Migraine Headaches- A Functional Medicine Approach

IMG_0267Migraine is no small thing. It can be debilitating with severe, throbbing pain that can come with changes in vision, nausea, vomiting, eye tearing, light and sound sensitivity and sweating lasting hours or even days. Sometimes sufferers get a warning the headache is coming, called an aura. While it might not seem helpful to experience strange flashing lights, tingling, blind spots, or weakness, having auras can at least allow for the use of preventative medication to lessen the intensity or duration of the attack and call out sick to work. A prodrome is a really early warning sign that occurs one or two days ahead of the migraine and can be cravings or mood changes, changes in bowels, fatigue, thirst- really anything out of the ordinary. After the attack is a time called the post-drome and patients feel very tired, confused, irritable, dizzy or even giddy.

My dad would hole up in his room with the curtains drawn and the horse water bucket in hand for vomiting you could hear outside in the yard. I was only a child but I wish I or his doctors knew then what I know now. It’s not too late to help anyone reading this however, so let me share the Functional Medicine approach to migraine so you can see how it may differ from the care you have already received and give you some ideas of lifestyle changes and avenues of exploration you could investigate to make your life more about living and less about headaches.

The most helpful thing is to keep a headache log. This could be a calendar where you note the headache time of onset, intensity, duration and symptoms you felt. Also note anything you did prior to the first feeling you were getting a migraine. Did you go out for Chinese food, start a new medicine or activity? Any information could be helpful. Look for patterns.

There are many causes for migraine that include genetics, medications, changes in weather, trauma, neurotransmitter imbalances, nerve irritation, dental issues, hormones, food or food additive intolerances, chemical sensitivities, stress, strong stimuli like lights or smells or sleep problems. Before looking at the list below, you may require imaging tests, an electroencephalogram or other standard medical workup depending on your symptoms, to be sure we are really dealing with migraine. Any costs cited below are based on the wholesale cost of the test as of the time of this article.  We do not profit from lab testing and costs change whenever the lab alters the price. Some tests are covered by insurance and some are not.

Considering most of the familial (inherited) migraines fall into the calcium channelopathies (when the calcium channels in your cells don’t work as they should), we can start by looking at genetics. Even non-inherited migraines may depend on how these channels function. Everyone has a migraine threshold. The key is to figure out what is lowering yours. Most patients don’t have to do everything mentioned here to raise the threshold. There are usually just a few key things for each person. Finding them is the trick.

Genetics: If you have DNA data, there are several software programs that can be used for analysis. See my post on DNA testing analysis for more details. If you wanted to look at your own raw data, we focus on the calcium, sodium, magnesium channel genes: CACNA1A, ATP1A2, SCN1A and the MTHFR variants. The CBS gene codes the enzyme cystathionine beta-synthase used to let vitamin B6 convert homocysteine and serine to cystathionine then to cysteine. If this doesn’t function well, toxins can build up in the blood and can affect hydrogen sulfide production (used for signaling and neuron protection). This maybe one of the reasons migraine sufferers have higher CVA and cardiac death risk, among other issues. Check genes for nitric oxide (NO) production. Look at the genes for SOD, catalase, MDA. If you don’t have data, 23 & Me is a good place to go for $99 as most of the analysis services work with the files they generate. Other genes to look at include, MSL3P1, TRPM8, ASTN2, PRDM16, PHACTR1, LRP1, MTDH, MEF2D and CYP2C19. There are likely far more, but this is a general overview. Most of the genes that increase risks for migraine also confer a risk for heart and/or blood vessel health so looking at one problem, hits more than one disease.

Homocysteine: A blood test. Folks with MTHFR (methyltetrahydrofolate reductase) variants can have elevated levels. If this is the case, adding methylated forms of the B vitamins can drop these levels and assists many cellular functions. Goal level is 6-8 micromoles/liter. Lab normal is 4-15 umol/L.

Vitamin D levels: Goal level of 50-70 nanograms/milliliter would be ideal but most labs consider >20-30  ‘normal’. Proper levels help TH1 and TH2 (Type 1 vs. 2 T helper cells) balance. These cells govern cell controlled immunity and white blood cell protective responses.

IgG testing: A test for an immune reaction to things you eat and done with a few finger sticks or a regular blood draw with a needle. Elimination diets are free and great but can be hard to do correctly and take a long time to test everything. Blood spot IgG panels for $165 can let you see the reactivity of all the regular foods and spices you might not be able to figure out easily. I think it would have taken me a long time to figure out I had an IgG reaction to pumpkin and hemp seeds but, looking back on it, I do agree that I did not feel great after eating those, usually healthy, foods. IgG reactions can trigger the immune system, release inflammatory cytokines, weaken gut and blood brain barriers and thereby, lower threshold.

Nutrient levels: SpectraCell labs offers one of the best panels for nutrients at $190 (insured)/ $390 (uninsured) and less for Medicare patients with appropriate diagnosis. This would look at all the nutrient levels, antioxidants and B vitamins as well as the T-lymphocyte response to stimulation which speaks to that TH1 vs. TH2 balance. Correcting imbalances helps raise the threshold.

CRP/ESR: A test to rule out temporal arteritis- a serious inflammation of blood vessels in the head that requires immediate attention.

Phospholipase A2: Is a blood test. We check it as it leads to the development of inflammation through the production of prostaglandin and/or leukotriene elevations.

Foods to avoid: Remove all non-nutritive sweeteners except Stevia. Remove MSG. Caffeine triggers some people as do foods high in sulfites like wine, sauerkraut, dried fruit, bottled lemon juice etc.

Hydration: Half the body weight in ounces of clean, non-bottled water daily.

Mitochondrial evaluation & support: One could argue, all chronic disease is mitochondrial disease. An organic acids test would show you this and much more about how your cells function. $239 gives you a look at GI pathogens, mitochondrial function, assesses the efficiency of B and folate dependent enzymes, amino acid levels, protein digestion/absorption, detox markers and availability of amino acids for neurotransmitter synthesis. There are many ways to support mitochondria which is a whole different discussion for another article, but some of these things are listed in this one.

Rule out sleep apnea: If you snore or wake feeling unrested, you could have moments during the night where you stop breathing. This can be caused by blockage of your airway from tissue in and around your mouth, upper airway or nose. This requires a prescription or referral to a sleep specialist for an overnight test where your vital signs and brain waves are monitored while you sleep. Correcting this is key to your overall health. Untreated sleep apnea leads to a wide range of bad including high blood pressure, diabetes, cardiac arrest, lung problems and overall shortened life span.

Remove environmental triggers: Artificial scents in household detergents, soaps, personal care products. Consider a HEPA/VOC filter for at least the bedroom- two good brands are Air Doctor and Austin.

Supplementation: Testing is the best but even without it, two things are generally safe:

Magnesium malate: Most folks (>90%) are low, at least intracellularly. Adding the malate form is less likely to produce diarrhea and gives the malate over to support the mitochondria via the Krebs cycle.

CoQ10: Looking at 100mg as a minimum but migraine sufferers may need up to 400mg PO daily to reduce oxidative stress and support the mitochondria. Talk to your provider about the right dose for you.

Others: Fish oil has some literature support for migraine sufferers as does vitamin E (not as D-alpha forms but as mixed tocopherols). A good B complex with methylated forms (like B-Right for instance). B2 at 400mg/day decreased migraines frequency and use of abortives by 50% in research.

Hydrogen water: A new kid on the block- a selective antioxidant. Tablets dissolve in water and are ingested quickly or you can buy this is pouches in the grocery store where the energy drinks are kept. The selectivity means we don’t have to worry about the blunting of exercise based oxidative gains or in cases where it would be potentially contraindicated like during cancer treatment. I have not seen the research in migraine so this is a guess based on the need to reduce oxidative stress in some migraine patients. Hey scientists- put this on the to-do list.

Oxygen: Some studies support its use during an attack. It’s a try it and see kind of thing. I have patients that swear by it so, no harm really. You would have to try this out at a hospital or doctors office unless you have an oxygen bar in your neighborhood. Home use of oxygen will require a prescription.

Trigger points: Hard lumps of muscle that hurt if you push on them in your shoulders, neck and spine. These are the areas that feel so terrible but good when you get a massage. If you feel trigger points in head/neck region, addressing these with myofascial release, trigger point injections or even botox (as a last resort as this can impair mitochondria) can be helpful. You can use a tennis ball on the floor or a wall to push into the areas yourself and hold it there until the ball of muscle relaxes. Not a DIY project if the areas are in your neck as there are sensitive nerves, muscles and blood vessels that should not be pushed hard.

Hormone levels: Check all these and consider repletion if needed.

Vision Problems: Have an eye exam to rule out issues with vision, ocular pressures, visual field and eye motion.

Rule out Celiac disease: Transglutaminase and gliadin antibodies at the minimum should be tested to look at this question. Much more detailed tests exist for all the wheat proteins if needed. For free- try 3 months strictly gluten free and keep a headache log. If improved, could warrant more detailed testing or remaining gluten free.

Amino acids: If nitric oxide production was thought to be low, via gene testing or symptoms, and no contraindications of blood pressure medication use or blood thinners among other things, you could consider a trial of L-arginine/L-citrulline supplementation. This would increase GTP to cCMP leading to blood vessel relaxation and decreased platelet aggregation and monocyte adhesion. This is something that should be advised only in consultation with your provider as many factors go into the decision if you are a candidate for such a trial.

Heavy metal testing: We are all exposed and have detectible levels. The key is, how much are you storing and do you have the genetics to flush it out? This testing is about $350 for the state of the art in mercury testing with blood levels of all the other metals including nutrient metals. Genes can be assessed for detox capacity if levels are high or assessed before using this test to see if it’s worth poking such an expensive a stick at this question.

EMF (Electromagnetic field) exposure: Not to get into the tin-foil hat realm too far, but EMFs target calcium gated channels. In the susceptible individual, dose makes the poison. Prudent to turn off the router during sleep, keep phones in purses or on a desk instead of touching the body. Talk using speakerphone setting or an air channeled headset.

Cervical traction: Mechanical issues maybe in play. I’m not a PT or chiropractor but these folks could help you decide if traction could help with your pain.

Beet root: Can be used as a trial and would help if you are low in nitric oxide (NO). If low in NO, it would help. If not, it could trigger HA.

Imitrex: This 5-HT receptor agonist that also decreases activity of the trigeminal nerve which is key in some cases. It’s only used at the start of an attack so it doesn’t help prevent anything. Nonetheless, it’s useful. Its effect has led to the recommendation of 5-HTP supplementation nightly as another therapeutic route. Some people are deficient in the enzyme to convert tryptophan to 5-HTP to melatonin/serotonin so giving the 5-HTP bypasses the most commonly pathway problem. I’d say, if Imitrex is a miracle drug for you, talk to your practitioner about giving 5-HTP a shot. This would not be appropriate for some people on Serotonin raising medications so don’t just order this off the internet.

Dental consult: Infections, including sub-clinical ones that irritate the trigeminal nerve. These might be old root canals, wisdom teeth or TMJ. Dental malalignment can trigger headache. Tell the dentist you are looking for dental triggers for migraine and they should be able to help.

Transcutaneous supraorbital nerve stimulation. Worn like a headband, it is worn to prevent migraines.

The host of standard therapies: Calcium channel blockers, Beta blockers, ARBs, Depakote and Tricyclics. All help symptoms but don’t address the root cause as the aforementioned workup would do and come with their own side effects.

None of this is presented as any specific medical advice for you and you should consult your own provider about your unique situation. A lot goes into sorting all the options into a prioritized list that doesn’t break the bank or cause you any undue risk. It gives you a glimpse into how functional medicine addresses the problem, if nothing else. If there is any way I can be of assistance and you’re in our area, feel free to call the office for information about an appointment and bring your headache log!

Sylvia Cooperman, CRNP, CFMP


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