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MIGRAINE HEADACHE PAIN: ALTERNATIVE AND COMPLEMENTARY APPROACHES

NOAH CARPENTER, MD

Dr. Noah Carpenter is a Thoracic and Peripheral Vascular Surgeon. He completed his Bachelor of Science in chemistry and medical school and training at the University of Manitoba. Dr. Carpenter completed surgical residency and fellowship at the University of Edmonton and Affiliated Hospitals in Edmonton, Alberta, and an additional Adult Cardiovascular and Thoracic Surgery fellowship at the University of Edinburgh, Scotland. He has specialized in microsurgical techniques, vascular endoscopy, laser and laparoscopic surgery in Brandon, Manitoba and Vancouver, British Columbia, Canada and in Colorado, Texas, and California. Dr. Carpenter has an Honorary Doctorate of Law from the University of Calgary, and was appointed a Citizen Ambassador to China, and has served as a member of the Indigenous Physicians Association of Canada, the Canadian College of Health Service Executives, the Science Institute of the Northwest Territories, Canada Science Council, and the International Society of Endovascular Surgeons, among others. He has been an inspiration to youth, motivating them to understand the importance of achieving higher education.

DANA BARTLETT, RN, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His clinical experience includes 16 years of ICU and ER experience and over 27 years as a poison control center information specialist. Dana has published numerous CE and journal articles, written NCLEX material, textbook chapters, and more than 100 online CE articles, and done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the subject of toxicology and was a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center. He lives in Wappingers Falls, NY.

ABSTRACT

While the common headache does not usually drive a patient to seek medical attention, migraine headaches often do. More than just a severe headache, a migraine headache is typically accompanied by intense pain, sensitivity to light and sound, and can include other symptoms like nausea and vomiting. The first-line treatment for chronic or frequent migraine pain is the use of medications with a goal to eliminate pain. Not all patients, however, will tolerate or respond to pharmacological treatment and will often seek alternative and complementary therapies for needed relief.

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Policy Statement This activity has been planned and implemented in accordance with the policies of NurseCe4Less.com and the continuing nursing education requirements of the American Nurses Credentialing Center's Commission on Accreditation for registered nurses. Continuing Education Credit Designation This educational activity is credited for 2.5 hours at completion of the activity. Pharmacology content is 0.5 hours (30 minutes). Statement of Learning Need Clinicians need to know complementary and alternative medicine options for the treatment of migraine headache when patients are unable to tolerate or respond to pharmacological treatment. Because people are increasingly seeking complementary and alternative treatments for pain relief, engaging patients in an individual treatment plan backed by scientific evidence and measurable outcomes is important for clinicians to determine treatment efficacy and safety, and to plan future treatment. Course Purpose To provide health clinicians with knowledge of complementary and alternative medicine approaches for patients with migraine headache who desire to pursue a nonpharmacological approach to control symptoms associated with migraine pain. Target Audience Advanced Practice Registered Nurses, Registered Nurses, and other Interdisciplinary Health Team Members. Disclosures Noah Carpenter, MD, Dana Bartlett, RN, BSN, MSN, MA, CSPI, Heidi Blossom BAN, MSN, William Cook, PhD, Susan DePasquale, MSN, FPMHNP-BC, Douglas Lawrence, MA, – all have no disclosures. There is no commercial support.

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Self-Assessment of Knowledge Pre-Test: 1. Acupuncture is primarily performed to produce

a. an analgesic effect. b. a sedate state of mind. c. muscle relaxation. d. a meditative state of mind.

2. During __________, the patient is often monitored with an

electroencephalogram (EEG).

a. acupuncture b. electromyography biofeedback c. thermal biofeedback d. neurofeedback

3. Vitamin B2 may help in the treatment of migraine headaches

because of its potential effectiveness in treating

a. muscular dystrophy. b. mitochondrial disease. c. serotonin syndrome. d. All of the above

4. True or False: Acupuncture is best used to resolve migraine pain

after it has developed, and not as a preventive treatment.

a. True b. False

5. Peripheral nerves are activated to provide analgesia during which

procedure?

a. Neurofeedback therapy b. Vitamin B2 administration c. Massage therapy d. Acupuncture

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Introduction

There have been many advances in treatments for migraine headache

pain within conventional medicine, and people who struggle with migraine pain often have various options for treatment, including combinations of medications that can be used as abortive or preventive measures. Prevention includes making lifestyle changes that can improve quality of life and reduce the frequency and intensity of headache pain. Many complementary and alternative medicine (CAM) techniques may also be used in conjunction with conventional medical practices to better control migraine headache pain. Various CAM therapies have been shown to assist with managing some of the more difficult symptoms of migraines, including pain, light sensitivity, and nausea and vomiting.

CAM Treatment Strategies

The first-line treatment for chronic or frequent migraine headaches is

the use of medications to manage the pain; however, not all patients tolerate or respond to pharmacological treatment plans.1 A patient may not tolerate the side effects of pharmacological treatments; or, a patient may want to use pain medications but in a lesser amount. Other patients may have contraindications for pain medications.1 In these cases, patients may look for alternative, non-pharmacological treatment options.1

Certain non-traditional approaches offer alternatives to a stand-alone pharmacological approach in treatment of migraine headaches.1 Guidelines from various medical institutions and societies have begun to include CAM strategies, such as acupuncture, biofeedback, or cognitive behavioral therapy (CBT), as adjuncts or alternatives to pharmacological approaches.1 For example, Diener HC, et al. (2019), reporting for that the German Migraine and Headache Society and the German Society of Neurology, included relaxation therapy, biofeedback, and acupuncture in their guidelines for treatment of certain types of migraines; e.g., migraine attacks during pregnancy.2 Diener HC, et al. also referenced a German study that found acupuncture was as

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effective as the migraine drug sumatriptan in the treatment of acute migraine attacks.2

In 1998, the Canadian Medical Association provided guidelines for healthcare professionals for the use of alternative, nonpharmacologic therapies in the treatment of migraine patients.3 These therapies included biofeedback, relaxation therapy, CBT, physical therapy, “physical measures” such as acupuncture, as well as others.3 These guidelines have been acknowledged by Luedtke, et al. (2020).1

In the end, there is great diversity among the different medical societies

regarding CAM therapies. Some therapies are recommended, while others are not recommended because there is a lack of scientific evidence that they are effective and should be included.1,4 The therapies that will be discussed here are acupuncture, biofeedback, massage therapy, CBT, and nutrition and vitamin supplement, specifically vitamin B2.

Acupuncture

Acupuncture is a form of traditional medicine that originated in China

and focuses on certain areas of the body needing treatment.5 It is a diversified type of treatment that has been used for a variety of conditions, and acupuncture encompasses a large array of styles and techniques.5 There is some research that describes acupuncture treatment as both beneficial and safe. On the other hand, the evidence for acupuncture has also been described as lacking or inconclusive.5

Common styles of acupuncture include “Traditional Chinese, Japanese,

Korean, Vietnamese, and French acupuncture, as well as specialized forms such as hand, auricular, and scalp acupuncture.”5 A specially trained and licensed acupuncturist inserts needles under the skin to reduce pain and to ease stress. Although the practice of acupuncture has been performed for several thousand years in various countries, it has only become more common in the U.S., within the last few decades.5

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In 1997 the National Institutes of Health recognized acupuncture as a treatment for various painful conditions, including headaches, fibromyalgia, menstrual cramps, carpal tunnel syndrome, and asthma.6 Peripheral nerves are activated and input signals transferred through various neural pathways affecting the brain and spinal cord during acupuncture. Acupuncture is performed to produce analgesia.7 No single factor produces analgesia, and there are multiple complex factors that result in pain relief, which are not fully understood by researchers.7

Acupuncture involves the insertion of fine needles under the skin at identified points. The body contains several meridians under the skin, which are pathways that are thought to conduct a life force energy that is called qi. The meridian system “is a complex network connected by 361 acupoints.”7 Qi is conducted in the meridians and collaterals through acupuncture points. By stimulating the acupoint, the “arrival of qi from the acupoint and along the meridian would appear, that is, propagated sensation along the channels.”7 The meridian system involves multiple physiological functions, such as the nervous system, endocrine system, and immune system, and acupuncture leads to the release of chemicals that affects the adjacent nerves. Another way to explain how acupuncture affects body systems is that it “first activates the small network of acupoint micro- environment, enabling acupuncture information to be initiated and cascaded locally.”7

Qi is important for regulating and supporting the body’s natural balance through yin and yang, which are the dark and light or positive and negative energy forces.5,8 When the yin and yang are in balance, the qi flows normally through the body. Alternatively, when the flow of qi is disrupted, it can cause pain or illness. Acupuncture seeks to restore qi to a normal amount to reduce illness or disability.5,8

There are several theories that have attempted to explain how acupuncture actually works to control pain. Needle placement may stimulate the body to produce endorphins, which control some pain signals.5 Additionally, acupuncture may have an impact on the regulation of pain signals as seen through the gate-control theory. Normally, the perception of pain

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comes from signals in the brain, but certain medications or therapies are thought to block the perception of pain by inhibiting neural impulses.2 The placement of acupuncture needles in or near neural structures is believed by some to block the perception of pain, preventing the patient from feeling the painful effects of the migraine.9 The exact mechanisms of how acupuncture works are still being investigated.

Acupuncture is reportedly more effective as a therapy to prevent migraines, rather than resolving the pain after it has developed.10 Acupuncture may also be more successful when used in conjunction with some other migraine therapies, including both abortive and preventive methods. Since there are several meridian pathways that distribute the flow of qi, meridians can be accessed through acupuncture at various locations in the body. However, with migraine headaches, the acupuncturist may focus on inserting the needles at points in the middle or lower areas of the body, rather than just those in the face, neck, and head.10,11

During an acupuncture session, information will first be obtained about the patient’s health history and a physical examination will be completed. Acupuncturists rely upon the "Four Pillars of Evaluation" similar to traditional medical practice, which are inspection, auscultation, inquiring, and palpation.5 If a person is seeking acupuncture as prevention of migraines, the acupuncturist may examine the areas where the patient most often feels pain and may gain more information about the person’s individual health and family history related to migraine pain. Part of the physical assessment may also include examination of the patient’s pulse and the tongue. The shape and appearance of the tongue is thought to reflect the health of other organs in the body.12

The effectiveness of acupuncture as a treatment for migraine pain or for preventing migraine headache has been extensively studied and the research findings have generally been favorable, but many of the studies have been short-term and involved only a small number of patients. Linde, et al. (2016) concluded that acupuncture plus symptomatic treatment of acute attacks reduced the frequency of migraines.10 Further, acupuncture was more

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effective than sham acupuncture but the difference was very small, and the available evidence suggested that acupuncture may be as effective as prophylactic medications.10 Arnold, et al. (2017) reviewed the literature on acupuncture as migraine prophylaxis and they stated that acupuncture reduced the frequency of migraine headaches by at least 50%, is more effective than sham acupuncture, and the effects persisted at three months post-treatment but not at six months.13

During the acupuncture procedure, the patient might lie on a table or

sit in a chair to allow the acupuncturist optimal access to the areas where the needles need to be inserted. Most people report that the needle insertion is not painful because the needles are so thin and are not placed too deeply into the skin.5 In general, most acupuncturists currently use disposable needles so that there is little risk of disease transmission between patients. Improper use of acupuncture needles could lead to infection and nerve damage, among other possible harmful side effects. Serious adverse effects like pneumothorax and puncture of an organ have been reported but these are very rare and usually caused by a poorly trained acupuncturist.5,14 Overall, acupuncture has been determined to be safe for the patient when a trained and licensed acupuncturist is performing the procedure.

Biofeedback

Biofeedback is a technique that teaches people how to control certain

bodily functions through their thoughts. Typically, these activities are not under voluntary control and may include such items as controlling heart rate or blood pressure.15,16 During a biofeedback session, the person is connected to a monitor that allows viewing of the results for feedback to occur. For instance, if an individual is using biofeedback to reduce blood pressure, connection to a monitor that exhibits fluctuations in blood pressure values may be done so that the patient knows whether the techniques used are making any progress. The monitor may issue a tone or a noise to notify the patient of blood pressure trends. Over time, the patient may no longer need the monitor to check progress, once the techniques taught through biofeedback are learned. The goal is for the affected person to eventually

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utilize biofeedback at any time (without the aid of a monitor) to bring physiological responses under control when needed.15,16

There is more than one type of biofeedback that can be used as part of

treatment for painful conditions, and patients with migraines may utilize different forms of biofeedback.17 For example, thermal biofeedback involves the assessment of overall body temperature to determine a person’s physical condition. The person utilizing thermal biofeedback may learn to self-monitor responses to the procedure through a temperature probe that is placed on the skin. Thermal biofeedback is sometimes used for the treatment of headaches, including migraines.18-20 Thermal biofeedback has also been used among headache patients to raise hand temperature, reversing the effects of cold and clammy hands that often occurs under stress or tension.19,20 As increased blood flow reaches the hands and increases hand temperature, the patient experiences a greater sense of relaxation and calm, which could help reduce some migraine triggers.

Neurofeedback is a type of biofeedback affecting parts of the brain.13,15 The individual is often monitored with an electroencephalogram (EEG) during neurofeedback.17 It may be used as part of the management of neurological conditions, including headaches, as well as memory problems or sleep issues.

Electromyography biofeedback can reduce tension in the muscles of the face and neck, which can contribute to migraines.19,20 It is used in conditions affecting the muscles. The patient uses an electromyogram during biofeedback, which assesses the electrical activity of the patient’s muscles.21,22 Electromyography biofeedback can be used for many different types of conditions that affect the muscles, including for a person diagnosed with a stroke, in cases of muscle sprains or strains, or in any other situation where there is muscle tension and/or pain that impacts the skeletal muscles.21,22

A biofeedback therapist engages in sessions with the patient to teach

the techniques. These are actually mental exercises that involve focus and relaxation to combat stress. It is a process of developing mental habits that eventually change how the body responds to certain situations, including

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those that are stressful. In fact, biofeedback is known for being a strategy that combats stress and its many negative health effects.23-25 Biofeedback has been shown to be helpful in managing a number of diseases and health conditions, including chronic pain, constipation, depression, seizures, incontinence, high blood pressure, motion sickness, and muscle spasms. While it is not a complete treatment in itself, biofeedback can help many individuals to overcome some of the more debilitating symptoms of disease and it can help them to cope with their conditions.23-25

Biofeedback has been shown through research to help with controlling

the pain of migraine headaches.25-27 Studies have proven that use of biofeedback, when combined with relaxation therapy, can be more successful in treating the pain and other negative symptoms associated with migraine headaches. Biofeedback is an effective prophylactic treatment, as well.25-27

A study by de Tommaso, et al. (2017) compared the use of a specific type of biofeedback among patients with migraines to biofeedback combined with an anticonvulsant drug, topiramate, and then topiramate alone.26 Subjects in the study underwent nociceptive blink reflex (NBR) biofeedback, in which a small amount of stimulation was applied to the area around the eye. The NBR is the reflex response of blinking in reaction to a painful stimulus. Subjects underwent the NBR and biofeedback, in which they monitored their reflex responses and performed exercises to relax and reduce the blinking response.26 The subjects who participated in the biofeedback sessions underwent three sessions per week for three months. Overall, NBR biofeedback was found to be as successful in reducing the frequency and disability of migraine and the results were comparable to those subjects who were given topiramate, which is sometimes used to prevent migraine headache pain.26

While not all individuals can necessarily go through this type of biofeedback and the time involved can be demanding, some people could significantly benefit from learning the relaxation procedures needed to reduce their reflex responses to pain. Reducing a person’s response to pain could then decrease the frequency and intensity of migraines in the long term, without

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using medication. The number of sessions a person needs for successful biofeedback varies between individuals.27 If someone is seeking treatment of severe migraines through biofeedback, more sessions may be needed in order to be successful in reducing some of the pain and disability. The number of sessions needed is individual, and may be more for some people with a severe condition. Most people, while undergoing regular biofeedback must continue to practice relaxation exercises while at home in between sessions.19,27

Relaxation is a very important component of biofeedback therapy.

Because many conditions that can be treated or better managed with biofeedback are stress related or are worsened with extreme stress, the affected patient must learn relaxation techniques that are part of biofeedback therapy.27,28 Many of the mental exercises performed during biofeedback involve relaxation of different areas to decrease the effects of stress. Additionally, the patient may learn specific breathing techniques that relax other parts of the body, as well. For example, one technique may involve diaphragmatic breathing to slow the heart rate, which also fosters overall relaxation.29

One of the greatest advantages of using biofeedback is the feeling of control that it gives to the patient. Symptoms of migraine that otherwise seem so out of control, such as pain or nausea, can be better regulated through these techniques. In addition to assisting with relaxation training, biofeedback techniques help to improve the resilience of patients to manage acute stress, and negative emotional and mental stimuli in their environment.27 Biofeedback techniques are developed to help promote a person’s self-confidence and feelings of success.29

Massage Therapy

More people are turning to alternative therapies such as massage for

help with controlling pain and stress. Massage is the process of manipulating the soft tissues through various techniques and movements. It is meant to support health and to improve the overall well-being of the patient.30,31 Massage therapy can also be used as a treatment of various health conditions

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and illnesses, including conditions that cause chronic pain such as arthritis or fibromyalgia, and has been shown to decrease muscle tension, improve blood flow, enhance sleep, increase lymph flow, improve relaxation, increase range of motion, and relieve some psychological illnesses, including anxiety and depression.32

Some of the available research has shown that massage may increase the availability of neurohormones.33 Neurohormones are created by the neurons; examples include vasopressin (antidiuretic hormone) and norepinephrine. Dopamine is another type of neurohormone that can be impacted by massage, and has an effect on various body systems, including mood regulation, movements, and sensations of pain.33 Decreased levels of dopamine could lead to increased pain, which may cause allodynia as well as symptoms similar to depression. Massage may also increase the availability of serotonin, which, as discussed, regulates behavior and mood and its levels are adjusted by some types of antidepressants.33

Researchers that studied the effect of activating neurotransmitters (serotonin and dopamine) showed that “an average increase of 28% was noted for serotonin and an average increase of 31% was noted for dopamine” and that these studies combined indicated there were “stress-alleviating effects (decreased cortisol) and the activating effects (increased serotonin and dopamine) of massage therapy on a variety of medical conditions and stressful experiences.”33 By increasing serotonin levels, the effects of massage are similar to those of taking an antidepressant medication, in which the patient may also find relief from migraine pain. In one study, Kim, et al. (2016), a 15-minute and 25-minute scalp massage for 10 weeks compared to a control group where scalp massage was not performed showed no significant difference in the time interval and interactions between groups for epinephrine, but significant differences occurred in the “time interval and interactions between groups for norepinephrine and cortisol.”34

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Types of Massage Therapy

Massage therapy has been utilized in various forms throughout history,

with evidence of the practice dating back thousands of years. The current and predicted use of massage therapy in the U.S. adult population is an estimated 56.3%, in which massage was used for wellness or disease prevention.35 By 2024, the American Massage Therapy Association (2017) has estimated >350,000 massage therapists will be providing services, and the U.S. Department of Labor (2015) predicts a 22% potential growth for massage therapists. Health promotion and education is currently included in the definition of massage therapy: “Massage therapy consists of the application of massage and non-hands-on components including health promotion and education messages for self-care and health maintenance…”35

Most types of massage take place on a table or a chair, with a patient

positioned to receive the therapy and with the massage therapist working over the patient.36 Other accessories, such as a pillow or neck roll may be used to support the patient’s head. The massage therapist often uses lotion or oil as a lubricant when touching the patient’s skin.36

The actual type of massage therapy performed can vary widely, and it

depends on the skill and training of the massage therapist, the patient’s reason for seeking massage therapy, and the tools available.36 Some of the more commonly used massage therapy techniques include Swedish massage, which is often considered a classic type, trigger point massage, which locates certain areas of pain or sensitivity in the muscles, sports massage, which is typically applied to athletes to keep them healthy and to prevent injury, myofascial release, which is a type of massage that focuses on the connective tissues, and deep tissue massage, which uses deep pressure to reach the underlying muscles and the fascia.36

Although the pain treated by massage is mostly considered to be related

to the musculoskeletal system, massage therapy can also be helpful in the treatment of other types of painful conditions, including migraine headaches. Many migraine sufferers feel an improvement in their symptoms after

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exposure to cool or cold temperatures with massage, rather than heat. Moore, et al. (2017) evaluated the use of manual therapies such as therapeutic massage for the treatment of migraines.37 The study used the term manual therapy to describe not only therapeutic massage, but also other techniques that may be employed as part of physical therapy or chiropractic, including spinal manipulation, and joint and spine mobilization.37

A review of the patient populations with migraine headaches showed that massage therapy use among patients with migraines ranged from 10% to 56%.37 Among subject responses, an average of 60% reported that they used massage therapy for pain relief, while an average of 43.8% sought manual therapy because of concerns regarding the safety or side effects of conventional headache therapies; and, finally, patient self-reports of headache relief after undergoing massage therapy ranged from 33% to 64.5%.37

Study findings suggest that massage therapy is sought after by people with migraines. Although the available research contains some limitations, the use of manual or massage therapy as a form of treatment or prevention of migraine is considered in general to show promise. There is other evidence that supports massage therapy as an effective treatment for migraine headache, but the research is limited.

Cognitive Behavioral Therapy

Long used as a treatment for mental health issues, CBT involves a

process of changing a patient’s thought and behavior patterns to ultimately change the way the patient feels. The concept of CBT has been used among patients diagnosed with mental illnesses that can affect their emotional states. CBT is used as a form of treatment for such diagnoses as anxiety or depression, as well as substance use disorder, insomnia, eating disorders, or post-traumatic stress disorder (PTSD).38-40

Cognitive behavioral therapy can be employed as part of treatment for migraines, since frequent migraine is often associated with other kinds of

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mental illness.38-40 Migraine headaches commonly have comorbidities, such as insomnia, depression, fatigue, anxiety, and stress-related issues. This type of therapy could be specifically beneficial in the treatment of some of the underlying psychosocial disorders that often accompany migraines. The concept of CBT is based on the idea that a person can have automatic thoughts that enter the mind that may be positive or negative.38-40 The thoughts may or may not be true, intrusive, and not necessarily under the control of the individual.

Recently, CBT research and intervention for co-occurring conditions, such as anxiety and pain, are being encouraged in terms of the efficiency of CBT to treat co-occurring conditions.41-43 Often, if a person is under stress or is dealing with mental health issues, automatic negative thoughts may be more likely to occur. These thoughts, in turn, then affect the person’s emotions and potentially the person’s behavior.41-43 Cognitive behavioral therapy recognizes that automatic thoughts happen and it teaches the patient to identify these thoughts, to understand that they may not be true, and to make appropriate behavioral responses to stressful situations.

Through CBT, a person learns that intrusive or automatic thoughts need not be accepted right away; instead, thoughts may be recognized as subject to change and under control of the individual.42,43 The patient can learn to modify responses to the environment so that the inclination to act out in a manner inappropriate to the situation does not occur; and, choose to change emotional and behavioral responses, replacing them with more realistic and true thoughts.42,43

Evidence has shown that CBT can be helpful in managing migraine

headaches as a stand-alone therapy in youth and adults, as well as adjunctive therapy to pharmacotherapy.44,45 The process is thought to work when psychological stressors such as anxiety, which can be triggers for migraine attacks. Further, once a person is aware that migraines tend to develop after being exposed to certain situations, succumbing to a downward spiral of negative thought patterns associated with these situations can be challenged.44,45

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The mere anticipation of a migraine may lead to further stress and problems with sleeping. For example, a patient might already know that developing a migraine coincides with trouble sleeping. After several nights of poor sleep, the patient may start to have automatic negative thoughts about experiencing a migraine headache and could start to feel helpless to prevent it.44,45 Cognitive behavioral therapy could help the patient to not only work through negative thought patterns, but it could also work as a form of treatment for insomnia, which is a migraine trigger.

Cognitive behavioral therapy is thought to be successful in the prevention and treatment of migraine because proponents of CBT view the issue of a migraine as being amenable to CBT.44,45 While people with migraines certainly suffer from physical symptoms of pain and nausea, when viewed as a psychosocial disorder, migraine can be treated using psychological therapies.42,44,45

The use of CBT among patients with migraine headaches has been reviewed. One review of the literature, Raggi, et al. (2018), involved 2110 participants whereby the use of CBT revealed a reduction of headache frequency higher than 35%, which was reported by the study participants regardless of the therapy approach used.46 The authors noted that “valuable impact disability and quality of life was observed, as well as improvements in depression, anxiety, self-efficacy, and intake of medications.”46 Cognitive behavioral therapy combined with medical treatment coincided with patient compliance with treatment overall.

When contrasting CBT with relaxation strategies, patients may be able to control their headache pain as compared to utilizing relaxation strategies alone without CBT. Cognitive behavioral therapy has been compared with relaxation combined with medication and there were mixed reports on whether CBT was more effective in improving headache pain and reducing the number of headache days. One meta-analysis, Lee, et al. (2019), reported that “psychological treatments for primary headache disorder are effective for headache itself not only for addressing the concomitant psychological distress.”47 Headache frequency and index showed significant improvements

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for treatment groups as compared to the control groups in the studies reviewed.

In some studies the relaxation training had better treatment outcomes than the control group while the emotional treatment group showed no improvement. No significant differences between groups in terms of frequency and disability were seen in migraineurs being evaluated, and the authors determined that the lack of efficacy for migraine pain “was due to the brevity of the intervention, as migraine treatment is more challenging and may require more comprehensive relaxation training.”47 Relaxation training was generally found to be more effective for pain severity for migraines. Based on the findings of this metaanalysis, patients who continue to struggle with migraines and stress may consider CBT combined with relaxation techniques for improved treatment outcomes.

Nutrition and Supplementation: Vitamin B2

Also called riboflavin, vitamin B2 is one of the B complex vitamins found

in food and is used as a dietary supplement.48 Vitamin B2 is a water-soluble vitamin, not stored by the body, and B2 may play a role in the treatment of migraine headaches.49

When more vitamin B2 is consumed than what the body can use at one time, it is not absorbed, but is instead excreted in the urine. Vitamin B2 is thought to have antioxidant properties that protect the body against free radicals.48 It is also an important component of two different coenzymes that are responsible for cell growth and development, energy production, and fat metabolism.48

Vitamin B2 is found in a variety of foods, including milk, eggs, yogurt,

organ meats, whole grains, and certain green vegetables.48 There are also products on the market such as cereal or breads that are fortified with vitamin B2. Vitamin B2 deficiency is a rare condition in developed countries because of B-vitamin fortification of many foods and because of dietary variety.48,49

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There are a number of people who develop riboflavin deficiency due to genetic conditions that affect their ability to absorb and utilize the vitamins, so that even in locations where there is a variety of food available that would contain vitamin B2, a deficiency could still develop. If a person develops a riboflavin deficiency, signs and symptoms may develop that include swelling around the mouth or in the throat, angular stomatitis or cheilitis, and redness and swelling in the eyes.49-51

Although most people get enough vitamin B2 through their diet if they eat a variety of foods, extra riboflavin may be needed in cases of illness or when deficiency is present. In particular, if an individual wants to take vitamin B2 to control migraine headaches, oral supplements can provide more of the vitamin. It can be taken as a supplement either alone or as part of a B-complex formulation that contains several other B vitamins as well.50,51 When taken as an individual supplement, the recommended daily allowance of vitamin B2 for adults is 100 mg orally once or twice daily.52 The dose is higher for women who are pregnant or breastfeeding and recommendations are lower for children.52

For migraine prevention, there is limited evidence of efficacy and

variable results in the literature, however studies have shown that for children ≥8 years and for adolescents, doses of 200 mg to 400 mg orally once daily was suggested as prophylaxis for migraine and migraine-type headaches. For adults, the recommended B2 dosing for migraine prophylaxis is off-label at 400 mg once daily.52

Some research has shown that taking supplements of vitamin B2 may

help to reduce the frequency and intensity of migraine headaches. Migraines can be more likely to develop when there is an abnormality within the cell mitochondria.53 Mitochondrial disease describes a collection of inherited conditions in which the cell mitochondria do not perform adequately and the cell loses energy. Eventually, the cell is so damaged that it slows down and ultimately dies. When this occurs over a larger area or within a particular body system, the affected person may experience the negative effects of loss of cell energy and disrupted metabolism, as well as difficulties in normal growth and

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function of the affected area. The condition can be difficult to diagnose because symptoms are diffuse and may be related to other health problems.53

Affected persons may have developmental delay, seizures, poor reflexes, weakness, fatigue, and short stature, in addition to specific abnormalities associated with particular organ systems. For example, if an individual experiences mitochondrial disease related to the gastrointestinal (GI) system, cramping, problems with digestion, irritable bowel syndrome, constipation, or reflux are more likely to occur. Many people with mitochondrial disease experience headaches, which may be actual migraines or other forms of head and neck pain, and they are more likely to develop migraines than people who do not have mitochondrial disease.53

Patients with mitochondrial disease may be more likely to develop migraines, with added nausea, vomiting, photophobia, and other commonly associated symptoms as well. Some of the causes of the migraine as related to mitochondrial disease could be a problem with energy metabolism.51 Alternatively, the mitochondrial disease may also increase the exposure to triggers that can set off a migraine. For instance, a person with mitochondrial dysfunction may have difficulties sleeping and may suffer from insomnia, despite feeling fatigued and weakened. Chronic insomnia may then act as a trigger that initiates more migraines overall. Part of treatment in this case would not only involve controlling the painful symptoms of the migraine, but also relieving those factors that contribute to migraine triggers, if they are related to mitochondrial dysfunction.53

Vitamin B2 supplementation may be used to treat mitochondrial

disease, as reduced levels of riboflavin have been shown to affect proteins and energy metabolism within cells.53 The coenzyme forms of vitamin B2, known as flavin mononucleotide and flavin adenine dinucleotide, are necessary for regulating mitochondrial pathways, and play a key role in the metabolism of amino acids and fatty acids. As a result, riboflavin is an important part of energy production and metabolism as related to the mitochondria.53

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Marashly, et al. (2017) stated that riboflavin has neuroprotective effects and can guard against certain neurological disorders, including Parkinson’s disease and migraines.54 As discussed, vitamin B2 has antioxidant properties, and brain tissue has been shown to be more likely to suffer from oxidative stress when compared to some other body systems. Oxidative stress is thought to be related to an increased risk of neurodegenerative disease development as well as development of migraine headaches. This review described studies that showed that patients with migraine headaches were more likely to exhibit oxidative stress and have decreased levels of total oxidants when compared to those without migraines. Migraine sufferers are also more likely to experience neurogenic inflammation, resulting in an increased release of inflammatory mediators.54 As described, mitochondrial disease is also commonly noted among persons with migraine headaches as well as several other types of neurodegenerative diseases. Because mitochondria play an important role in inflammatory signaling, outcomes such as migraines may be another consequence of mitochondrial dysfunction.

Supplementation with riboflavin can improve circumstances in which oxidative stress is present.55 Oxidative stress occurs when there is an increase in reactive oxygen species (molecules that contain oxygen and that react to other molecules), causing damage to DNA, RNA, or proteins. Oxidative stress has been associated with the development of a number of illnesses, including cancer and diabetes.55,56

The antioxidant properties of vitamin B2 impact the effects of glutathione, which is also an antioxidant that controls levels of reactive oxygen species. Vitamin B2 administration is thought to impact a number of metabolic and systemic processes to not only control oxidative stress, but also to improve neurogenic inflammation, correct mitochondrial dysfunction, reduce glutamate toxicity, and support homocysteine metabolism.57 When used as part of treatment for migraine, vitamin B2 may be administered prophylactically for the prevention of headaches. When given prior to migraines, there is evidence that riboflavin may reduce the overall frequency as well as the intensity of migraine headaches in adults and children.

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Systematic Review and Case Study: Patient’s Perceptions of CAM

The following systematic review and case study has been obtained

through a PubMed search that considered patient perceptions of CAM for pain control.58

The authors of the systematic review considered patients' perceived needs of physiotherapy, chiropractic therapy and CAM for low back pain (LBP).58 Between January 1990 and June 2016, a comprehensive search was performed by a multidisciplinary team that reviewed patient input. Data was broadly grouped along the lines of health discipline. For example, the term “physiotherapy” was used to capture general interventions, such as “therapeutic exercise, general exercise or physical activity guided or prescribed by a physiotherapist, manual therapies, education, or other physical therapies or aids commonly applied or used by a physiotherapist.”58 Similarly, the term “chiropractic therapy” referenced general interventions such as “spinal and joint manipulation delivered by chiropractors.”58 CAM was referenced to cover “a variety of healing resources including acupuncture, homoeopathy, osteopathy, massage therapy, reflexology, heat therapy, naturopathy, traditional Chinese Medicine and Reiki.”58

While potential for overlap existed between the varied treatment modalities included in this review, the results of the search strategies were “reviewed independently and in duplicate for relevance.”58 The authors described their review as including all study designs in order to retain relevant data and inclusion criteria, such as the age of study subjects (>18 years), reporting on patients' perspective of treatment needs for LBP, and LBP with or without leg pain, excluding fractures, malignancy, infection and inflammatory spinal disorders.58

Patients' perceived needs were explained by the authors as the patients'

“capacity to benefit from services, including their expectations of, satisfaction with and preferences for various services.”58 There were 2202 articles reviewed, and 44 studies explored “LBP patients' perceived needs of physiotherapy, chiropractic therapy and CAM.”58 The majority of studies were

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conducted in the United Kingdom, and the remainder were from North America, Asia, Middle East and other European and Australasia.58

There were nine studies that focused on patients' willingness to try CAM. The results were mixed according to the authors:58 ● 4.4% of patients reported that they relied primarily on CAM. ● Patients were willing to try CAM, mostly acupuncture, massage therapy,

spinal manipulation and local heat therapy, according to four studies. ● In patients reporting chronic non-specific LBP (from an integrated health

system), one-third preferred acupuncture. However, those with chronic LBP preferred medical treatment to CAM and primary care patients viewed CAM as experimental or “a desperate measure when their pain became intolerable or when medical doctors were unavailable for consultation.”58

● Higher out-of-pocket costs for acupuncture or low frequency infrared radiation treatment, and female gender, corresponded with less willingness by patients to include such CAM therapies.

Patients reported that CAM was able to address physical impairments

causing LBP, such as muscle relaxation, nerve stimulation, join and pain relief through manipulation techniques, and they reported seeking CAM therapies for improved physical fitness and function. Heat therapy and massage therapy were reportedly found to be effective by patients, and CAM practitioners were perceived as more empathic and understanding with better diagnostic skills compared to medical clinicians.58

Patients reported that CAM practitioners were generally provided longer consultations and time for a thorough examination, diagnosis and prognosis. Psychological benefits of CAM were raised, such as patient reassurance, and a more positive approach that reduced anxiety and fear.58

Patient’s concerns of CAM focused on specific treatments, such as

acupuncture and a fear of needling and procedural pain. Patients' apprehensions with adverse psychological effects of spinal manipulation were raised, including fear and embarrassment. Some patients “believed that CAM

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therapies provided limited and transient effects, which were perceived to stand outside of the biomedical model.”58 Also, some patients questioned the legitimacy of CAM and raised a fear of being “ripped off.”58

Discussion

The authors of this large literature review on CAM in the setting of lower back pain identified relevant studies focused on patients' perceived needs for CAM therapy and other treatment modalities aimed at alleviating low back pain. The authors raised patients’ perceived lack of information regarding the pathogenesis of low back pain and best-practice best practice treatment with a focus on active rehabilitation and patient education.58

Chiropractic therapy was discussed relative to patient perceptions and preference of its use for low back pain. While some patients reported that chiropractic therapy was effective there were others who felt it only provided temporary relief and caused muscle pain. Chiropractic therapy was reported to be widely used, mostly by males, and coincided with patient preference for fast and non-pharmacological pain relief of low back pain.58

Patients in general reported a belief that CAM therapies provided pain

relief and sought CAM for improved physical fitness. They viewed CAM clinicians to be “more understanding, empathetic and provide more time for consultations than medical practitioners and more capable of providing a diagnosis.”58 The authors emphasized the importance of pain relief for low back pain that involved a holistic approach for most people and that many patients expressed dissatisfaction with conventional treatment of low back pain, including the poor communication and limited therapy offered by conventional healthcare clinicians. While most people preferred the CAM approach to low back pain treatment there were others who stated that CAM offered temporary benefit and questioned whether it was useful.58

In general, the authors highlighted the need for patient education for

the treatment of low back pain. While CAM was used extensively by patients seeking immediate pain relief, the authors indicated that “the current evidence

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supporting the use of these therapies is limited.”58 More studies were recommended to improve clinician knowledge of CAM treatment and the benefits and risks of CAM for the treatment of low back pain.58

Case Study: Migraine Pain and CAM Treatment

The authors of this PubMed case study reported on a 66-year-old

Caucasian female who reported debilitating migraine pain since she was nine years of age.59 She reported symptoms of “severe headache, pain, and vomiting, with unknown trigger factors.”59 At the age of 48, she was in a motor vehicle accident (rear-ended) and suffered severe neck, jaw, teeth and bilateral temporo-mandibular joint injury with worse headache pain from that time on. Prior to the car accident, the patient was a self-employed life coach/counselor and maintained a program of physical activity that included walking in addition to light housework and gardening.59

The patient had initially sought a form of CAM therapy that involved a

form of therapeutic touch and had noticed a reduction of migraine symptoms as well as improved sleep. Her prior medical treatment involved multiple medical providers, neurologists, and chiropractors who diagnosed the patient with “migraine, degenerative cervical vertebrae, intervertebral disc changes, and right-sided thoracic outlet syndrome (TOS) causing numbness and ache in her right arm and thumb.”59 Prior treatments involved: “frequent chiropractic and massage therapies, mostly focused on her head and neck areas ... various narcotic and muscle-relaxant medications, which she did not find effective and she disliked their central nervous system (CNS) depressing effects.”59 Ibuprofen 200 mg tablets, >10 tablets per day (in divided doses) were taken by the patient in addition to prescribed medical treatment. She would also apply ice packs to the forehead and neck, and required a quiet, dark space to rest until symptoms resolved. She reported suffering severe migraine episodes, 3 to 4 times every week, had frequent disrupted nighttime sleep and complained of feeling right arm/thumb numbness. She felt fatigued during the day, and limited her activities because she felt physically unwell.59

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The patient’s migraine pain started as pain at the right mid-back area that extended to the neck, head and right eye. The right arm and thumb pain would increase during these episodes. The patient’s neck and bilateral shoulder range of motion appeared to be within normal limits without increased pain or discomfort. She was asked to identify “two major symptoms (physical or mental) of most concern, daily activity limitations (physical, social or mental), and general feeling of well-being, numerically rated on Likert-type scales.”59 In addition, she was asked to describe the amount of medication used and her preference to reduce medication to control pain symptoms. The patient rated her migraine pain and chronic neck pain as 6/6, and activities that were reduced while having pain included “housework, gardening, walking her dog, driving her car, and attending social activities.”59 During most of the week she had to lie down and apply ice packs to her neck and head. She required ongoing use of ibuprofen and described the need to lower medication use as “very important.”59

The patient initially received weekly to bi-weekly therapy sessions and

reported feeling improved. The author stated that therapeutic touch, such as the Bowen technique involves a holistic approach to address the patient’s condition. After each session, she was recommended to 1) maintain fluid hydration and metabolic waste elimination through adequate hydration, 2) daily walking, 3) avoid sitting for >30 minutes (to reduce postural triggering of migraine and neck pain), and to avoid “other bodywork within four to five days before/after a session.”59

The author highlighted the use of an outcome measure tool to evaluate

the patient’s response to therapy. The endpoint measure was the reduction of migraine pain. Following an estimated four months, the client reported resolution of migraine and neck pain. She also reported being migrain free after 10 months of follow up.59

Discussion

Migraine triggers, pathology, and symptoms vary widely, as do clients’ responses to therapeutic touch techniques, such as used in this patient’s case.

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The author described how the clinician utilized a subjective screening tool to determine progress following therapeutic procedures. The patient presented with multiple other body symptoms (right arm and thumb numbness and ache, respiratory infection, etc.), which complicated the clinician’s evaluation of migraine and chronic neck pain reduction.59

The patient described this CAM approach as “deeply relaxing and “life-

changing,” enabling her to live migraine and neck pain free and engage in previously limited daily and recreational activities.59 She was particularly pleased to not be dependent on Ibuprofen anymore.”59 The author emphasized the multifaceted, complex factors and inflammatory condition associated with migraine pain. Migraine pain is not always a result of musculoskeletal or cervical pathology. The research on CAM techniques, such as touch therapy without pharmacological intervention is limited. More research is needed on CAM treatment of migraine pain to determine the benefit of CAM interventions to reduce migraine symptoms.59

Summary

The first-line treatment for chronic or frequent migraine headaches is

the use of medications to manage the pain; however, not all patients tolerate or respond to pharmacological treatment plans. A patient may not tolerate the side effects of pharmacological treatments; or, a patient may want to use pain medications but in a lesser amount. Other patients may have contraindications for pain medications. In these cases, patients may look for alternative, non-pharmacological treatment options.

Certain non-traditional approaches offer alternatives to a stand-alone pharmacological approach in treatment of migraine headaches. Guidelines from various medical institutions and societies have begun to include CAM strategies, such as acupuncture, biofeedback, or CBT, as adjuncts or alternatives to pharmacological approaches. Acupuncture is reportedly more effective as a therapy to prevent migraines, rather than resolving the pain after it has developed. Biofeedback may be used to treat migraine headaches, and there is more than one type of biofeedback technique, e.g., thermal

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biofeedback, neurofeedback and electromyography biofeedback. Massage therapy may increase the availability of neurohormones, which may help reduce a patient’s pain and improve a patient’s mood. Cognitive behavioral therapy can be employed as part of treatment for migraines, since frequent migraine is often associated with other kinds of mental illness, such as depression, fatigue, anxiety, and stress-related issues. Dietary supplements, such as vitamin B2, may play a role in the treatment of migraine headaches.

Other forms of CAM may be sought by patients seeking pain relief, such

as touch therapy discussed in the case study. Clinicians need to be informed about the growing public interest in CAM and patient perceptions of CAM treatment for chronic pain conditions, specifically as it relates to migraine headache.

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Self-Assessment of Knowledge Post-Test: Please take time to help NurseCe4Less.com course planners evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the article, and providing feedback in the online course evaluation. Completing the study questions is optional and is NOT a course requirement. 1. Acupuncture is primarily performed to produce

a. an analgesic effect. b. a sedate state of mind. c. muscle relaxation. d. a meditative state of mind.

2. During __________, the patient is often monitored with an

electroencephalogram (EEG).

a. acupuncture b. electromyography biofeedback c. thermal biofeedback d. neurofeedback

3. Vitamin B2 may help in the treatment of migraine headaches

because of its potential effectiveness in treating

a. muscular dystrophy. b. mitochondrial disease. c. serotonin syndrome. d. All of the above

4. True or False: Acupuncture is best used to resolve migraine pain

after it has developed, and not as a preventive treatment.

a. True b. False

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5. Peripheral nerves are activated to provide analgesia during which procedure?

a. Neurofeedback therapy b. Vitamin B2 administration c. Massage therapy d. Acupuncture

6. Massage therapy may increase

a. the availability of neurohormones. b. the production of T cells. c. ATP synthesis. d. neural pathways that affect the brain and spinal cord.

7. Complementary and alternative (CAM) treatments are useful in

patients who

a. cannot tolerate the side effects of pharmacological treatments. b. want to decrease the amount of medications they take. c. have contraindications for migraine pain medications. d. All of the above

8. True or False: Patients who underwent massage therapy for

migraines preferred being exposed to cold temperatures rather than warm temperatures.

a. True b. False

9. Cognitive behavioral therapy (CBT) states that negative thoughts

a. should be addressed in group therapy. b. may or may not be true. c. are under the person’s control. d. are a reality.

10. In traditional chinese acupuncture, what are the pathways of

life force energy called?

a. Qi b. Channels c. Meridians d. Circlets

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11. One of the greatest advantages of using biofeedback is

a. the proven legitimacy of this treatment. b. increases the availability of neurohormones. c. increases cortisol. d. the feeling of control that it gives to the patient.

12. True or False: Relaxation training may be more effective for

pain severity associated with migraines.

a. True b. False

13. Vitamin B2 is a B complex vitamin that is

a. absorbed and stored by the body for future use. b. metabolized by the liver. c. known to cause migraine headaches. d. water-soluble.

14. Vitamin B2 is thought to have _____________ properties that

protect the body against free radicals.

a. inflammatory b. oxidative c. antioxidant d. trigger

15. Vitamin B2 may provide

a. relief from inflammation during a migraine headache. b. prophylaxis for migraine and migraine-type headaches. c. a type of cure for migraine headaches. d. relief for cramping associated with mitochondrial disease.

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