Cognitive-behavioral therapy (CBT) has been convincingly proven to help pain and headache sufferers. Many people are very skeptical about the value of psychological treatments and tell me, just get rid of my migraines and I will be fine. Unfortunately, sometimes it takes time to relieve chronic headaches and pain. So, while we are trying to find relief, it helps to learn how to function better despite pain, how not to panic and become completely paralyzed by headaches, how to inform and interact better with family, friends, and employers. Research indicates, that people who take charge of their care, get involved in working with the doctor to find relief, learn relaxation techniques, rather than just sit back and wait for doctors to “fix” the problem, do much better. CBT, which usually involves relaxation training, is one way to improve your care and it usually involves 8 to 12 structured sessions. Here is an example of what might take place during these sessions:
1. Three-component CBT model (thoughts, feelings, behaviors), pain monitoring
2. Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery)
3. Migraine trigger avoidance
4. Pain-fatigue cycle, activity pacing, and pleasant event scheduling
5. Identifying and challenging negative thoughts (Activity, Belief, Consequences, Dispute model)
6. Problem-solving skills training and assertive communication
7. Review and practice
8. Review and practice
9. Relapse prevention
Another form of CBT is Acceptance Commitment Therapy (ACT) and this is what a typical schedule of sessions of ACT looks like:
1. The limits of control (short and long-term costs and benefits; finger
traps), focus on experience (body scan)
2. Values (what you care about, how you want to live your
life)
3. Cognitive defusion (observing thoughts without trying to evaluate or
change them)
4. Mindfulness (being in the moment, raisin exercise)
5. Committed action (“road map” connecting values, goals, actions,
obstacles, and strategies)
6. Review and continued action in support of values
7. Review and continued action in support of values
8. Moving forward
CBT usually is conducted by a a social worker or a psychologist and sometimes this treatment is covered by insurance. Group sessions have also been shown to be effective. However, sometimes insurance does nor cover this service or a therapist is not available. Online, web-based CBT seems to work too. Two Australian web sites offer free CBT for anxiety, depression and other problems, although they are not specifically tailored for people with headaches or pain. ThisWayUp.org.au and moodGYM.anu.edu.au are both excellent free resources for people who are looking for help, but cannot find or afford a therapist. The psychologists who developed and run these sites published results of their treatments in scientific journals, showing that self-taught CBT can be very effective. Here is a schedule of lessons for anxiety and depression on ThisWayUp website:
Lesson 1
About anxiety and depression
Learn about your own symptoms of anxiety and/or depression, and learn to tackle the physical symptoms of anxiety/depression.
Lesson 2
Identifying thoughts and tackling low activity
Learn to identify the thought symptoms of anxiety/depression, and learn to tackle the behaviours associated with anxiety/depression.
Lesson 3
Tackling thoughts
Learn to tackle the thought symptoms of anxiety/depression.
Lesson 4
Tackling avoidance
Learn to tackle avoidance behaviours associated with anxiety/depression by facing your fears.
Lesson 5
Mastering your skills
Learn to master your ability to face your fears using graded exposure, and learn to cope with the distressing emotions associated with anxiety/depression.
Lesson 6
Staying well
Learn how to avoid relapses and how to keep getting better!

There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and other topical products can provide relief of milder headaches. There are no scientific studies proving that these treatments work beyond the placebo effect, although we do have some evidence established by Hartmut Gobel and his colleagues in Germany suggesting that the smell of peppermint can provide some pain relief. So it is possible, that the smell of herbs in Tiger Balm and possibly the cooling effect of these ointments combined with placebo effect is what accounts for the popularity of these products.
I have been using a prescription ointment for some of my patients with headaches and neck pain. This ointment has to be prepared by a compounding pharmacy and typically is not available from big chains, such as CVS or Walmart, although Walgreens does offer compounding services at some of its pharmacies. We do not have any information about the best combination of ingredients to use for the relief of headaches and pain. However, some studies indicate that topical skin application of some products does provide relief. Ketamine, which blocks the so called NMDA pain receptor can relieve pain of complex regional pain syndrome, a very serious and painful condition. Application of clonidine, a blood pressure medication has been shown to relieve pain of diabetic neuropathy – painful nerve damage due to diabetes. We also know that lidocaine is very effective when applied to the skin and it is the active ingredient in a prescription pain patch, Lidoderm. Anti-inflammatory drugs, such as aspirin or similar salicilate drugs (Aspercreme), diclofenac (Flector patch), piroxicam and other also help pain when applied to the skin. There are no studies of topical application of muscle relaxants, such as baclofen and tizanidine or an epilepsy drug gabapentin, but these drugs are often also included in compounded creams.
My usual prescription is to combine ketamine with lidocaine, piroxicam and baclofen. Unfortunately, we do not know what is the most effective combination and it would be very difficult to compare so many available ingredients in a scientific study. However, these creams are safer than oral drugs and for some patients can be as effective. Another drawback of the compounded products is that insurance often will not pay for it.

Omega-3 fatty acids (most abundantly found in fish oil) may relieve migraine headaches but only one small study found this to be the case. However, there is mounting evidence for beneficial effects of omega-3 fatty acids for various conditions, such as strokes, heart disease, dementia, and other. A just published study in the journal BMC Cancer shows that omega-3 fatty acids prevent nerve damage caused by a chemotherapy drug used to treat breast cancer. Paclitaxel (Taxol) caused peripheral neuropathy in 60% of women who received placebo and in only 30% of those who were given omega-3 fatty acids (640 mg three times a day). Using this safe and natural supplement may allow many more women receive this life-saving chemotherapy without causing crippling side effects. Considering all of the positive studies of fish oil for a variety of neurological and other conditions and, considering its safety and low cost, it is reasonable to try this supplement for the prevention of migraine headaches despite the lack of definitive studies.

Slow breathing can reduce pain, according to a recently published study in The Journal of Pain. Researchers at the University of Tulsa led by Satin Martin evaluated the effect on pain of slow breathing, normal and fast breathing in 30 healthy volunteers. Pain was induced by an electric shock to the leg. Slow breathing (50% of normal rate) significantly reduced pain perception when compared to normal or fast (at 125% of normal rate) breathing. Slow breathing has been long utilized for the reduction of pain and is usually included in biofeedback, meditation, and other relaxation methods. This study provides solid scientific support for this simple and ancient technique, which should be utilized more widely in the management of pain, including migraine and other headaches.

Extraordinary benefits of meditation are described in the current issue of Neurology Now – The American Academy of Neurology’s Magazine for Patients & Caregivers”. Dr. Mauskop is extensively quoted in this article.

Many patients ask about the best type of magnesium supplement to take for the prevention of migraines and other symptoms. Research studies have compared magnesium oxide with chelated magnesium and a slow release form of magnesium chloride and showed that all three types are absorbed equally well. I usually recommend starting with 400 mg of magnesium oxide but chelated magnesium is also very inexpensive and either one can be effective. However, if one type of magnesium causes upset stomach or diarrhea, another one should be tried. Chelated magnesium is a form of magnesium which is attached to an amino acid and depending on the amino acid it is called magnesium aspartate, glycinate, gluconate, orotate, malate, and other. Besides chelated and magnesium oxide, magnesium citrate or carbonate can be tried. When these magnesium salts are not tolerated or not absorbed, slow release forms should be considered, although they are much more expensive. There are two slow release forms, Mag Tab SR (containing magnesium lactate) and Slow Mag (magnesium chloride with calcium). Each tablet of these two products contains only a small amount of magnesium and the daily dose is at least 4 tables. Presence of calcium in Slow Mag may impair absorption of magnesium, making Mag Tab SR the preferred product. People who need to take calcium as well as magnesium should be taking these two separately because calcium interferes with the absorption of magnesium. The reason calcium and magnesium are often combined in one pill (Cal-Mag, Slow Mag, and other) is that magnesium helps improve the absorption of calcium, so it would not be too much to take Cal-Mag with one meal and magnesium alone with another. Patients with serious kidney problems should not be taking magnesium or any other supplements without consulting their nephrologist and having regular blood tests.

Boswellia extract may relieve migraine, cluster and indomethacin-responsive headaches. Boswellia serrata (Indian frankincense) has been long reported to relieve migraines, although I could not find any scientific articles. A study recently published in journal Cephalalgia by Christian Lampl and his colleagues describes four patients with chronic cluster headaches whose headaches improved after taking Boswellia extract. The dose of Boswellia was 350 to 700 mg three times a day. All four patients failed at least three standard preventive medications for cluster headaches, such as verapamil (Calan), topiramate (Topamax), and lithium. It is very surprising that an herbal remedy helps what many consider to be the most painful type of headaches.
Dr. Eric Eross reported that Boswellia extract was also reported to help another very severe headache type – indomethacin responsive headache syndrome. Of the 27 patients with this type of headaches who were given Boswellia, 21 responded. The starting dose was 250 mg three times a day and then the dose was increased as needed, although it is not clear what the highest dose was. Indomethacin is a very strong non-steroidal anti-inflammatory medication, but it also tends to have strong gastro-intestinal side effects.
Finding a safe natural alternative is a very important discovery. Unlike butterbur, Boswellia has no toxic ingredients and is safe to consume in any form. The mechanism of action of Boswellia is not entirely clear, but it seems to have anti-inflammatory properties similar to aspirin. Obviously, it does more than that since aspirin is usually ineffective for cluster or indomethacin-responsive headaches.

Photo credit: wikipedia

We no longer recommend butterbur to our patients. We participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in the leading neurological journal – Neurology and the American Academy of Neurology recently endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex and other brands), where it had to pass strict safety studies. However, Germany is no longer allowing butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur made in Germany and in the US is still sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany. This is why we no longer recommend butterbur for our patients.

Behavioral therapies, such as biofeedback, progressive relaxation, cognitive therapy, and other alternative therapies are routinely recommended only by a quarter of headache specialists, according to research presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles by Robert Nichols of St. Louis. This despite the fact that these therapies are considered proven (so called, Grade A evidence) to relieve migraine and other headaches. Physicians are more likely to prescribe medications, even if they are less proven to work and carry a risk of serious side effects, which are absent with behavioral therapies. Cost of biofeedback and cognitive therapy can be one of the obstacle for some patients, but many techniques such as relaxation training or meditation are inexpensive and are easily learned without the help of a mental health professional. Other studies have shown that combining a behavioral technique with a preventive migraine medication results in better outcomes than with either therapy alone. So, if you take a medication it does not mean that you could not find additional relief from behavioral approaches, as well as aerobic exercise, magnesium, and other alternative therapies.

Biofeedback is an excellent preventive headache treatment with its efficacy proven in many rigorous studies. What prompted me to write this blog post is seeing yet another child (I see kids with headaches aged 10 and older) who had seen his pediatrician and a pediatric neurologist and neither physician mentioned biofeedback. Instead, they just prescribed drugs. Biofeedback is very effective for adults as well, but seeing a 10-year-old child with headaches who is prescribed medications as the only option was somehow more upsetting than when I see and adult under the same circumstances. Children tend to learn biofeedback with greater ease than adults – sometimes they need only 4 – 5 sessions instead of the usual 10 or more. Biofeedback is a way to learn to relax and stay relaxed under pressure, at least relaxed as far as your body goes, if not the mind. The person learning biofeedback is usually connected to a computer by a probe which measures body’s temperature or muscle tension (or brain wave activity in case of neurofeedback). The computer displays this information on the screen, which helps you learn how to relax your body. Biofeedback is taught by a psychologist, a nurse or another trained professional. Some insurers will cover this treatment, but many do not. Fortunately, studies show that self-taught relaxation training can be as effective as biofeedback. There are many free sources and some that you can buy. Many people are skeptical about biofeedback, but there is a simple explanation why it works. You are supposed to stop for a minute or even less to take an inventory of neck, facial, and other muscles, to make sure you are not tensing them up, then take a few deep breath. This will bring your tension down just a little, but if you repeat this one minute exercise every hour, at the end of the day you will avoid having knots in your shoulders and your neck and may avoid a headache. Eventually, this exercise becomes subconscious as you automatically monitor your body and whenever you feel that you are frowning, holding shoulders up, or holding your breath, you stop doing that without having to pause.
In addition to biofeedback and obvious sleep, exercise, and food recommendations, I suggest that all children take a magnesium and CoQ10 supplements. Both have been shown to help children with migraines.

Risks involved in using Chinese herbs are highlighted in the just released AFP report, which you can read on Yahoo News. Here is an edited quote from this story: The samples analyzed for this study included herbal teas, capsules, powders and flakes were tested by scientists at Australia’s Murdoch University. 68 different plant families that were detected in the 15 samples can be toxic if taken in the wrong doses, but the packaging did not list the concentrations of the elements inside.
I am a big proponent of alternative and complementary medicine, recommend herbs, and am a certified acupuncturist. I think acupuncture and many herbal products have a place in the modern medicine because they’ve been shown to be effective. However, many people who go to acupuncturists are often given Chinese herbs along with acupuncture. Unfortunately, there is very little or no quality control in the production of the Chinese herbs. The most dramatic example of this problem was described in the New England Journal of Medicine in 2000 – an herb people were taking for weight loss was contaminated by a toxic plant which caused kidney failure and urinary cancer in 18 of 105 patients. China (just like India, Russia, etc) still has extreme levels of corruption, which means that we cannot rely on their herbal products unless they are first tested in an American laboratory for purity. For now, stick with herbal products made in the US or Western Europe. Feverfew, boswellia, ginger, valerian root, and other are available from major manufacturers, such as Solgar, GNC, Nature Made, and other.

Omega-3 fatty acids, found in fish oil, have been reported to relieve migraine headaches, although the only such study was relatively small. The dose of omega-3 fatty acids was 6 grams taken daily as a preventive treatment for migraines. A recent study published in Neurology shows another reason to take fish oil. Researchers at UCLA measured levels of omega-3 fatty acids, DHA and EPA in red blood cells of 1,575 healthy people with an average age of 67 +/- 9 years. They discovered a strong correlation between low levels of DHA and EPA and shrinking of the brain as well as impaired cognitive function even in people without any signs of dementia. High fish intake has been associated with reduced risk of death from heart disease and strokes and this study shows another highly beneficial effect of omega-3 fatty acids.