Alternative Headache Treatments
Once patients have received an accurate diagnosis and been reassured that their attacks are not caused by a secondary or more serious pathology, clinicians and patients should work together to identify the most appropriate treatment plans. Although pharmacologic management presents many effective options, the therapy of most patients can be optimized with the addition of various nonpharmacologic approaches. This chapter looks at some of the newer, or alternative, approaches to managing headache. These approaches are summarized in the table below.
Alternative Headache Treatments |
TREATMENT |
EFFECTIVE/SAFE |
Feverfew
Butterbur root extract (Petadolex®)
Riboflavin
Magnesium
Botox®
Transcutaneous electrical nerve stimulation (TENS)
Cold application
Intraoral appliances
Acupuncture
Manipulative treatment
Physical therapy
Cognitive behavioral treatment
Biofeedback
Relaxation therapy
Nerve blocks
Homeopathy |
Yes/Yes
Yes/Yes
Yes/Yes
Yes/Yes
Possible/Yes
No/Yes
Possible/Yes
Possible/Guarded
Yes/Yes
No/Questionable
Possible/Not known
Yes/Yes
Yes/Yes
Yes/Yes
Possible/Some risks
No/Yes |
Patient Education
Patient education (see National Headache Foundation guideline on "Patient Education") is an essential component of any treatment plan. Migraine patients should be given a basic explanation of the physiologic etiology of headache. Printed materials are an effective way to educate patients about the role of genetic predisposition, as well as the relationship between headache and the central nervous system, the peripheral nervous system, and vascular and humeral mechanisms. Patients' knowing that their attacks are a real and treatable condition may enhance compliance with therapy and ultimately improve the chance for a successful treatment outcome.
Trigger factors (see table below) should be discussed; these may be different for each patient. Clinicians should work with patients to set realistic treatment expectations, with an emphasis on management, not cure, and should encourage patients to remain active partners in their treatment throughout its course.
Some Potential Triggers of Migraine Headache |
- Emotional stress
- Changes in behavior: missing meals, changes in sleep duration
- Environmental factors: light, noise, odors, allergens, barometric changes
- Foods and beverages: chocolate, cheese, cured meats, caffeine beverages, alcohol
- Chemicals: aspartame, monosodium glutamate, benzene, insecticides, nitrates
- Drugs
|
Herbal Remedies and Supplements
Herbal remedies remain very popular, in part because they are perceived to be natural and therefore safer than prescription drugs. This perception is often not accurate, as the Food and Drug Administration (FDA) does not regulate herbal and nutritional remedies. One herb that appears to be safe and possibly effective in the prevention of migraine headaches is feverfew. This herb has been subjected to double-blind trials and has an extensive safety record. A second herbal remedy, butterbur root extract (the only purified form of this extract is sold as Petadolex) has 2 published trials of safety and efficacy. Herbal remedies have the potential to interact with prescription drugs and should always be used under a physician's supervision. Specifically, feverfew can cause increased bleeding time and enhance the effect of aspirin and warfarin. Because of lack of regulation, patients should use only products manufactured by large and reputable companies.
Riboflavin (vitamin B2) has been studied at doses of 400 mg per day (divided), and although it can take several months to provide optimal efficacy, it may benefit some patients with migraine. There are no known significant adverse effects. Coenzyme Q10, another supplement, has been subjected to one open-label trial that suggested efficacy; the results were later confirmed in a double-blind trial using a 300 mg dose. Magnesium has been studied extensively, both for acute treatment intravenously (IV) and for preventive treatment. The IV acute studies suggest it may be effective for treating acute attacks of migraine. In oral doses of 400 to 600 mg per day, the results of 3 of the 4 double-blind studies were strongly positive. The negative study had a very high incidence of diarrhea, which suggests that the magnesium salt used in this study was poorly absorbed. Magnesium oxide and chelated magnesium tend to be better tolerated.
Botulinum Toxin Type A
Botulinum toxin type A (Botox® [Btt A]) was approved by the FDA in 1989 for the treatment of blepharospasm and strabismus. Widespread use of Btt A for the treatment of forehead wrinkles (approved by the FDA in 2002) led to the discovery of its efficacy in relieving headaches. Many anecdotal reports and several controlled trials confirm the efficacy of Btt A in preventing migraine headaches. The effect of a single Btt A treatment lasts an average of 3 months. The procedure takes 5 to 10 minutes and causes minimal discomfort. Approximately 10 to 20 sites are injected at each session. The dosage and the location of the sites to be injected remain subject to continuing study. In general, the number and the location of the injection sites depend on pain distribution and the presence of trigger points. Side effects from Btt A injections are very rare and mild.
Transcutaneous Electrical Nerve Stimulation (TENS)
The use of TENS has been reserved primarily for the treatment of body or extremity pains because of fear of potential epileptogenic effects of electric current running through the head. With proper placement of electrodes and the use of low-intensity currents, it appears to be safe to apply this technique to the head. However, there is little objective evidence about the efficacy of TENS. Considering the inconvenience and the limited efficacy, this treatment is not recommended.
Vagus Nerve Stimulation (VNS)
VNS is an approved procedure for the treatment of drug-refractory epilepsy. Several case reports and indirect evidence from epilepsy trials suggest that VNS may also be effective in the treatment of refractory migraines. That anticonvulsants are effective in the prevention of migraines suggests that VNS may also work in migraines. However, in the absence of a controlled trial, it is premature to recommend this treatment for migraine headaches.
Cold or Pressure Application
Cold or pressure application to the head has been shown to be an effective headache strategy. Application of vapocoolant spray (fluoromethane) has been demonstrated to decrease myofascial pain in tension-type headache. The use of cold gel packs is beneficial as a self-help technique.
Acupuncture
Although there is no consensus in the clinical literature to support the efficacy of acupuncture, studies have shown that some patients experience significant pain relief. A meta-analysis of 14 controlled trials of acupuncture indicates a strong trend in favor of acupuncture.
Intraoral Dental Appliances
Intraoral dental appliances have also been used to treat headache, but more definitive studies are needed. The patient should be made aware of the risks associated with intraoral splint therapy other than conventional full arch coverage stabilization devices.
Chiropractic, Osteopathic Medicine, and Physical Therapy
The value and cost-effectiveness of chiropractic, osteopathic medicine, and physical therapy in migraine have not been proven in clinical trials. Conflicting results and poor clinical trial design limit the ability to judge the effectiveness of manipulative treatments. Physical therapy, although limited in its study, has proven more effective than manipulative treatment in selected cases.
Cognitive Behavioral Therapy (CBT)
CBT is designed to help patients identify and change maladaptive behaviors that may be aggravating the headaches. CBT is usually combined with other behavioral therapies but has been shown to be effective on its own. The goals are to identify the maladaptive thoughts, develop an action plan to deal with the headache, and encourage long-term implementation of the techniques. CBT is discussed in detail in a separate guideline titled "Behavioral Interventions for Management of Primary Head Pain".
Psychiatric Therapy
Psychiatric therapy is not indicated, except in patients with coexisting psychiatric disorder.
Biofeedback
Biofeedback refers to the use of monitoring instruments to detect, amplify, and display internal physiologic processes, so the patient may learn to alter the process at will. Patients should be selected based on their motivation, as well as equipment availability. A meta-analysis has indicated that the benefit of biofeedback is similar to that of prophylactic therapy. Biofeedback may also serve as an excellent adjunct to pharmacologic therapy. Biofeedback is discussed in detail in a separate guideline titled "Behavioral Interventions for Management of Primary Head Pain."
Relaxation Training
Relaxation training is a biobehavioral approach that involves progressive muscle relaxation, breathing exercises, or imagery. A meta-analysis has suggested that relaxation is as effective as biofeedback. The treatment may be enhanced by combining relaxation and biofeedback and adding pharmacologic intervention where appropriate. Patients should be selected if they are motivated and likely to use the techniques. Relaxation training is discussed in detail in a separate guideline titled "Behavioral Interventions for Management of Primary Head Pain."
Hypnosis
Hypnosis may be an excellent tool in a small subgroups of patients who are willing to undergo the procedure and suitable for it.
Neural Blockade
Neural blockade--occipital, supraorbital, sphenopalatine ganglion, stellate ganglion, cervical facet, epidural, etc.--may serve a diagnostic or therapeutic role in headache patients. The specific role of neural blockade in migraine and tension-type headache may be more limited to occipital or supraorbital block in the acute stage when the pain is localized. The effect of this procedure may be only to change what is being perceived by the brain, however, and does not imply that the pain is generated from the structure injected. Trigger point injections to the muscles of mastication or the cervical muscles may also aid the therapeutic outcome.
Exercise
The benefits of exercise are generally accepted. Sleep may be improved with regular exercise, and that in turn helps headache. It is also suggested that routine exercise may enhance central pain inhibition. Although there are no specific studies showing a direct relationship between exercise and headache, developing an appropriate exercise regimen with the patient is encouraged.
Homeopathy
Homeopathy has not proven effective in controlled clinical trials. Even if safe, it may not provide any specific benefit beyond a placebo effect.