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 Non-drug Treatment Alternatives
Frequently Asked Questions
Click here to read
the content disclaimer
Non-drug
Treatment Alternatives (by C. David
Gordon MD, Robert Hamel, PA-C, Alvin Lake III, PhD & MHNI Staff)
Biofeedback and
relaxation therapy
Cognitive-behavioral
therapy
Exercise
Sleep
Smoking cessation
Diet
Are there non-drug alternatives?
Drugs are not the only means of
effectively treating head pain. For many people with intermittent migraine and tension-type
headaches, the consistent practice of behavioral methods can actually reduce the
intensity and frequency of attacks. For others, behavioral treatment may primarily
be of value in creating a sense of well-being, coping with the stress created by
the headache, or helping the headache sufferer continue to function. For frequent
and severe headaches, behavioral methods are usually combined with drug therapy
and may lead to better headache control than would be the case with either type
of treatment alone.
Some behavioral methods, such as
biofeedback, relaxation training,
and cognitive-behavioral therapy, have demonstrated their effectiveness
in over 25 years of rigorous research and well over 100 experimental studies in
these combined areas. Others, such as aerobic exercise,
sleep regulation, dietary regulation, and
smoking cessation, make sound physiological sense and are
supported by clinical experience. All of these behavioral approaches share the advantages
of minimal if any negative side effects and negligible cost once the techniques
are learned and practiced regularly.
Biofeedback and Relaxation Therapy:
Biofeedback therapy involves learning
to reduce muscle tension in the head and neck or modifying blood flow, usually by
warming the hands (an indirect but easily measured way of reducing stress-related
responses). In most cases biofeedback is combined with relaxation training. This
involves practicing slow abdominal breathing, focusing on feelings of heaviness
and warmth in different parts of the body, or visualizing positive images. While
the outcomes of biofeedback and relaxation training are generally similar, there
is experimental and clinical evidence that the addition of biofeedback may increase
the effectiveness of relaxation, particularly for individuals who do not get good
results from relaxation therapy alone. When the method of training is geared to
the patient's level, biofeedback and relaxation therapy have been shown to be effective
across a wide range of ages from children to the elderly.
Comparisons of results across a
large number of studies find average reductions in headache from 45% to 60% for
migraine and tension-type headache (depending on how headaches are measured). This
response rate is roughly equivalent to the effectiveness of certain drugs, such
as beta blockers (propranolol) for migraine and tricyclic antidepressants (amitriptyline)
for tension-type headache. The combination of biofeedback and medication may provide
superior treatment results. For example, the average improvement in migraine with
propranolol is 44% to 55%. When propranolol was added to biofeedback, one recent
study found a significant increase in effectiveness for the combination of propranolol
and biofeedback (79%) vs. biofeedback alone (54%).
When is biofeedback effective
and for whom? Although the definitive answers to these questions are not yet
certain, clinical research has indicated a better response to treatment in persons
who are able to raise hand temperature above 95°, practice the technique at home,
learn to pay close attention to fluctuations in tension throughout the day, and
apply brief relaxation techniques on a daily basis. There is some preliminary evidence
that individuals who gain a sense of self-efficacy -- a belief that they are in
fact capable of exerting some control over their physiology and headaches -- achieve
a better outcome regardless of the actual level of physiological control achieved.
If this finding holds true, it may be that those who develop such a belief in an
internal locus of control are more likely to apply a wide variety of coping
techniques in addition to the frequent practice of biofeedback skills, thus increasing
their chances of reducing headache.
In a follow-up study of 154 biofeedback
patients with combined migraine and tension-type headaches, Dr. Jeff Pingel and
I found that 80-84% reported success in preventing stress-related headaches. In
contrast, these patients reported less success in preventing migraine (34%) and
tension-type headaches (56%) triggered by other factors, such as menstruation or
weather changes.
Analgesic rebound (caused by taking
large amounts of pain relievers on a near-daily basis) interferes with the effectiveness
of biofeedback. Chronic daily high intensity headache rarely responds to biofeedback
alone, although it can help in coping with the pain.
Cognitive-Behavioral Therapy:
This type of therapy involves attention
to the connections between thoughts (cognitions), beliefs, feelings, behavior, and
pain. The therapist may assist the patient in developing positive coping thoughts
to combat negative thinking and reduce emotional arousal. For example, to counteract
negative thoughts such as "Why me? What did I do wrong? How much longer is this
going to last?", the headache sufferer might respond with alternative self-talk,
such as "I have a biological predisposition toward headache. Thinking about what
I did or did not do never got me out of a headache. Deal with that later. For right
now, focus on the next five minutes." The addition of cognitive-behavioral therapy
to biofeedback may enhance effectiveness.
Exercise:
A small number of studies have shown
reductions in the frequency and intensity of migraine following consistent aerobic
exercise over several weeks. Aerobic means oxygen-utilizing. It requires continuous
movement for 20 minutes or more at a time, such as walking, bicycling, swimming,
running, or aerobic dancing. In our inpatient unit for chronic head pain, we found
that 45% of those who were able to complete a 20-30 minute group walk at a moderate
speed had at least temporary reduction in moderate to severe headache.
Unfortunately, some people also
find that exercise can trigger or aggravate headache. A useful guideline is to move
at a pace that can be tolerated for 20 minutes without a significant increase in
pain, following the rule that "some is better than none." How much exercise is enough?
Exercise should take place at least three days a week to accumulate significant
benefit. Keeping a simple calendar record of exercise can help build motivation
to increase the frequency of exercise. A good goal is to build up to a total of
three hours a week.
Sleep:
Sleeping patterns can have a dramatic
effect on headaches. Falling asleep may help reduce a moderate or even severe headache.
However, too much or too little sleep, including naps, can also provoke headaches.
It is generally considered important to rise at the same time each day and avoid
"sleeping in" on weekends, particularly if headaches are at their worst in the morning.
Maintaining consistent sleep habits and using relaxation as a sleep-aid can greatly
increase quality of life and help provide the energy to cope with problem headaches.
Smoking Cessation:
Cigarette smoke contains carbon
monoxide, a known headache trigger, and nicotine has been shown to reduce the effectiveness
of many, if not most, headache medications by interfering with the liver's ability
to break down (metabolize) these drugs. Smoking can also reduce the benefits of
nonpharmacological treatments, such as exercise and relaxation.
A recent survey of over 1,000 people
in the Detroit area found that 33% of migraine sufferers use tobacco. This is almost
twice the rate of cigarette smoking found in those who did not have migraine. One
study at a headache clinic found that smokers had more intense headaches (as well
as more depression and other physical symptoms) than nonsmokers. In summary, continuing
to smoke can place any headache treatment program in serious jeopardy.
Diet:
Diet can make a difference. Some
research and case studies have shown that strict adherence to a diet involving elimination
of all possible food-related headache triggers (such as chocolate, nitrite-preserved
meats, aged cheese, broad beans, MSG, and excessive salt) can lead to significant
improvement in patients who do not respond to other treatments. Subtle drops in
blood sugar levels can trigger headaches.
(Click here for a more complete list of food triggers)
Prevention steps include eating
regularly, not skipping meals, as well as experimenting with eating multiple small
meals during the day at intervals of three to four hours. A recent study completed
in Oregon found a 50% improvement in migraine frequency, with significant reductions
in headache duration and severity for patients who participated in a program that
emphasized strict dietary regulation and avoidance of all known environmental triggers.
The medication program in this study was very conservative and avoided the use of
analgesics with rebound potential as well as prescription preventive medications.
Summary:
Many who suffer from problem headaches
can benefit significantly from behavioral, nonpharmacologic treatment. These approaches
do require a certain amount of effort and a "take charge" attitude. The best chance
for success probably comes with making use of all appropriate behavioral techniques,
in combination with a sound medication program.
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How common are alternative medicine therapies?
It is possible that between 30-40% of adults in
the United States seek nonmedical alternative treatment at least once during the
year. Annual expenditures for alternative treatment are now over $27 billion. Individuals
may choose alternate treatments because of their dissatisfaction with conventional
medicine, because they view alterative treatments as “safer,” or “more natural,”
or because they simply get more personal attention from an alternative health care
therapist.
Patients seeking pain management can choose from
a wide variety of possible treatments including acupuncture, chiropractic, herbal
medicine, folk medicine, massage, body work, Reiki, homeopathy, naturopathy, prayer,
magnets, and more.
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Have alternative medicine therapies been “tested”?
Randomized controlled trials of alternative treatments,
such as acupuncture, chiropractic, and massage, are now underway to assess the value
of these practices for treating daily headache or neck pain. Placebo-controlled
trials are more difficult for therapies such as acupuncture and chiropractic.
Some alternative practitioners have resisted randomized
clinical trials because of what is perceived to be the disruption of the “therapeutic
and holistic milieu.” However, standardized studies are required before an alternative
treatment for head and neck pain can be considered safe, scientifically valid, and
beneficial.
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Herbal and alternative medicines such as feverfew
and St. John’s wort have grown in popularity. Are these herbal medicines helpful
for headache disorders?
Some controlled
studies suggest that feverfew can be effective in the prevention of migraines, though
there are only a few studies supporting this contention. Feverfew's mechanism of
action appears related to platelet stabilization, though there seem to be some anti-inflammatory
properties. Lack of dose and form standardization, information about side-effects
and long-term studies are lacking, however, which makes this herb less than suitable
for migraine treatment.
There is no evidence
that St. John’s wort is helpful in migraine treatment, though its monoamine oxidase inhibitor activity suggests antidepressant value.
A healthy lifestyle is the best "natural" remedy. A well-balanced diet, proper sleep,
avoidance of tobacco and alcohol, regular exercise, biofeedback and relaxation treatment,
and the proper use of medications are all necessary as a great start toward migraine
control.
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What about the use of vitamins for headache
treatment?
Most vitamins are not relevant to headache treatment. However, several studies now
suggest that very high dosages of riboflavin (vitamin B2) may help prevent headaches
in some individuals. Very high dosages, upwards of 200-400 mg a day, are required,
and this is substantially greater than the average daily recommended dose of this
vitamin. Nonetheless, it appears safe and may be of some help.
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How effective
is the use of acupuncture?
Acupuncture is not a proven remedy for the treatment
of headache. However, there are many individuals who cite acupuncture as having
contributed somewhat to their improvement. While we await well-controlled studies
establishing this point, we would not discourage anyone from undertaking acupuncture
treatment to relieve their pain. At least short-term benefit might result. We recommend
that licensed and highly skilled individuals be consulted.
In the journal Alterative Therapies (September-October
2003), a review of numerous research results was carried out inquiring into the
effectiveness of acupuncture for headaches of unknown cause (idiopathic). The authors
compared 26 trials including a total of 1,151 patients. They concluded that the
majority of trials had “methodological and/or reporting shortcomings.” The trials
examined both tension-type headache and migraine. The authors noted that the “quality
and amount of evidence are not fully convincing . . .” that acupuncture is a valuable
treatment for idiopathic headache. It was noted that few adverse effects were associated
with acupuncture, therefore limiting associated cost of treatment.
On the other hand, the National Institutes of Health (NIH) has found clear evidence
of acupuncture’s efficacy for chemotherapy-related nausea and vomiting, the nausea
of pregnancy, and postoperative dental pain. In 2000 the British Medical Association’s
Board of Science and Education also approved acupuncture for such conditions as
nausea and vomiting, dental and back pain, and migraine headache.
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Is it dangerous to take herbal medicines with some of
the commonly prescribed preventive medications (e.g., Pamelor, Corgard, Depakote,
or Prozac)?
It can be quite
dangerous taking any herbal preparations without appropriate medical supervision.
Contrary to public perception, herbs such as these each contain hundreds of chemicals,
many of which can cause dangerous reactions in humans. "Natural" does not connote "safe," as anyone
consuming the wrong
mushroom will understand. Herbals, in this context, more than any other pharmaceutical
drug, should be given their due respect, and may cause numerous related side effects
or potential drug interactions. For example, St. John’s wort has potential to interact
negatively with Depakote and other antidepressants, such as Pamelor, Prozac and
Nardil, leading to unpredictable side-effects including over-sedation. Feverfew,
in a double-blind placebo-controlled study, was observed to cause mouth ulcers,
dry and sore tongue, swollen lips and mouth, loss of taste, abdominal pain, diarrhea,
nausea, vomiting, and severe hypersensitivity reactions. Thus, it is not wise to
use herbal preparations, especially when using conventional medications, without
medical supervision.
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What foods can provoke a headache?
People with headache do not suffer
from headache because of food-related issues. Even when a particular food does seem
to provoke a headache attack, it may be an "inconsistent trigger" which is not always
capable of provoking such an attack. It is widely believed that internal biological
factors more than anything else determine when and if a headache attack will occur.
Therefore, external trigger factors, such as foods, may be more or less likely to
provoke an attack, based upon internally determined vulnerability.
The foods listed below have been
known to trigger attacks based upon this vulnerability.
|
Chocolate: |
Candy, foods, drinks |
Sugar:
(in excess)
|
Candy, cookies, cake |
|
Ripened cheeses:
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Cheddar, brick, mozzarella, Gruyere,
Emmentaler, Stilton, Brie, Camembert, Boursalt |
|
Dairy products: |
Milk, ice cream, etc. |
|
Alcoholic beverages: |
Beer, red wine, sherry, etc. |
|
Fruits and their juices: |
Bananas, plantain, avocado, figs,
passion fruit, raisins, pineapple, oranges, and other citrus fruits |
|
Vegetables: |
Onions, pods of broad beans (lima,
navy, pea pods), nuts, peanut butter |
|
Fermented, pickled, marinated
foods: |
Herring, sour cream, yogurt, vinegar |
|
Yeast products: |
Yeast extracts, hot fresh breads,
raised coffee cakes, doughnuts |
|
Meats with nitrites: |
Bologna, hot dogs, pepperoni, salami,
pastrami, bacon, sausage, canned ham, corned beef, smoked fish |
|
Sulfites: |
Salad bars, shrimp, soft drinks |
|
Monosodium glutamate: |
Chinese foods, Accent, Lawry's Seasoned
Salt, instant foods (canned soup, TV dinners), processed meats, roasted nuts, potato
chips |
|
Nutrasweet®:
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Soft drinks, diet foods |
|
Caffeine:
|
Coffee, tea, cola (stimulant effect,
blood vessel constriction, rebound phenomenon) |
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Can smoking contribute to headaches?
Current scientific evidence suggests that cigarette smoke may contribute substantially
to headache disorders. There are several mechanisms by which this may occur:
- Smoking may cause headache by raising carbon monoxide levels in the blood and brain,
in much the same way as a faulty furnace or a car running in an enclosed garage
can provoke headache.
- Reduced oxygenation will also cause headache and deprive tissues of needed oxygen
which may be relevant to other pain-related illness.
- Nicotine itself has a toxic effect on the brain and also alters liver metabolism
which has an adverse effect on many of the drugs that are used to control headaches.
It is our recommendation that all patients experiencing recurrent headache should
discontinue cigarette smoking as part of their treatment program. We also strongly
encourage a smoke-free environment in the home and workplace.
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