The key to migraine treatment and prevention is understanding how migraines form and how they react. There is no one form of migraine, and no one trigger. Which is why treatment and prevention are often very difficult. To begin the journey in the treatment of your migraines, you should start by understanding your migraine presentation.
Migraines affect over 50 million Americans. Most migraine sufferers are women between the ages of 30-39. Which is increasingly concerning as the connection between migraines, birth control and increased stroke risk are 9x higher.
What are Migraines?
I like to describe migraines as a wave of neurological activity, doesn't that have a nice ring to it? Migraines are described as episodic events that reoccur. Anyone can have a migraine if the conditions are right, you only get diagnosed with migraine disorder when it becomes a pattern.
Episodes can be short and sweet, or last for days. The classic migraine is that of a severe headache with visual aura, but in reality there are many different presentations.
A typical Migraine has four phases.
60% of Migraine sufferers experience the prodrome phase. It begins 24 - 48 hours prior to the onset of the aura. This phase is the buildup phase. It is basically the neurons beginning to become either hyperstimulated or depressed. Symptoms include; manic behavior or depression, irritability, increased food cravings, constipation, neck stiffness, and/or increased yawning.
Each of these symptoms would be a clue to different underlying causes.
The Aura phase is the hyperexcitability or depression of the CNS. Those who have migraines often describe sensory changes or loss prior to, or at the onset of a headache...this is the aura.
A positive aura is the hyperexcitability of the CNS. This would be increased sensory sensitivity, such as sensitivity to light, sounds and touch.
A negative aura is the depression of the CNS. This would be decreases sensory sensitivity, such as vision loss (curtain effect), hearing loss, or numbness.
There is a rare condition in which migraines appear only as aura without headache. This is called a Vestibular Migraine and can present as unexplained vertigo.
The Headache phase is the hallmark of a migraine...the head pain associated with CNS dysfunction. It is classically unilateral (but can present as bilateral) with a feeling of throbbing and pulsing. There is usually fatigue and nausea associated with it. The feeling can last from hours to days, which is why most people with chronic migraines are willing try anything for relief.
If the headache appears during a positive aura, it is associated with vasodilation.
If a headache appears during a negative aura, it is associated with vasoconstriction.
The postdrome phase is the recovery phase of a migraine. The main effects of the migraine, the aura and headache, are gone but there is a bruised sensation in the head. Sufferers are often extremely tired and depressed.
Understanding Migraine Threshold
Migraines are the over or under activity of the Central Nervous System in the cortex of the brain. Like I said above, everyone has to potential to have a migraine, the difference between those that do and and those that don't is threshold.
There are many factors that determine a person's threshold. What we are really talking about when we say threshold is the amount of stimuli needed to produce either an overexcited neurological response or a depressive neurological response.
When a person has hit their threshold, the brain has hit a point of overstimulation and a migraine can occur. The way the stimulation flows over the brain and whether or not it is followed (and how quickly) by a depressive state of neurological function, depends on the individual. Generally, though, as the brain hits a point of overstimulation, this is the beginning of positive aura. As the neurotransmitters are depleted through overuse, it can be followed by the negative aura or loss of function.
There are patterns that occur that are CNS depression without hyperstimulation. This is a pattern of neurotransmitter deficiency or malfunction.
So to simplify:
Threshold for neuron stimulation.
Lower threshold = More Migraines
Higher threshold = Less Migraines
Pathophysiology - What Causes Migraines?
There is no simple answer to this question. As I mentioned above there is the threshold theory. Many different biological processes and environmental factors can contribute to lowering one's threshold.
It has been well established that migraines run in families. Therefore it is easy to acknowledge that there is a genetic component for many. There are two primary groups of genetic mutations associated with an increased risk of migraines.-
MTHFR gene mutations have been a pretty hot topic as of late, and are connected with multiple different disorders. The main characteristics of this gene mutation is that it limits the person's ability to convert Folate into Methylfolate (the usable form of folate in the body.) Inadequate amounts of folate limit the ability to methylate (this is a complicated topic, so let's just go with it). A deficiency in methylation is associated with increased levels of Homocysteine, Increased Cardiovascular risk, and an Increased Risk of Stroke if taking birth control. Those with this gene mutation are more likely to have Migraines without aura.
The FHM family of genes is probably one that you have not heard of, and it is nowhere near as easy to say as MTHFR. These genes control the calcium and ion channels in the body. A mutation in these genes is associated with increased levels of Calcitonin Gene-Related Peptide, Lower levels of Serotonin and Lower levels of Estrogen. Those with these gene mutations are more likely to have Migraines with aura.
When we talk about oxidative stress, we are talking about the balance of antioxidants to free radicals. In a nut shell, free radicals are naturally produced in the body during the Citric Acid/Krebs Cycle production of ATP in the Mitochondria. In order to neutralize them before they can cause harm, we have an array of antioxidants that bind to and excrete these toxins. If the load of free radicals is more than the amount of antioxidants, or we have a deficiency in our antioxidants, then we start to have toxic buildup. This buildup lowers neuron function, and lowers the threshold. High oxidative stress is associated with Migraines with extreme fatigue postdrome phases.
Excess free radicals can be chemical exposure in our environment, heavy metals, or toxic molds.
For a long time, the cardiovascular effects in the brain were considered the number one cause of migraines. Mostly contributed to vasoconstriction, we know now that vasodilation is also a cardiovascular cause. Although there is a connection with vasoconstriction and headaches that appear with negative aura, this is not the cause of the migraines, but a symptom of dysfunction.
Nitric Oxide is a muscle relaxing compound found in the blood. It's main function in cardiovascular health is to maintain contraction and relaxation of the blood vessels. It is also responsible for inhibiting platelet aggregation, and reducing vascular inflammation. Those with vasoconstriction migraines also tend to have low NO. How does the NO get low? Well, there are several reasons this could happen.
In order for your body to make NO, you need adequate oxygen, proteins, and estrogen.
Oxygen + L-Arginine + Enzymes + Cofactors = Nitric Oxide
The formation of NO is stimulated by Estrogen.
So, we just mentioned that estrogen plays a role in the formation of Nitric Oxide, therefore a deficiency or dysfunction in estrogen would lower threshold and increase the possibility of migraines. Many women who experience migraines have seen associations with their menstrual cycles. If there are imbalances in the ratios of estrogen to progesterone we can also see the decrease in threshold and increase in migraines.
In another scenario, higher levels of estrogen activate the receptors for Glutamate, an excitatory neurotransmitter that is often high during migraines. Glutamate in normal levels is responsible for learning and memory, but in higher amounts will over excites the brain. In biology there are always mechanisms in place to maintain balance and homeostasis, in the case of Glutamate, this is GABA. Progesterone is responsible for the activation of GABA receptors. Therefore a balance between Estrogen and Progesterone important in the prevention of migraines.
Celiac is a complicated topic, and in reality is more than just a digestive issue. It is associated with a specific set of genes. (So could have been discussed under the genetics header) These genes are activated by gluten. The main disorder associated with the gluten activated genes is autoimmune digestive damage. BUT, these genes are also associated with a number of other complaints, and can be associated with damage elsewhere in the body without visual digestive damage.
Migraine sufferers are 10x more likely to carry the Celiac genes. The same process that causes damage in the gut, also causes damage to the myelin sheaths (the fatty protect layer than insulates nerves), increasing their sensitivity and reactivity.
There several environmental factors that must also be addressed in migraine cases. These are known to lower the threshold and increase the sensitivity of neurons.
Prevention & Treatment
Of course proper diagnostics is important in formulating a protocol that will be effective. As you can see, there are many different possibilities in pathophysiology, and thus also many different possibilities in treatments.
Of course I am starting here. I truly believe health begins and ends with what we put in our mouths. Proper testing should be done to rule out a gluten connection, or food allergies.
There is significant research supporting specific diets to the treatment and prevention of Migraines. The Mediterranean diet is the one with the most support. The Ketogenic diet is also gaining in research to support its benefits in the treatment of migraines. Be aware that ketogenic is a dietary type that needs medical supervision and often supplements to prevent nutrient depletion that is common.
Remove External Toxins
Our body produces its own free radicals and by products that need to be dealt with every day. If we are increasing the detoxification load with external chemicals we can lower our threshold by increasing oxidative stress. Changing cleaning supplies, removing food preservatives and testing your home for mold exposure a few ideas to decrease your external toxin load.
Different types of migraines benefit from different forms of exercise. Overall migraines are reduced by relaxation promoting exercises, such as yoga, pilates, Qi Gong, and tai chi. The main take home is to start slow, incorporating activity into your daily life. Try riding your bike or walking to nearby destinations. Have a family dance party. Play a game of tag with your kids. This is all exercise, but positive activity, but doesn't feel like a trip to the gym. Which, I'll be honest, is not how I exercise. Find a new athletic hobby. My family participates in Brazilian Jiu Jitsu. Heck of a workout, learning a new set of skills, and oh so much fun.
Sleep is extremely important for clearing out naturally byproducts in the brain, and for the recovery and repair of neurons. Melatonin is more than just a hormone that helps you fall asleep, it also has a role in the immune system and is a powerful antioxidant that helps reduce oxidative stress.
If you are fatigued, but have difficulty sleeping, try working on a sleep routine. Remove electronics 1 hours before bed, meditate, limit artificial lighting and incorporate Epsom salt baths. Melatonin is triggered by a drop in Cortisol and darkness.
Adding Acupuncture to your treatment protocol can aid in reducing acute migraine symptoms and preventing future episodes.
Research shows that Acupuncture provided a 50% reduction in migraine frequency and severity in 60% of patients. Which is as effective as medications, but without the side effects, and with some other added benefits.
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