Thursday 30 April 2020

The Migraine World Summit: Day 6

*This post is not sponsored by the Migraine World Summit but I am a participant in the Migraine World Summit affiliate program. This means I earn a commission from any qualifying purchases of the summit made through my link.

Non pharma approaches for migraine?

Every migraine patient should be taking magnesium.

-        Up to 50% of migraine patients are deficient in magnesium
-        Serum magnesium blood test is unreliable – best for everyone to try taking magnesium

Diets are often poor in nutrients. Stress and chronic illness deplete nutrients. Even if you have a very healthy diet, TAKE THE SUPPLEMENTS.

Genetic factors:

-        Vitamin deficiency
-        Not absorbing nutrients properly
-        Kidney problems – mag deficient

 Which supplements are good for migraine?

-        Magnesium
-        CoQ10
-        Vitamin B2
-        Vitamin B12
-        Feverfew
-        Frankincense


-        Only helpful if deficient, you have a bout a 50% chance that it will help
-        Some people are unable to absorb it properly and need an injection
-        400mg per day. Some take this dose twice a day.
-        Take it with food. Don’t take with calcium.

Symptoms of magnesium deficiency?

-        Cold hands
-        Night cramps
-        PMS
-        Brain fog
-        Palpitations


-        Vitamin B2
-        Trial – took 3 months to work
-        Makes your urine turn bright yellow
-        Not to be used in pregnancy


-        1/3 migraine patients are deficient
-        Effective if deficient
-        Harder to tell if deficient usually best to just try
-        100 – 300mg daily dose
-        Best to take in morning as can give people energy


-        150 mg better than placebo
-        Toxic as plant
-        UK and Germany don’t allow product


-        Grow your own
-        Eat in in a salad or add to tea
-        Very safe
-        Its very effective for some patients
-        Good to get it from Germany as they are very rigorous in their manufacturing protocols


-        Anti-inflammatory spice
-        Ginger capsules for anti-nausea

 Should we introduce the supplements one at a time?

-        If clear there is a mag deficiency then best to start there
-        Add a few at a time just don’t start them all on the same day

Swedish study: 40,000 migraine patients. Frequency of exercise up – less headaches.
3 groups of patients

1)     Topamax
2)     Relaxation
3)     Exercise

All 3 groups did equally well at reducing migraine.

Magnesium can be very dangerous if you have poor kidneys.
People can have allergies to supplements too so something to consider.
Pregnancy- avoid any herbal supplements

How to approach non pharma options with your Doctor?

-        Come prepared to appointment. Bring the scientific paper as evidence for why you want to try something.

You have many options and may don’t involve medications”.

-        Our brains are wired to change
-        Activities we engage in can strengthen or weaken these circuits

-        Intentional practice
-        Paying attention to present moment without judgement

Focusses attention
-        Focus on breath
-        When thoughts/emotions arise. Notice them, acknowledge them and then let them go.
-        Non-judgmental and focus on breathing

Open monitoring
-        Tuning into other sensations
-        Being aware without appraising them
-        Takes practice to be able to learn to do it

How does mediation change the brain?

-        SNS (fight or flight) vs PNS (calm) – mindfulness enhances our parasympathetic nervous system.

-        Neuroimaging during meditation: the areas of the brain that light up; emotional regulation, concentration and attention.

-        Brains of meditators have differences to non-meditators. Hard to tell if they are born with it or there are changes in the brain due to meditation itself.

-        Change the structure of the brain – mindfulness – focussed intended practice – not relaxation

Stress is the number one reported trigger for migraine

Stress has two parts:
1)     Our perception of the stressor
2)     Our response to the stressor

Let down stress linked to migraines – the change in level of cortisol.

Mindfulness meditation & chronic pain research?

-        Global research
-        May help people relate to headache and improve disability associated to headaches
-        Emotional control

-        New York study looking at mindfulness – changes in disability – decreased disability
-        Pilot study – stress reduction – improvement in headache duration

-        Italy – study with CM patients with 20+ headache days & MOH. 2 groups (1) meds, 2) mindfulness). Both groups reduced severity, frequency and intensity of attacks. Not randomized study so potential bias.


Tuesday 21 April 2020

The Migraine World Summit: Day 5

*This post is not sponsored by the Migraine World Summit but I am a participant in the Migraine World Summit affiliate program. This means I earn a commission from any qualifying purchases of the summit made through my link.

Why can’t people with chronic migraine skip meals?
The migraine brain does not tolerate any change in routine well.

Why is intermittent fasting dangerous for chronic migraine?

-        Normal things already trigger a migraine so easily such as exercise and menstruation
-        If you are fasting on religious grounds and you have CM then please speak with your church leader as you shouldn’t be fasting and normally allowances are made for medical reasons.

Is weight associated with migraine?
-        Overweight association with more migraines

Why? (possible hypotheses)

-        ­fatty tissue – inflammation – promotes migraine
-        Obese – leaky gut syndrome
-        Postural factors – more pressure on lumbar and cervical spine
-        Fatty tissue modifying hormones

Migraines association with weight gain also contributed by medications that can cause weight gain as a side effect.

Topiramate – only 10- 15% will experience weight loss.

How to lose weight if you do have migraine?

-        PATIENCE
-        Drop calories
-        Glucose regulation
-        Drink more water
-        Increase your protein and veggie intake
-        No refined sugars
-        Reduce portion size

Sleep is key for weight loss.

Focus on why we eat! Is there an emotional component to our eating behaviours?

Exercise helpful for both mood and weight loss!

How about the Ketogenic diet?

-        Some evidence – regulate sugars – help migraine
-        Not safe diet for everyone and very difficult to stick to

-        Hydration is so important

Vomiting & dehydration?

-        Acute therapy to control
-        Sip on electrolytes
-        Sometimes iv fluids are necessary

Food and drink to boost hydration?

-        Vegetables. Careful with fruit as lots of sugar
-        Water and herbal teas
-        Add some lemon, mint or cucumber to your water to add some extra flavour
-        Coconut water? Why not.
-        Gatorade? For mild to moderate exercise its not necessary

Should I focus more on healthy lifestyle or food triggers?

-        Trigger lists are rarely effective unless patient knows specific foods
-        Worrying over food triggers tends to increase anxiety and the lists of potential ones are endless.

What is CGRP?

Calcitonin gene related peptide

-        Small protein made up of 37 amino acids
-        Increased during migraine attack
-        Induce a migraine in health participants

Central nervous system (CNS) – Brain & spinal cord

Peripheral nervous system – outside of the CNS. Connecting the CNS with organs and blood vessels

Is CGRP all bad?
Maybe helpful in protecting against high blood pressure


-        Restricting vasal constriction
-        Inhibits the release of CGRP


-        New drug
-        Antagonist receptor of CGRP
-        Binds to CGRP receptor (stops CGRP doing its thing and inhibits binding)


-        Binds to the molecule itself (Ajovy & Emgality)
-        Binds to the receptor (Aimovig)

Will there be issues of MOH with the gepants?
-        Hopefully not the case as with other pain meds as works differently

CGRP side effects?

-        In clinical trials – no real side effects
-        Don’t have enough data yet to know potential longer-term side effects
-        Cardiovascular safety?
-        In clinical practice – mild side effects (constipation and injection site reaction)

Pros & cons?

-        PRO: first drug specifically for migraine. Tolerability is very good.

-      CON: Need to know more about long term safety. Access to treatment is tricky for some. Doesn’t help everyone (not a cure).


-        Extreme sensitivity to light
-        Light makes pain wore (aggravates the pain)

Light is painful to blind people. This is why they wear sunglasses.

Vision and pain are two different pathways so doesn’t make sense?

Optic nerve – required for photophobia or trigeminal nerve?

1)     Blind patients with no optic nerve – no photophobia
2)     Light without sight patients – photophobia

In order for photophobia to occur, optic nerve must communicate with migraine pathway.
Neurons in a distinct area of the thalamus (which process pain), receive a direct input from the retina through the optic nerve into these neurons. We can see that these neurons fire up with light.

Why migraine patients have visual disturbances?

Visual cortex
75000 websites about filtering out blue light. Only true for blind patients. If you only block out blue light it won’t make a difference.

Blue and red light make head more painful.

Yellow and white also painful but less so than blue and red.

In contrast green light has the opposite effect. Green light decreases headache and autonomic symptoms.

Light increases the intensity of pain by about 20-25%.

-        Sunlight uncomfortable for migraine patients
-        Flickering lights – exacerbate headache

Can we get green light to help us?

-        YES. Green lightbulb currently $250. It will get cheaper over time. Already come down in price a lot.
-        Company aims to bring green light to migraine patients who need it

Testing green light in real life?

-        When patients exposed to green light for 2-2.5 hrs their pain goes away or is improved by 80%.
-        Patients also report that they feel less anxious, brain fog lifts and their cognitive function improves.

Should we be using glasses/screen filters?

-        Cutting down on blue light is a good thing for everyone
-        To filter it out properly would cost thousands of dollars
-        They filter out some of it but not all of it

Sleep in the dark is important.

Emotional component – aversion to light better definition than phobia.


Sunday 19 April 2020

The Migraine World Summit: Day 4

*This post is not sponsored by the Migraine World Summit but I am a participant in the Migraine World Summit affiliate program. This means I earn a commission from any qualifying purchases of the summit made through my link.

 Depression (30% of migraineurs) and anxiety (50% with migraine)

Comorbid disorders

Common wiring?

-        Serotonin
-        Peptides
-        Inflammation
-        Neurotransmitters

As migraine “chronifys”, mood disorders increase.

Brazilian study showed that if you experience one or less migraines a week (twice as likely depression). If you have daily headache you are seven times more likely to have depression.

Generalised anxiety:

-        Persistent daily worry (6 months)
-        Irritability
-        Poor sleep
-        Restless
-        5 fold greater in migraine patients

Panic disorder:

-        Severe scary intermittent surge
-        Fearful of next attack – alter behaviour
-        Anticipating panic- fearful

Migraine and panic:
Inherit some hyperexcitability in the nervous system

Bipolar disorder:

-        2.5-3-fold greater in migraine patients
-        Big spectrum
-        Diagnosis requires at least one manic or hyper manic episode
-        Often misdiagnosed with depression. Anti-depressants could make them worse.


-        Not good data in migraine patients
-        Migraineurs tend to be highly efficient – making up for lost time

Suicidal thoughts:

-        Pain severity is a big indicator of this
-        Cluster headache & high frequency migraine

Important to treat mental health AND migraine. Co occurring disorders that require aggressive treatment.


-        Biofeedback (good evidence)
-        Relaxation therapy (diaphragmatic breathing)
-        CBT (decrease the cognition of threat), can be done online
-        Mindfulness/ meditation

Cyclical vomiting syndrome (CVS)- Occurs in both adults and children but we are unsure of the exact prevalence.

Tricky to diagnose: Confused with GI issues, metabolism issues. Lots of other disorders can look like CVS.


-        Fatigue
-        Irritable
-        Vomiting
-        May have headache too
-        Nausea
-        Abdominal pain

Abdominal migraine Vs CVS?

-        Periodically: CVS tends to come in cycles for example if patient says every 6 weeks
-        Abdominal tends to have random frequency of attacks
-        What is the dominant symptom? Vomiting for CVS patients

CVS triggers?

-        Could be premonitory symptoms. Hard to tease out specific triggers
-        Not a lifestyle issue. Periodic nature of it.

Is it a neuro or GI disorder?

-        CVS is a neurological disease
-        Helpful to see gastro too to check nothing else has been missed.
CVS often predates migraine. Between 50% and 2/3 of CVS patients go on to develop migraine.


-        Acute: anti-nausea drugs
-        Prevention: tends to be the same for adults and children
-        CoQ10, Riboflavin and tricyclic antidepressants can all be used for prevention

How difficult is it to stop an attack?

-        Tricky working with oral treatments because of vomit
-        Nasal sprays and suppositories may be useful
-        Injections at home
-        IV in urgent care is sometimes necessary when patients are persistently vomiting
-        The earlier you treat the better, just like with migraine

Age of patients?

-        Youngest CVS patient she had seen was 2yrs old
-        5/6/7 typical start age
-        Can start mid 20’s
-        Possible link to infant colic

Prevent trip to ER?

-        Toolkit
-        Having a second rescue option if 1st line attack does not work
-        Sometimes ER is inevitable because of dehydration concerns


-        Not a good idea
-        Could trigger cannabinoid hyperemesis syndrome (CHS)

Advice for patients?

-        Find a good doctor who is interested in CVS
-        Take your toolkit with you wherever you go so that you are prepared and can treat early
-        Written documentation for ER can be useful to help bridge the gap in knowledge

Nausea can be even more disabling than headache

Strategies to help with Nausea?

-        Pharma (serotonin receptor antagonist, drugs that work on dopamine receptor, neurokinin receptor)
-        Acute meds (NSAID’s and triptans)
-        Non-Pharma (seabands, tens units, ginger chews/drops, frequent small sips of drink, graze on bland foods, aromatherapy lavender/peppermint)

Migraine meds and nausea?

-        Oral route (dissolving melts)
-        Nasal spray for triptans
-        Injectables (sumatriptan)
-        Per rectum suppositories
-        IV options at ER

Several options to bypass the GI tract. Even if no nausea, take anti-nausea tablets when treating migraine attack because stomach shuts down during migraine.