An Integrative Approach to Migraine
Throughout my time at the University of Colorado Headache Clinic, I have always been interested in an integrative approach to migraine care. I frequently offer patients recommendations on nutraceutical supplements, nutrition and lifestyle interventions in addition to prescribing the latest medications and performing procedures. At the University we often see patients with chronic migraine who have been refractory to dozens of medications and with most of these patients, I tend to see missing links in the lifestyle realm that are keeping them in this chronic pain state. Let’s dive into my integrative approach to migraine treatment!
Nutraceuticals and Supplements
I’m a big fan of supplementing when it may be needed and there are some good studies and data on a handful of supplements that may be helpful with chronic migraine:
Magnesium: Probably my first choice and top supplement due to the lack of magnesium rich foods in many patients diets and its wonderful health benefits beyond migraine. Even with perfect diets our food supply contains less magnesium than it once did due to depletion of the quality of our topsoil. I also see patients who struggle with constipation, muscle spasm, mood disorders, and painful menstrual cycles, and magnesium can be beneficial for all of these. Magnesium is generally safe in those who have normal kidney function. I tend to recommend magnesium glycinate as my preferred form of magnesium due to its high absorption rate but magnesium citrate may be good for some with chronic constipation. Start low and go slow, you’ll know if you are taking too much because you will experience GI upset and loose stools. I generally have patients start around 200mg nightly and increase from there with max dose being about 1000mg or to bowel tolerability. Red blood cell magnesium levels can be drawn to assess levels.
Vitamin B2 (riboflavin): The B vitamins in general may be good for migraine but we have the best evidence for Vitamin B2. Riboflavin or Vitamin B2 plays a role in cellular energy production at the level of the mitochondria (back to middle school biology – the powerhouse of the cell!). It is well tolerated and recommended at doses of 200-400mg daily. Vitamin B12 may also be helpful and can also see improvements in neuropathy symptoms. I will often check aB12 level and if low will recommend a B complex.
Coenzyme Q10: Similar to the B vitamins, CoQ10 is needed for cellular or mitochondrial energy. Multiple studies have shown that supplementing with CoQ10 can help reduce the frequency of migraine attacks, aiming for a dose of 100-200mg daily.
Melatonin: For those with sleep troubles, I will sometimes recommend melatonin. It has also been shown that those with chronic migraine produce lower levels of melatonin and in recent years melatonin has been found to be a potent antioxidant. Improved sleep, decreased inflammation and its regulation of neurotransmitters may make melatonin an effective migraine preventive for some. Strictly speaking about sleep, melatonin is not my go-to supplement and I do not recommend use of melatonin in children, especially for long periods (read more about my favorite sleep supplements HERE).
Botanicals and herbs: Feverfew and Butterbur have the most evidence for their use in migraine prevention. There are some smaller studies looking also at curcumin (turmeric) and boswellia serrata. Of these, I recommend curcumin the most because it has many anti-inflammatory benefits including locally in the gut which may help with widespread inflammation and migraine (more on this below). Caution: butterbur has known liver toxicity issues due to the plant alkaloids so extreme caution should be used.
Other nutrients to consider: Omega 3 fatty acids, found in fatty fish and nuts or fish oil supplements have anti-inflammatory effects and a recent meta-analysis was published looking at patients with migraine who consumed higher levels of Omega 3s compared to Omega 6s (generally more inflammatory oils) had a reduction in frequency and severity of migraine. Vitamin D deficiency or insufficiency has been linked to a higher prevalence of migraine and vitamin D supplementation may reduce the frequency of attacks. I routinely test vitamin D levels and am always shocked to see how low many patients are. I have never seen an optimal vitamin D level (50-100ng/dl) in someone who is not actively supplementing, even here in sunny Colorado. As always, test don’t guess.
The Gut and Migraine
As we learn more about the gut microbiome and its relation to chronic disease, there is no doubt in my mind that it plays a role in migraine and the chronification of migraine. Multiple mechanisms may be at play but two major things may contribute: dysbiosis (imbalance) and increased intestinal permeability and these things often go hand in hand. Thanks to our Standard American Diet (SAD) and our exposure to chronic stress, toxins and a multitude of other factors our gut microbiome is losing diversity and we are seeing more evidence of increased intestinal permeability or “leaky gut” which drives systemic inflammation. Migraine is an inflammatory condition and if the intestinal barrier is compromised, inflammatory particles can leak out into circulation and may be a trigger for migraine attacks. Along these lines, if there is an imbalance of gut microbes and a higher abundance of inflammatory strains (thanks to the SAD diet) and not enough of the healthy and anti-inflammatory strains this dysbiosis can directly impair our intestinal barrier.
Unfortunately it is not as simple as taking a probiotic, though that may be a start. Cultivating a healthy gut microbiome starts with diet, incorporating prebiotic and probiotic foods and feeding our microbial friends the things they need to thrive like fiber and phytonutrients (think a diverse array of plants) and minimizing processed foods. We also need to flip into our parasympathetic nervous state for optimal digestion and absorption of nutrients so practicing mindfulness particularly around eating is helpful in allowing for good gut and overall health. For more on gut microbiome health: see my past blogs on: The Gut Microbiome, Increased intestinal permeability, The 5R Approach to Gut Health, Prebiotics and Probiotics, and Mindful Eating.
Lifestyle Pillars of Migraine
I like to think of the lifestyle pillars as being foundational for all chronic disease and longevity and this includes migraine. There needs to be a focus on nutrition, sleep, movement, stress management and social connection. Sleep is a big one for migraine because inadequate sleep promotes inflammation and doesn’t allow our brains natural cleaning mechanism to occur. I’ve written about more on these pillars in my recent blog on Longevity. There have been great medication discoveries in recent years that have been life changing for many who have migraine but if the lifestyle pillars are not addressed, even the best medications and procedures will not work optimally. Migraine takes a truly integrative approach to keep things under control.
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Also! Join us in Denver for the Miles for Migraine 5k and 2 mile walk fundraiser to raise awareness for migraine coming up on July 29! I will be joining the fundraising and doing a virtual 5k from Michigan but the in person event in Denver is FREE and a wonderful community focused morning!