The successful treatment of conditions ranging fromthe common cold to many cancers remains beyond the reach of modern medicine,despite its tremendous advances. It is not surprising, then, that patientsseek a variety of alternative or complimentary therapies.
Complementary techniques are those that lack definitive proof of efficacy and are not accepted by the medical mainstream. While many treatments widely used in modern medicine also lack scientific proof, they are not considered complementary or alternative because of their wide acceptance by the medical establishment.
Headaches and alternatives
While the experience of an occasional headache may beuniversal and usually is tolerable, chronic headache is an important causeof distress and disability. The vast majority of people who suffer fromheadaches have either tension-type or migraine headaches. Headache onlyrecently began to receive attention from the pharmaceutical industry andorganized medicine. Selective serotonin-agonist drugs like sumatriptanhave revolutionized treatment of migraines and dramatically changed thelives of millions of people. However, even these "designer" drugs do notwork for at least 30% of patients. Unpleasant side effects may occur, anda very small proportion of patients can suffer serious side effects. Theseconcerns encourage many patients who have tried conventional therapy formigraines to explore complementary therapies. Most headache sufferers,however, have never seen a physician for their headaches and may turn directlyto complementary treatments, which seem cheaper, safer (though this maynot always be the case), and more holistic.
In numerous double-blind treatment trials, a large proportion(30-40%) of headache patients respond favorably to placebo. This "placeboeffect" can account for completely useless therapies being effective insome patients. If a particular therapy appears to be clearly ineffective,but at the same time is harmless and inexpensive, I would not discouragean interested patient from trying such an approach, in hopes of a favorableplacebo response.
Types of complementary therapies
Acupuncture
This ancient method has recently received a boost in popularitybecause of the consensus statement by a panel convened by the NationalInstitutes of Health. This statement strongly suggests that acupunctureis a legitimate therapy proven to be effective for some conditions anddeserving additional studies for others. The panel concluded that nauseaand acute dental pain clearly respond to acupuncture, while many painfulconditions, including headaches, may respond to acupuncture but requireadditional studies.
Acupuncture treatment is done using very thin disposableneedles, which cause very little discomfort or pain. In patients with chronicheadaches treatment involves ten or more weekly 20-minute sessions. Electricalstimulation of the needles is frequently used instead of the traditionaltwirling of the needles.
Double-blind study of acupuncture is very difficult becauseblinding for insertion of a needle is impossible, and inserting needlesinto non-acupuncture points has been shown to relieve pain.
A large number of animal studies indicate that differentmechanisms of action (involving different chemical substances) may be involvedin pain relief from acupuncture. Only about 70% of humans and animals respondto acupuncture. Patients with chronic headaches who did not respond toacupuncture were shown to have low endorphin levels.
Despite the lack of definitive proof of its efficacy,acupuncture has a significant potential to help some patients with headaches.Issues of cost, convenience and patient preferences should be taken intothe account when deciding on this treatment.
Mind-body techniques
Biofeedback is another therapy where definitive proofwill be hard to obtain. Most specialty headache clinics offer biofeedback,which strongly suggests that a large number of patients benefit from it(but does not prove its efficacy).
Biofeedback is only one of many relaxation and stress management techniques which can be equally effective if strictly adheredto. This is a big "if." Biofeedback is a preferred technique because itgives the patient a structure and a therapist, who acts as a coach.
The essence of biofeedback, which is often combined withbehavior modification, is to teach a patient how to encounter stress withoutadverse physiological effects. A typical course of biofeedback consistsof 8-10 weekly 30-45 minute sessions. Learning to control body functionssuch as temperature can be achieved only by first learning to relax theskeletal muscles. This is achieved through progressive relaxation, visualizationand breathing techniques. Most important though is the daily practice ofthese techniques. The practice sessions can be only a few seconds or minuteslong, but have to be very frequent. A conscious effort is required in thefirst few weeks of training, but gradually self-monitoring and very briefrelaxation techniques become a subconscious habit. This appears to allowmany patients to lower tension throughout the day and this results in fewerheadaches. Children are especially adept at biofeedback. They can oftenlearn not only how to prevent their headaches in 4 to 5 sessions, but attimes can learn how to stop their headache once it begins.
Nutritional therapies
Dietary approaches to the treatment of migraines are widelyadvocated, but have very little scientific basis, which places them inthe category of complementary methods. Dietary avoidance is a widely-advocatedstrategy. Migraine can be triggered in susceptible individuals by tyramine-containingfoods, some food additives and sugar substitutes, as well as by skippingmeals. Some patients report that their headaches get better with eliminationof wheat, sugar, or milk products from their diets. While we do not havescientific proof, it is possible to speculate on why these dietary changesmay work. If the patient is so inclined there is no reason to discourageher from trying these dietary changes, which are usually safe and inexpensive.Strict vegetarian and other unusual diets, on the other hand, can leadto vitamin B12 and other deficiencies, which can make headaches worse andcause other health problems.
Magnesium is a vital element which plays an importantrole in the pathogenesis of migraines. Many studies have found low magnesiumlevels in the serum and tissues of migraine patients. In one study, anintravenous infusion of 1 gram of magnesium sulfate was given to 40 consecutivepatients with acute migraine. Twenty-one (53%) had very good and sustainedrelief of their headache. Of the responders, 86% had low serum ionizedmagnesium levels, while of the non-responders only 16% had low values.A study of intravenous magnesium in the treatment of cluster headachessuggests a possible 40% success rate in this difficult-to-treat disorder.
Oral magnesium supplementation was attempted as preventive therapy of migrainesin three double-blind trials. Two of the three trials were positive, whileone was negative. The negative study might have used a more poorly absorbedsalt of magnesium. The absorption of various salts of magnesium has notbeen studied, so it is difficult to recommend a specific product to patientsinterested in trying magnesium for their headaches. Magnesium oxide, magnesiumdiglycinate and slow-release magnesium chloride seem to work for some patientswhen used in 400-600 mg daily dose.
Wider availability of serum ionized magnesium testingmay enable us to identify patients who have low ionized magnesium levelsand who are most likely to benefit from magnesium supplementation. In orderto remove magnesium from the list of complementary therapies and move itinto the mainstream we need large trials unequivocally proving its efficacy.
Riboflavin or vitamin B2 has been reported to relievemigraine headaches better than placebo. The maximum effect was achievedafter three months of daily intake of 400 mg of riboflavin. The study involvedonly 55 patients, but the treatment is very benign and potentially veryeffective, which makes riboflavin a good candidate for further extensivetrials.
Herbal remedies
Feverfew is the only herbal remedy studied in double-blindfashion. In a trial of 24 patients, a daily dose of feverfew was foundto be better than placebo as prophylactic therapy for migraines, thoughthe difference was not dramatic. Because feverfew is fairly safe and mayhelp some patients, this is the herb to recommend to patients interestedin herbal remedies. Migra-Lieve is a product made by Natural Science Corporationof America which contains magnesium, riboflavin and feverfew in one tablet.Having these three ingredients in one tablet greatly improves complianceand has been effective for many of my patients. To be fair, I must disclosethat I have a financial interest in the success of this product. However,my involvement started only after I became convinced that it helps my patients.
Guarana is a relatively recent import from Brazil,which is being used for headache relief. It may very well have some analgesicproperties because of its high caffeine content. However, daily caffeineconsumption is one of the leading causes of rebound headaches (see articleon Rebound Headaches). Guarana and all other caffeine-containing foods,drinks and medications should be avoided in patients with frequent headaches.
Anecdotal reports suggest that ingestion of ginger, gingkoor valerian root, all of which are well tolerated, may help some patientswith headaches.
Aromatherapy
Aromatherapy may not appear as far fetched if we considerhow much of our brain is devoted to olfaction and that strong odors canalmost instantly induce a migraine.
A double-blind study of healthy volunteers showed thatan external application of peppermint extract raises pain threshold andhas strong relaxing effects, while eucalyptus has calming and relaxingeffects and improves cognitive performance without analgesic effect. Anotherstudy which used peppermint oil for tension headaches showed positive results.This gives some scientific support to a variety of topical products beingpromoted for the treatment of headaches.
Homeopathy
Homeopathy is based on an unproved concept of using extremelysmall amounts of substances (usually herbal), which in large amounts caninduce a symptoms which are being treated. Since the treatment is extremelybenign and relatively inexpensive it can be tried by patients who believethat it may help.
Physical approaches
Regular and frequent aerobic exercise as a treatmentfor headaches is impossible to study in a double-blind trial and wouldrequire a very large comparative trial to confirm efficacy. However, thereis little doubt that it offers effective relief for many stress-provokedconditions, including headaches. Other unsubstantiated but anecdotallyeffective modalities include application of heat and cold, massageand many other similar techniques. As long as they are safe and affordable,patients should not be discouraged from trying them.
Chiropractic manipulation has several potentialbenefits, which must be weighed against possible complications. Controlledtrials in tension headache have yielded mixed results, while small trialslooking at migraine prevention have been encouraging. More than 100 casesof serious complications of this approach have been reported. The numberof unreported complications must be certainly much larger. Most of thecomplications involve neck manipulation resulting in a stroke. Becausethere is no proof that this treatment works, and in view of the potentialfor very serious complications it seems prudent to strongly discourageheadache patients from trying chiropractic treatment.
©2007 Healthology, Inc.