sufferer. It does not provide medical advice, which should be obtained directly from a physician.