Another large scientific article on the benefits of cognitive behavioral therapy (CBT) was just published in the Journal of the American Medical Association. In this study by doctors at the Cincinnati Children’s Hospital led by Dr. Andrew Hershey, CBT was combined with amitriptyline (an antidepressant used for the treatment of pain and headaches) and compared to headache education plus amitriptyline.

They enrolled 135 children (79% girls) aged 10 to 17 years who were diagnosed with chronic migraine (15 days with headaches per month or more) and who had migraine-related disability. The study was conducted between October 2006 and September 2012. An unusually large number of kids completed the trial – 129 completed 20-week follow-up and 124 completed 12-month follow-up.

The treatment consisted of ten CBT or 10 headache education sessions involving equivalent time and therapists’ attention. Each group received the same dose of amitriptyline per pound of weight.

The main end point was days with headache and the secondary end point was the disability score determined at 20 weeks. Durability was examined over the 12-month follow-up period.

The results at the 20-week end point showed that days with headache were reduced by 11.5 for the CBT plus amitriptyline group vs 6.8 for the headache education plus amitriptyline group. The disability score decreased by 53 points for the CBT group vs 39 points for the headache education group. At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education group;

The authors concluded that among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with use of headache education plus amitriptyline. These findings support the efficacy of CBT in the treatment of chronic migraine in children and adolescents.

The accompanying editorial strongly endorsed the results of the study, which is only the last one of many studies showing the benefits of CBT with or without biofeedback in treating headaches in children and adults. The editorial also pointed out several obstacles to the implementation of these findings. First, many doctors do not refer their patients for CBT because they are not aware of these studies or, more often lack the time and the training to explain the benefits of CBT without implying that the headache is a purely psychological problem, which obviously it is not. Secondly, even if they do refer for CBT, less than half of children and adults actually pursue this treatment.

Most doctors usually just prescribe amitriptyline or an epilepsy drug used for chronic migraines. In my experience with adolescents, Botox provides excellent relief for chronic migraines in children as well as it does in adults, although Botox is approved by the FDA only for adults. Botox has far fewer side effects than medications and I find that it is well accepted and tolerated by kids as young as 10. However, I always start with dietary changes, sleep hygiene, exercise, supplements such as magnesium and CoQ10 and CBT, biofeedback or meditation. These measures alone are often sufficient to provide significant relief and in many children there is no need for medications or Botox.

Mindfulness appears to reduce the effect of pain on day-to-day functioning in adolescents, according to a new study published in The Journal of Pain by Canadian researchers. This was a scientifically rigorous study of 198 boys and girls aged 13 to 18 years. The researchers made an effort to recruit some children who meditated and some who did not. They were all subjected to the Child and Adolescent Mindfulness Measure questionnaire and to the Pain Catastrophizing Scale (questions such as “When I have pain I feel I can’t stand it anymore). They were asked about their daily pains, such as headache, stomachache, tooth pain, muscle pain, back pain. They were also subjected to experimental pain, which was produced by submerging their hand into ice cold water. The results showed that mindfulness had a direct effect on pain interference with daily activity and an indirect effect on the experimental pain intensity and tolerance by producing less catastrophizing.

The good news is that mindfulness is something that can be learned by meditation and can be taught as part of a course of cognitive-behavioral therapy. Kids with migraines, headaches, and other pains should be always advised to start with meditation, biofeedback, or cognitive-behavioral therapy.

The risk of dying from a variety of causes can be reduced by exercise, according to a new study published in the British Medical Journal. The effect of exercise was as strong as the effect of drugs for the prevention of diabetes, coronary heart disease, rehabilitation of stroke, and treatment of heart failure. The authors reviewed 305 previous trials that involved almost 340,000 people, making their findings very reliable.

Exercise has been also proven to prevent migraine headaches (see my previous post). This finding was based on a review of over 46,000 patient records, also a very large number that suggests a true effect. Most people don’t need these studies to convince them of the benefits – they know that exercise improves their headaches and makes them feel better. The most common problem is lack of time and motivation. However, headaches also cost time and reduce productivity, so exercising 30 minutes four days a week will save time.

Doctor recommendations often do influence their patients’ behavior and doctors need to remember to emphasize to their patients the importance of exercise, both for headaches and other conditions.

Vitamin D seems to prevent relapses of multiple sclerosis, according to a large study by Dr. Ascherio and his colleagues at the Harvard School of Public Health. My previous posts mentioned that a high proportion of migraine sufferers have low vitamin D levels and that low vitamin D levels have been associated with Alzheimer’s disease, other dementias, and strokes. This latest study of patients with MS indicates that those with higher levels of vitamin D did better than those with lower, even if the lower level was still within normal range. Studies of vitamin D in other conditions also reported similar findings of progressive benefits with increasing levels. Many laboratories consider a level between 30 and 100 to be normal. However, even in the absence of definitive proof of benefit, it is probably prudent to aim for a level of at least 50. Just taking vitamin D, even at doses of 2,000 to 5,000 units a day does not guarantee a good level because many people do not absorb it well. Ideally, you should have your vitamin D level rechecked after taking vitamin D for a few months.

A study of 13,573 people by a Harvard physician Catherine Beuttner examined the role of nutrition in patients with migraines and severe headaches. Among these participants of the National Health and Nutrition Examination Survey who were 20 years old or older, 22% or 2,880 suffered from migraines or severe headaches. A large variety of factors that could influence headaches were examined, including age, sex, race/ethnicity, education, smoking, alcohol intake, physical activity, health status, body mass index, diabetes, and number of prescription medications used. Sophisticated statistical analysis established that carbohydrate intake as a percentage of energy consumption and caffeine use were associated with higher prevalence of migraine and severe headaches. On the other hand, fiber intake appeared to reduce the prevalence of migraines and severe headaches. Dr. Beuttner also discovered that intake of foods rich in folate (folic acid, or vitamin B9), thiamine (vitamin B1), and vitamin C was also associated with lower prevalence of migraines and severe headaches.

This large study confirms some of the previous reports about the role of carbohydrates and caffeine in the development of headaches. According to one small study, three out of four migraine sufferers have reactive hypoglycemia. Reactive hypoglycemia is a condition that causes blood sugar to drop too low after eating a carbohydrate-rich meal. This drop of sugar seems to trigger headaches. Many migraine sufferers figure this out on their own and reduce their carbohydrate intake, but some fail to make this connection. So, if you suffer from severe headaches try eating small frequent meals that are low in carbs.

Caffeine is a well-known and proven trigger of migraine headaches. Caffeine can sometimes cause headaches directly, but more often headaches occur due to caffeine withdrawal. This is why many people wake up in the morning with a headache – they’ve gone all night without caffeine. Since caffeine is a short-acting drug withdrawal can occur throughout the day leading people to consume more and more caffeine. Eventually the headache become constant with some improvement after each dose of caffeine, whether it is from coffee, soda, strong tea or medications, such as Excedrin, Anacin, Fioricet, and Fiorinal. Getting off caffeine is the only way to stop these headaches. It can be done gradually or “cold turkey”. Your doctor can prescribe medications to make this process less painful because headaches will get worse before they get better. These medications may include triptans (Imitrex, Maxalt, and other), Migralex, or naproxen (Aleve). Botox injections can also help. Many of my patients argue that caffeine is not the cause of their headaches since headaches started long before they were consuming any caffeine. It is true that caffeine does not cause headaches, but if you suffer from migraines and other headaches, caffeine can make them worse. And getting off caffeine may not eliminate all headaches, but will make them much more amenable to treatment.

As far as folic acid and vitamin B1, there have been some studies proving that B vitamins (including B12) can prevent migrianes, but fiber and vitamin C have not been reported to help headaches in the past.

In summary, if you suffer from migraines or severe headaches try to keep your carbohydrate intake low, eliminate caffeine, increase your intake of foods rich in fiber, B vitamins, and vitamin C. You may also want to consider taking a supplement of these vitamins, along with B12, magnesium, CoQ10, and possibly some herbal products mentioned earlier in my blog or on our main site, nyheadache.com.

Art credit: JulieMauskop.com

Omega-3 and omega-6 fatty acids are needed for our body to produce pain-relieving and pain-enhancing substances. Researchers at the University of North Carolina at Chapel Hill conducted a randomized, single-blinded, parallel-group clinical trial, which was published in the journal Pain, to assess clinical and biochemical effects of changing the dietary intake of omega-3 and omega-6 fatty acids on chronic headaches.

After a 4-week baseline, patients with chronic daily headaches undergoing usual care were randomized to 1 of 2 intensive, food-based 12-week dietary interventions: a high omega-3 plus low omega-6 intervention, or a low omega-6 intervention. Clinical outcomes included the Headache Impact Test, which measures headache-related disability, headache days per month, and headache hours per day. They also measured omega-3 and omega-6 levels in red blood cells. Fifty-six of 67 patients completed the intervention.

The first intervention (increasing omega-3 and lowering omega-6) produced significantly greater improvement in the Headache Impact Test score and the number of headache days per month compared to the second group (lowering omega-6). The first intervention also produced significantly greater reductions in headache hours per day. The authors concluded that dietary intervention increasing omega-3 and reducing omega-6 fatty acids reduced headache pain and improved quality-of-life in chronic headache sufferers.

The omega-3 fatty acids are generally considered good and the omega-6 are considered bad, but it appears that what is more important is the balance between the two types. The known beneficial effects of fish oil include their effect on the heart, brain, peripheral nerves, mood, inflammation, as well as headaches. There is little downside to taking omega-3 supplements, as long as you buy fish oil from a reputable store chain or a well-know brand, which is purified of mercury.

A variety of electrical devices have been tried for the treatment of headaches and have been mentioned in several of my previous blogs. One study showed that passing direct current through the head may help migraines and depression. Another study recently presented at the joint meeting of the International and American Headache Societies showed that passing alternating current, just like done by any TENS (transcutaneous electric nerve stimulation) machine, but using a proprietary device, Fisher Wallace Stimulator, did not provide relief. This study performed by Dr. Tietjen and her colleagues in Ohio was blinded and involved 50 patients. They applied the stimulator for 20 minutes every day for a month with one half receiving stimulation and the other half not. After a month both groups used real stimulation for another month. While this device did not cause any serious side effects, it also did not help. Hopefully, we will soon see results of large studies using direct current stimulation since this method appears to be more promising than alternating current used in TENS devices.

Fish oil supplements may protect the heart in stressful situations, according to a study conducted in Michigan with 67 healthy volunteers. The researchers, led by Jason Carter, looked at the effect of fish oil on body’s stress response. The volunteers were given either nine grams of fish oil pills or nine grams of olive oil as a placebo, over a two-month period. The heart rate, blood pressure and other parameters were measured before and after the study.

After two months, both groups took a math test, which involved adding and subtracting numbers in their head. Their stress response was measured. Those who took fish oil supplements had a milder response to mental stress, including heart rate and sympathetic nervous system activity, which is part of the “fight or flight” response, compared to those who took olive oil instead.

The author concluded that “these results show that fish oil could have a protective effect on cardiovascular function during mental stress, a finding that adds a piece to the puzzle on why taking fish oil helps the heart stay healthy,”

This study supports the evidence that the omega-3 fatty acids have positive health benefits on the nervous and cardiovascular systems.

The author concluded that “In today’s fast-paced society, stress is as certain as death and taxes,” he added. “Moreover, our eating habits have deteriorated. This study reinforces that fish oils may be beneficial for cardiovascular health, particularly when we are exposed to stressful conditions.”

He also suggested “If you don’t do it already, consider taking fish oil supplementation, or better yet, eat natural foods high in omega-3 fatty acids.” Such foods include Alaska salmon, rainbow trout and sardines.

As far as the effect of omega-3 fatty acids on headaches, there is only one small but blinded study of 15 patients that suggests that they might help prevent migraines. Considering that in addition to counteracting the effect of stress, a major migraine trigger, omega-3 fatty acids reduce inflammation (which is one of the underlying processes during a migraine attack), it is very likely that omega-3 fatty acids may help some migraine sufferers.

Most people do not eat enough fish, so it makes sense to supplement your diet with omega-3 fatty acids. It is important to make sure that the brand you take does not contain mercury and other impurities. One of the brands I came across recently, Omax3 was developed by physicians from Yale university. It is pure and concentrated, meaning that you need to take only 2 capsules a day to get 1,500 mg of omega-3s. Most people who do take a supplement often don’t take enough of it. The study mentioned above used 9 grams of fish oil daily, while the headache study used 15 capsules with each containing 300 mg of omega-3s. To get the same amount from Omax3 you’d have to take 6 instead of 15 capsules.

Art credit: JulieMauskop.com