Non-pharmacological

treatment of Migraine

Pete Miller

Exeter Headache meeting 2017

Non pharmacological management

Weight loss

Diet

Riboflavin, Magnesium etc

Neuromodulation

Acupuncture

Mindfulness

CBT and neurofeedback

Physical therapies

Homeopathy

Weight loss

Migraine associated with obesity and metabolic syndrome

Increased risk chronic migraine

Inflammatory mediators –adipocytokines

2 small studies – bariatric surgery reduction in frequency and disability; helped in children

One prospective study in adolescents- helped but multiinterventional

Diet

Low sodium - DASH

Low fat – 12 week

max 20g/ day study

Elimination – children ( unselected ags helped; amines didn’t )

Adult – histamine free

Adult- igG response

Ketogenic diet change in neuronal excitability and reduction of CSD in short term

1928; 1930s 78% response

Studies compared to low calorie diet show benefit

High fat/ low CHO/ controlled protein

Low sucrose

Tryptophan reduced

High omega-3 cf 6

Neutriceuticals

Mg CoQ10

Riboflavin Feverfew

PUFAs

Butterbur

RIBOFLAVIN

Oxidation-reduction reactions

Mitochondrial energy depletion

Several open label studies; = propranolol 6 months in one

Well tolerated

Not as clear in children

Helped adolescents with chronic migraine

Acupuncture

Traditional more than western

Several reviews

Neuromodulation

Transcranial magnetic stimulation

TMS

Fluctuating magnetic field

ionic current

Single , repetitive, low / high

frequency

Cerena / Spring

Acute and preventative

Vagal Nerve stimulation

nVMS

Acute 65% reduction

EVENT – chronic migraine

Supraorbital nerve stimulation

STS

Cefaly

PREMICE trial 6.9 days to 4.8 days

Other neuromodulation

Other

Non- invasive

Direct current

Mastoid Caloric

Invasive

ONS Spheno-palatine

Mindfulness

Intentional, non-judging mental awareness; curiosity, openness and acceptance

Non-judgemental attitude towards internal sensations to make intentional choices

MBSR, MBCT, DBT, ACT ……

Studies in chronic pain

Sun, Kuo, Chiu – accidental headache

Maybe some direct physiology effects

Physical Therapies

Spinal

Soft tissue

Exercises

biofeedback

TENS

Physical therapies

More effective in TTH overall?

Spinal manipulation/ mobilization : less in TTH ; ? Migraine ( conflicting ); more likely cervicogenic

10% side effects unpreventable?

Soft tissue therapies- for TTH?Recent metaanalysis shows multimodal manual therapies may help

CeH – sternocleidomastoid trigger points

Physical Therapies

Exercises

Exercise-induced hypo-analgesia

related to activation of

descending inhibitory pathways

Aerobic exercise helps in migraine

Therapeutic exercises help TTH

and CeH : deep neck flexors

Physical Therapies

TENS

TENS ? Can help TTH, migraine

and CeH but “poor

methodological rigor” means

hard to interpret

Bowen?

Biofeedback

Two meta-analyses show reduced

sensitivity and frequency in TTH

and migraine

Neurofeedback combines

behavioural techniques and

neurophysiological recordings to

control aspects of brain activity

Homeopathy