I. Migraine Without Headache
It is also known as migraine aura without headache or Silent Migraines. Migraine aura without headache should be considered as a diagnosis in anyone who has recurrent episodes of transient symptoms, especially those that are visual or neurological or involve vertigo. Visual and neurological symptoms due to migraine are not unusual and most commonly occur in older persons with a history of migraine headaches. Migraine aura without headache should be diagnosed only when transient. Migraine auras are reversible and recurrent episodes of neurological symptoms that resolve within 1 hour. They are associated with migraine but may not precede a headache, according to "Migraine aura without headache:
Benign, but a diagnosis of exclusion" by ROBERT S. KUNKEL, MD Consultant, Headache Center, Department of Neurology, The Cleveland Clinic Foundation (Page 529)(a)
I. Symptoms
A. Since it is a chronic condition with recurrent attacks, pain is usual very intensive and divided into 4 possible phases(1)
1. The prodrome
The prodrome symptoms happen in 40–60% of those with migraines is an occurrence of early symptoms indicate the start of a migraine headache attacks, including altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food, etc.. In the study of a total of 893 migraine patients (IHS 1.1-1.7) were evaluated at first visit. Prodrome frequency, duration, and characteristics were analyzed in the total migraine population IHS 1.1-1.7 and IHS 1.1-1.6 migraine conducted by Leslie Kelman MD, found that A total of 32.9% of IHS migraine 1.1-1.6 patients reported prodrome symptoms with an average of 9.42 hours. IHS 1.1-1.7 migraine reported 29.7% and 6.8 hours, respectively. The most commonest symptoms were tiredness, mood change, and gastrointestinal symptoms; all three of these symptoms were present together in 17% of the patients with prodrome. The duration of prodrome was less than 1 hour in 45.1%, 1-2 hours in 13.6%, 2-4 hours in 15.0%, 4-12 hours in 13.1%, and greater than 12 hours in 13.2%. IHS 1.1-1.7 patients showed similar findings.(2)
2. The aura
The aura, happens to approximately 20 -40% Migraine sufferers. In general, the symptoms of comprised focal neurological phenomena appear gradually over five to 20 minutes and last fewer than 60 minutes. But in some cases, a sudden onset of severe bilateral facial pain radiating bilaterally into the medial cervical region after defecation. The pain was accompanied by scotomas in the right visual field and hypaesthesia in both upper limbs of that required medical attention.
3. The pain phase
The headache phase of the migraine attack usually begins within 60 minutes of the end of the aura phase. The pain of the headache is intense, throbbing from moderate to severe, may be bilateral or unilateral at the onset, and occur on one side or alternate sides from one attack to the next.
4. The postdrome
After the pain phase, 68% of the sufferers may experience the postdrome of which can be lasted for average of 24 hours, including tiredness (71.8%), head pain (33.1%), cognitive difficulties (11.7%), ‘hangover’ (10.7%), gastrointestinal symptoms (8.4%), mood change (6.8%), and weakness (6.2%) with commonest symptoms being tiredness and low-grade headache(3)
B. The symptoms
Migraine Without Headache shares all the symptoms of other migraine headache but with no headache pain, but some researchers believe Migraine Without Headache are Episodic Neurologic Symptoms(a), sharing the following features: (1) They are intermittent; (2) they are recurrent; (3) they are usually brief, lasting minutes to hours; (4) the patient is usually asymptomatic between attacks; and (5) the symptoms are usually stereotyped for an individual patient (b), with the auras slowly develop over a few minutes and last less than 60 minutes, according to the International Headache Society, migraine auras
1. Visual symptoms
a. Flashing lights
b. dots or spots in vision
c. Partial alteration in one's field of vision
d. Blind spots
e. Tunnel vision
f. Double vision
g. Blindness
h. Vision images appear distorted
i. Etc.
2. Neurological symptoms
a. Sensation of tingling
b. Burning, pricking
c. Numbness
d. Pricking
e. Vertigo
f. Amnesia
g. Confusion
h. Irritability
i. Hearing loss
j. Euphoria
k. Weakness on one side of the body
l. Etc.
3. Physical symptoms
1. Cyclic vomiting
2. Thirst
3. Increased urination
4. Fatigue
5. Recurrent abdominal pain
6. Coronary artery spasm
7. circulatory disorder
8. Etc.
II. Causes and risk factors
A. Causes
Migraine without headache is a result of a attack apparently starts in the brainstem and involves activation of the fifth cranial nerve (CNV), containing both sensory and motor fibers and areas of the cortex, that lead to release of various peptides and other vasoactive substances at the neurovascular junction, causing constriction followed by dilation of blood vessels, resulting of blood vessels inflammation.
B. Risk factors
Even though Migraine Without Headache can happen to anyone in any age with out history of migraine, but older people who have suffered with migraine with aura headache in Young age at higher risk to develop migraine without headaches
III. What trigger Migraine without Headache
Reduction of cardiovascular risk factors, smoking cessation and use of non-estrogen-containing oral contraceptives in female patients are beneficial strategies to reduce the risk of ischaemic events in patients with migraine (especially those with aura). Attack frequency, acute medication overuse, obesity and coexisting depression and anxiety disorders are particularly strong but potentially modifiable independent risk factors for progression to chronic migraine(d)
1. Cigarette smoking
Researchers in Geisinger Wyoming Valley, Department of Neurology, Wilkes-Barre, PA, USA., may have found the link between cigarette smoking and the development of cranial autonomic symptoms with migraine, according to "A history of cigarette smoking is associated with the development of cranial autonomic symptoms with migraine headaches" by Rozen TD.(4)
2. Trigeminal nerve and autonomic reflex
Scientist at the Texas Tech University Health Sciences Center - Cell Physiology and Molecular Biophysics, Lubbock, TX 79430, USA. have found out that the Migraine Headaches were initiated by night guard-initiated irritation of the trigeminal nerve and a trigeminal autonomic reflex resulting in unilateral migrainous headache with autonomic signs, according to "Unilateral or "side-locked" migrainous headache with autonomic symptoms linked to night guard use" by Strahlendorf J, Schiffer R, Strahlendorf H.(5)
3. Depolarization
Some researchers suggested that migraine with aura may be result of the spreading depolarization which describes a wave in the gray matter of the central nervous system characterized by swelling of neurons, distortion of dendritic spines, a large change of the slow electrical potential and silencing of brain electrical activity (spreading depression) of that cause migraine headache and increase the risk of developing an ischemic stroke(6)
4. Hormonal contraceptives
Some reserachers suggested that women who use hormonal contraceptives and hormone replacement treatment may increase the risk of migraine occurrence.(7)
5. IgE levels
There are no direct evidence to associate migraine headache to cow's milk or egg-white allergy. However, the elevation of egg-white-specific IgE levels in migraine-type headache may signify the possible presence of shared pathogenetic pathways in the development of migraine and food allergies(8)
6. Stress
Stress can have an impact on one’s mental and physical well-being, including migraine headache. Stress describes a negative concept, life events, and concomitant psychosomatic illnesses should be considered important when evaluating individuals with migraine, and gender aspects need to be taken into account(9)
7. Serotonin
Serotonin, a type of neurotransmitter, passes messages between nerve cells, low serotonin levels in the brain may increase the risk of the process of constriction of the blood vessels as it alters levels of dopamine and stress hormones, and may be part of a complex cellular membrane trafficking dysfunction involving not only the serotonin transporter but also other transporters and ion channels of which trigger a migraine (10)
8. Reduced Magnesium Levels
Magnesium, plays an essential in many intracellular processes and in migraine pathogenesis, low levels of magnesium may promote cortical spreading depression, hyperaggregation of platelets, affect serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters of which can trigger migraine headache(11)
9. Maxillary alveolar mucosal inflammation
Migraine, tension-type headache and facial pain patients are found to be associated with a maxillary alveolar mucosal inflammation and can be treated by chilling, application of anti-inflammatory gel and low-level (non-cutting) laser. Local treatment also mediates cervical muscle spasm, adding to its overall effectiveness(12)
10. Other causes
Beside the factors above, out of 126/179 replies, other factors triggering migraine attack include too much work (under the stress category 54/64), reflected sunlight (under the light category 35/44), too little sleep (under the sleep category 19/24), red wine (under the alcohol category 20/22), passive smoking (under the smoke category 11/11), menstruation (under the menstruation or break from the pill category 12/14) and perfume (under the fumes/heavy scents category 12/15). Hormones, light and stress were reported to cause at least 50 % of MA attacks in 62%, 47% and 42% of participants, respectively. No participants reported alcohol to be the trigger of 50% or more of their attacks. In the groups of participants with "light", "fumes/heavy scents", "smoke" or "physical effort" as triggers, nearly all patients reported that an exposure time to the trigger of less than 3 hours (90-100% of patients) was necessary to trigger an attack and a latency to onset of attack of less than 3 hours (90-100% of patients) in the study conducted by University of Copenhagen and Glostrup Hospital, Denmark J. (13)
11. Abnormal Calcium Channels
Abnormal Calcium Channels can interference with cells in the transportation of necessary minerals of which increase the risk of Migraine Headaches. some researchers found that mutated Ca(V)2.1 channels activate at more hyperpolarizing potentials and lead to a gain-of-function in synaptic transmission. This gain-of-function might underlie alterations in the excitatory/ inhibitory balance of synaptic transmission, favoring a persistent state of hyperexcitability in cortical neurons that would increase the susceptibility for cortical spreading depression (CSD), a mechanism believed to initiate the attacks of migraine with aura.(14)
12. Etc.
IV. Complications and Consequences
A. Complications
Complications of migraine headaches can be divided into the following, according to the International Headache Society's classification of headaches.
1. Chronic migraine
Chronic migraines is defined as headaches in the absence of medication overuse, occurring on ≥15 days per month for ≥3 months, of which headaches on ≥8 days must fulfill the criteria for migraine is that they continue over a long period of time. It is also known as transformed migraine, as chronic migraines can evolve (or transform) from episodic to almost daily headaches with mild symptoms (15)
2. Status migrainosus
Status migrainosus is defined as a condition of migraine episodes that persist for less than 3 days, but in most case, there are periods of relative relief, but these generally last no longer than four hours. With symptoms similar general migraine. Dihydroergotamine and the triptans, has found to reduce the number of headache episodes that persist after initial treatment or fail to respond to self-administered therapy(16)
3. Persistent aura without infarction (PAWI)
Persistent aura without infarction (PAWI) is a rare complications of migraines with neurological and ophthalmological examinations. The visual symptoms is a result of decreased left fronto-parieto-occipital and right occipital blood perfusion.(17)
4. Migrainous infarction
Migrainous infarction is a rare complication after usual attacks of migraine with aura. Some studies suggested that "possible" cases of migrainous infarction should undergo an extended diagnostic workup to rule out symptomatic migraine due to extra/intra-cranial vascular pathology (artery dissection/malformations, venous thrombosis) and to exclude a causal role for other conditions(18)
5. Migraine seizures
A migraine seizure is an epileptic seizure that follows a migraine with aura, meeting the definition for a migraine with aura, and an epileptic seizure must occur within one hour of the migraine aura. Some researchers suggested thatthe occurrence of common susceptibility loci for epilepsy and migraine on chromosomes 14q12-q23 and 12q24.2-q24.3, implicating a shared genetic etiology for these 2 diseases(19). Other suggested the hypothesis of modification in threshold of cortical hyperexcitability from migraine to epilepsy.(20). Symptoms of the complication include some sort of visual change or loss, zigzagging lines, bright flashes, etc.
B. Medical consequences
1. Stroke
Migraine migraine with aura headache can increase the risk of ischemic stroke in women of childbearing age, according to "Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age" by Donaghy M, Chang CL, Poulter N; European Collaborators of The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.(21)
2. Epilepsy
There is a link associated between headache/migraine and epilepsy by using the PubMed data base, according to "Links between headaches and epilepsy: current knowledge and terminology.[Article in English, Spanish]" by Caminero A, Manso-Calderón R.(22)
3. Vascular diseases
Some researchers suggested that women who use hormonal contraceptives and hormone replacement treatment may increase the risk of migraine occurrence and administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease(23)
4. Erectile dysfunction
There are indication that ED is associated with having been previously diagnosed with migraines, particularly in younger populations in 5763 patients with ED as in the cases study of randomly selected 17,289 patients as the controls conducted by National Taiwan University, and Taipei Medical University(24)
5. Celiac disease
Celiac disease is defined as a digestive disease that damages the small intestine as a result of an immune-mediated toxic reaction of which interferes with absorption of nutrients from food. People with Celiac disease cannot tolerate gluten and 28% of the patient found to be association with migraine(25)
6. Etc.
C. Diseases associated with Migraines
1. Oxidative stress
Oxidative stress are associated with increased risk of migraine metabolic risk such as nitrosative stress, an atherogenic lipid profile and hyperinsulinemia(26)
2. Obesity
In the study of One hundred and twenty-four patients (77 female, 36 with aura; mean age 12.9 +/- 2.8 years; age range 4.0-17.0 years) conducted by Baskent University, the percentage of obesity was 17.7. Although pain severity and duration were not different among groups, obese patients had more frequent attacks than the overweight and normal weight patients (5.3 +/- 2.4, 4.4 +/- 2.4 and 3.8 +/- 2.4 attacks/month, respectively, P = 0.018)(27)
3. Depression and anxiety disorders
Depression and anxiety disorders obese migraineurs. The relationship of obesity with migraine frequency and migraine-related disability is modified by depression and by anxiety, with the strongest effect observed in migraineurs with both depression and anxiety.(28)
4. Cerebellar Brain Infarctions
Cerebellar Brain Infarctions refers to to the death of brain cells which control cognitive functions as a result of a local lack of oxygen due to obstruction of the tissue's blood supply. In the article of "Migraine with Aura in Women Is Associated with Cerebellar Brain Infarction", Dr. S. Andrew Josephson, MD wrote"Infarcts were significantly more commonly found in women with migraine with aura than in those women without headache (31% vs. 25%; p=.04), but no significant differences were seen in men; this difference in women persisted after adjustments for age, sex, and follow-up time. Cerebellar infarctions, but not those in the cortical or subcortical regions, were significantly more common in women with migraine with aura compared with those without headache. No significant differences were seen in cerebellar infarcts among men. Migraine without aura and non-migraine headache were not associated with any increased risk of infarction"(29)
5. Stroke
Migraine migraine with aura headache can increase the risk of ischemic stroke in women of childbearing age, according to "Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age" by Donaghy M, Chang CL, Poulter N; European Collaborators of The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.(30)
6. Epilepsy
There is a link associated between headache/migraine and epilepsy by using the PubMed data base, according to "Links between headaches and epilepsy: current knowledge and terminology.[Article in English, Spanish]" by Caminero A, Manso-Calderón R.(31)
7. Vascular diseases
Some researchers suggested that women who use hormonal contraceptives and hormone replacement treatment may increase the risk of migraine occurrence and administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease(32)
1. Oxidative stress
Oxidative stress are associated with increased risk of migraine metabolic risk such as nitrosative stress, an atherogenic lipid profile and hyperinsulinemia(26)
2. Obesity
In the study of One hundred and twenty-four patients (77 female, 36 with aura; mean age 12.9 +/- 2.8 years; age range 4.0-17.0 years) conducted by Baskent University, the percentage of obesity was 17.7. Although pain severity and duration were not different among groups, obese patients had more frequent attacks than the overweight and normal weight patients (5.3 +/- 2.4, 4.4 +/- 2.4 and 3.8 +/- 2.4 attacks/month, respectively, P = 0.018)(27)
3. Depression and anxiety disorders
Depression and anxiety disorders obese migraineurs. The relationship of obesity with migraine frequency and migraine-related disability is modified by depression and by anxiety, with the strongest effect observed in migraineurs with both depression and anxiety.(28)
4. Cerebellar Brain Infarctions
Cerebellar Brain Infarctions refers to to the death of brain cells which control cognitive functions as a result of a local lack of oxygen due to obstruction of the tissue's blood supply. In the article of "Migraine with Aura in Women Is Associated with Cerebellar Brain Infarction", Dr. S. Andrew Josephson, MD wrote"Infarcts were significantly more commonly found in women with migraine with aura than in those women without headache (31% vs. 25%; p=.04), but no significant differences were seen in men; this difference in women persisted after adjustments for age, sex, and follow-up time. Cerebellar infarctions, but not those in the cortical or subcortical regions, were significantly more common in women with migraine with aura compared with those without headache. No significant differences were seen in cerebellar infarcts among men. Migraine without aura and non-migraine headache were not associated with any increased risk of infarction"(29)
5. Stroke
Migraine migraine with aura headache can increase the risk of ischemic stroke in women of childbearing age, according to "Duration, frequency, recency, and type of migraine and the risk of ischaemic stroke in women of childbearing age" by Donaghy M, Chang CL, Poulter N; European Collaborators of The World Health Organisation Collaborative Study of Cardiovascular Disease and Steroid Hormone Contraception.(30)
6. Epilepsy
There is a link associated between headache/migraine and epilepsy by using the PubMed data base, according to "Links between headaches and epilepsy: current knowledge and terminology.[Article in English, Spanish]" by Caminero A, Manso-Calderón R.(31)
7. Vascular diseases
Some researchers suggested that women who use hormonal contraceptives and hormone replacement treatment may increase the risk of migraine occurrence and administration of exogenous hormones may cause worsening of migraine as may expose migrainous women to an increased risk of vascular disease(32)
V. Diagnosis
A. Symptoms dependent
A. Symptoms dependent
Depending to the differentiate of symptoms of which are similar but
difference than others with a complete medical history and physical
exam(c)
B. Types of diagnostic technique
The aim of the diagnosis is to rule other causes of the diseases
1. CT scan
CT scan can dive your doctor a three-dimensional view of your bladder and the rest of your urinary tract to look for masses and other abnormalities that cause migraine
B. Types of diagnostic technique
The aim of the diagnosis is to rule other causes of the diseases
1. CT scan
CT scan can dive your doctor a three-dimensional view of your bladder and the rest of your urinary tract to look for masses and other abnormalities that cause migraine
2. Magnetic resonance imaging (MRI)
By using radio waves and magnetic fields to take pictures, MRI scan provides very high quality of a cross-sectional slice and lengthwise slices of the brain and thus providing the better and detail image of location of tumor and the surrounding structures. It is one of most likely early test ordered by a doctor to diagnose tumors, strokes, aneurysms, neurological diseases and other brain abnormalities and the blood vessels around the brain.
3. Spinal tap (lumbar puncture)
A spinal tap is a procedure performed when a doctor needs to look at the cerebrospinal fluid (also known as spinal fluid), by inserting a thin needle between two vertebrae in your lower back to extract a sample. If your doctor suspects the onset of migraine headache is caused by inflammation of the membranes and cerebrospinal fluid surrounding your brain and spinal cord
4. Etc.
VI. Prevention
A. E.A. Do's and Do not's list, if you are experience migraine headache because of foods, food additives, chemical compounds, alcohol, smoking, stress, life style, etc.
1. Food elimination diet
Certain foods which trigger the over production of IgG antibodies if eliminated from the diet can result in the decreased number of migraine like headaches over 4weeks, some studies suggested that using the ELISA test with subsequent diet elimination advice significantly reduce the number of migraine like headaches at 4 weeks.(33)
Diet restriction based on IgG antibodies is an effective strategy in reducing the frequency of migraine attacks. In the study conducted by Istanbul Faculty of Medicine, Department of Neurology, Istanbul, Turkey in a 6-week baseline, IgG antibodies against 266 food antigens were detected by ELISA(34)
3. Foods and chemical compounds trigger migraine headache
a. Certain foods can trigger the migraine headache attack through an allergic reaction. Citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables and cola drinks have been cited as possible allergens associated with migraine. If you are experience the attack after taking some of those, the best way is to avoid them. Researchers also suggested that substances are tyramine, phenylalanine, phenolic flavonoids, alcohol, food additives (sodium nitrate, monosodium glutamate, aspartame) and caffeine may be the cause of modifications in vascular tone and bring migraine on(35)
a. Certain foods can trigger the migraine headache attack through an allergic reaction. Citrus fruits, tea, coffee, pork, chocolate, milk, nuts, vegetables and cola drinks have been cited as possible allergens associated with migraine. If you are experience the attack after taking some of those, the best way is to avoid them. Researchers also suggested that substances are tyramine, phenylalanine, phenolic flavonoids, alcohol, food additives (sodium nitrate, monosodium glutamate, aspartame) and caffeine may be the cause of modifications in vascular tone and bring migraine on(35)
4. Alcohol
As we all known that a small dose of alcohol increase the protective effect on cardiovascular disease, but excessive drinking can increase the frequency of migraine headache as alcoholic drinks are a migraine trigger in about one third of patients with migraine in retrospective studies on trigger factors(36)
As we all known that a small dose of alcohol increase the protective effect on cardiovascular disease, but excessive drinking can increase the frequency of migraine headache as alcoholic drinks are a migraine trigger in about one third of patients with migraine in retrospective studies on trigger factors(36)
5. Smoking
There is evidence that migraine was associated with several lifestyle and socioeconomic factors, In the investigation conducted by University of Copenhagen with a questionnaire containing validated questions to diagnose migraine and questions on lifestyle and socioeconomic factors was sent to 46,418 twin individuals residing in Denmark. 31,865 twin individuals aged 20-71 and most associations such as low education and employment status were probably due to the negative effects of having migraine while others such as smoking were risk factors for migraine.(37)
6. Others may trigger headache migraine attacks to certain people, such as
a. Too much work (Stress)
b. Too little sleep (Sleep related)
c. Passive smoking (Smoking)
d. Perfume (Chemical compound)
e. Etc.(38)
7. Moderate exerciseThere is evidence that migraine was associated with several lifestyle and socioeconomic factors, In the investigation conducted by University of Copenhagen with a questionnaire containing validated questions to diagnose migraine and questions on lifestyle and socioeconomic factors was sent to 46,418 twin individuals residing in Denmark. 31,865 twin individuals aged 20-71 and most associations such as low education and employment status were probably due to the negative effects of having migraine while others such as smoking were risk factors for migraine.(37)
6. Others may trigger headache migraine attacks to certain people, such as
a. Too much work (Stress)
b. Too little sleep (Sleep related)
c. Passive smoking (Smoking)
d. Perfume (Chemical compound)
e. Etc.(38)
In a study of Forty women with general migraine attending the Neurology Department of the Faculty of Medicine Faculty of Dokuz Eylül University, regular long-term aerobic exercise is found in reduced migraine pain severity, frequency and duration possibly due to increased nitric oxide production.(39)
8. Management of migraine
Hygiene and behaviour measures capable of ensuring the best possible well-being (regular meals and balanced diet, restriction of alcohol and smoking, regular sleeping pattern, moderate physical exercise and relaxation) have found to reduce the frequent migraine attack(40)
9. Avoid medication overuse headache (MOH)
There are report that overuse of migraine medication can result of
increased frequency to daily or near-daily as a rebound effect comes
into play(41)
10. Etc.
E.B Nutritional Supplements for Migraine Headache
1. Magnesium
Some studies indicated that deficiency of magnesium is associated with patient with migraine headache as may promote cortical spreading depression, affecting serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters and suggested that empiric treatment with at least oral magnesium is warranted in all migraine sufferers.(E.B.1)
2. Calcium
Calcium deficiency can lead to Hypocalcemia, a serum level of calcium that is below normal, it is manifested by increased neuromuscular irritability, leading to neuromuscular hyperexcitability, anxiety, dysautonomia, oculofrontal headache and migraine(E.B.2)
3. DLPA (DL-phenylalanine)
DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(E.C.9)
4. Vitamin B2
Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (E.C.7)
5. Melatonin
Serotonin, a type of neurotransmitter, passes messages between nerve cells, low serotonin levels in the brain may increase the risk of the process of constriction of the blood vessels as it alters levels of dopamine and stress hormones, and may be part of a complex cellular membrane trafficking dysfunction involving not only the serotonin transporter but also other transporters and ion channels of which trigger a migraine (B.A.7)
6. Coenzyme Q 10 (CoQ10)
In some studies found that deficiency of CoQ10 are common in pediatric and adolescent migraine, but determination of deficiency and consequent supplementation may result in clinical improvement and involving more scientifically rigorous methodology to confirm this observation.(E.B.3)
7. Omega 3 fatty acids Diet with long-chain n-3 polyunsaturated fatty acids might reduce frequency and severity of migraines in adolescents in astudy conducted by Divisions of Adolescent Medicine. Dr. Harel Z, and the team also sadi that results of this preliminary study suggest that both fish oil and olive oil may be beneficial in the treatment of recurrent migraines in adolescents. Further studies are warranted to compare each of these treatments with other interventions.(E.B.4)
Treatments in conventional medicine
F. A. Types of therapy (Non medication treatment)
1. Biofeedback and Cognitive-behavioral therapy
Some studies find that following sequence: blood-volume-pulse biofeedback followed by cognitive behavioral therapy (Group I) or were given the treatment in reverse order (Group II). The application of biofeedback helps the patient to recognize the influence of thoughts and emotions on bodily reactions and therefore prepares the way for successful cognitive treatment.(F.A.1)
2. Relaxation training/thermal biofeedback (RTB)
Relaxation therapy is a technique helped to enhance the relaxation response with an aim to relieve stress, control anxiety, improve sleep, and have a better quality of life in general. In the study conducted by University of Pittsburgh Medical Center, found that 41.3% of patient reported a significant headache reduction in relaxation training/thermal biofeedback (RTB).
(F.A.2).
3. Etc.
F. B. Medication
F.B.A. Medication to relieve acute migraine pain
Depending to the severity of the disease, acute attacks may be best prescribed by a prescription version of an NSAID, of which have a potent vasoconstricting action (constricting blood vessels) and patients are instructed to take them during or at the onset of a migraine. including
1. Triptan
a. Triptan are a family of tryptamine-based drugs used in the treatment of migraine headache and cluster headache. In the comparison of subcutaneous sumatriptan and oral administration formulation, subcutaneous formulation has a faster time of onset and high rate of efficacy when compared with the oral formulation, but the oral formulation appears to be better tolerated.(F.B.A.1)
b. Side effects of Triptan are not limit to
b.1. Nausea
b.2. Dry mouth
b.3. Tingling
b.4. Burning,
b.5. Dizziness
b.6. Drowsiness
b.7. Warm or cold sensations
b.8. Feelings of heaviness, pressure, or tightness
b. Other severe symptoms include coronary spasm, heart disease, shortness of breath, changes in vision, etc.
2. Ergotamine
Ergotamine has been used to treat migraine for a century and is still considered to be the most effective therapeutic agent for acute attacks andt good responses of the medication are associated with plasma concentrations of 0.2 ng/ml or above within one hour of administration.
In the same study, researchers also emphasized the principal adverse effects of ergotamine include nausea, vomiting, weakness, muscle pains, paraesthesiae and coldness of the extremities and suggested dosage must therefore be limited to no more than 10mg per week to minimise toxicity.(F.B.A.2)
3. The oral calcitonine gene-related peptide antagonist telcagepant
In a recent study conducted by University of Liège, in comparison of the oral calcitonine gene-related peptide antagonist telcagepant(CGRP) and triptans, found that its efficacy is almost comparable but its tolerance is superior. The same is true for the 5HT-1F agonist lasmiditan, another agent devoid of vascular effects. Researchers also said that the drugs with a better efficacy or side-effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.(F.B.A.3)
4. Etc.
F.B.B. Medication to prevent migraine pain
Medication used to prevent migraine pain are normal prescribed for patient who are experience frequent migraine attacks, severe side effects from acute treatment drugs or ineffectiveness of acute treatment drugs and together with behavioral therapy and lifestyle adjustments.
1. Beta-blocker (usually propranolol [Inderal] or timolol [Blocadren])
a. Beta-blocker are also known as beta-adrenergic blocking agents, use to block norepinephrine and epinephrine from binding to beta receptors on nerves to prevent migraine headache. Some researchers suggested that the addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment.(F.B.B.1)
b. Side effects are not limit to
b.1. Beta-blocker may interact with other medicines, such as thioridazine, chlorpromazine, etc.
b.2. Most common side effects include dastrointestional discomfort such as stomach cramps, nausea and vomiting.
b.3. The medication may also increase nervous symptoms, including headache, depression, confusion, dizziness, etc.
b.4. Etc.
2. Anticonvulsants (usually divalproex [Depakote] or topiramate [Topamax])
a. Anticonvulsants or anti seizure are medication used to treat epileptic seizures, bipolar disorder as mood stabilizers and neuropathic pain. In the study conducted by Department of Neurology, Canisius Wilhelmina Ziekenhuis, anticonvulsants, considered as a class, reduce migraine frequency by about 1.3 attacks per 28 days compared with placebo, and more than double the number of patients for whom migraine frequency is reduced by > or = 50% relative to placebo.(F.B.B.2)
b. Side Effects are not limit to
1. The medication may also increase central nervous symptoms such as dizziness, drowsiness, unsteadiness, feeling dull difficulty concentrating, focusing, mood swing, etc.
2. The medicine may cause gastrointestinal discomfort such as nausea, and vomiting.
3. Other side effects include liver or kidney damage and decrease the amount of platelets in your blood
4. Etc.
3. Tricyclic antidepressants (usually amitriptyline [Elavil])
a. Tricyclic antidepressants are also known as cyclic antidepressants, a chemical compound used to treat depression by affecting chemical messengers, neurotransmitters, in the brain. In the study conducted by Ohio University, Athens, found that amitriptyline is more effective than placebo for migraine and tension headache. Amitriptyline also seems to be more effective than serotonin reuptake inhibitors, although few direct comparisons are available.(F.B.B.3)
b. Side Effects are not limit to
b.1. The medication may cause central nervous symptoms, such as blurred vision, confusion, drowsiness, etc.
b.2. Loss of sexual desire
b.3. Lowered blood pressure
b.4. Tremors and sweating
b.5. Etc.
The doses and duration is depending to the nature of the migraine, but in general, patient started the medication at a low dose, and then gradually increased.
F.B.C. Medication for children
According to the recommendation of The American Academy of Neurologys practice guidelines
1. children Under 12 years old
a. Ibuprofen (Advil)
a.1. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used as as an analgesic for relief of symptoms pain as aresult of inflammation of certain diseases. In adult, researchers found that ibuprofen 200 and 400 mg are effective in reducing headache intensity and rendering patients pain-free at 2 hours. Photophobia and phonophobia improved with 400 mg dosing (F.B.C.1). Children should reduce the amount of medication according to the guideline.
a.2. Side Effects are not limit to
a.2.1. Common side effects include nausea, dyspepsia, gastrointestinal ulceration/bleeding, headache, dizziness, rash, etc.
a.2.2. Less common side effects include esophageal ulceration, heart failure, renal impairment, confusion, etc.
a.2.3. Etc.
b. Acetaminophen
b.1. Acetaminophen is a pain reliever to treat moderate to moderately-severe pain. Some researchers suggested that Tramadol/acetaminophen reduces the severity of pain, photophobia, and phonophobia associated with migraine headache, but does not reduce migraine-associated nausea. Tramadol/APAP might be an appropriate option for the management of moderate-to-severe migraine headache(F.B.C.2)
b.2. Side effects are not limit to
b.2.1. Common side effects include nausea, vomiting, sweating, diarrhea, irritability, etc.
b.2.2. Less common side effects include liver or kidney failure, heart problems, seizures, etc.
b.2.3. Etc.
2. Children 12 and older
a. Sumaptriptan (Imitrex) is a triptan sulfa drug used for the treatment of migraine headaches. some researchers found that nasal sumatriptan may be effective in aborting migraine in young children (aged 5 to 12 years). It also suggests that there may be subgroups for which it works well. This information suggests that double-blind, placebo-controlled studies are necessary to determine the overall effectiveness of nasal sumatriptan in this age group(F.B.C.3)
b. Side effects are not limit to
b.1. Most common side effects include flushing, sensations, weakness, drowsiness, or dizziness, etc.
1. Peppermint
Peppermint contains high amounts of menthol which have long been used in herbal medicine to treat various pain conditions including headache. In a randomised, triple-blind, placebo-controlled, crossed-over study conducted in the neurology Clinic of Nemazee Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, southern Iran, from March 2007 to March 2008. Menthol solution can be an efficacious, safe and tolerable therapeutic option for the abortive treatment of migraine(G.1)
2. Feverfew
Feverfew and it's ingredient parthenolide have shown the inhibition of the brain chemicals that dilate blood vessels and cause a migraine. Some researchers suggested that a CO(2)-extract of feverfew decreased the migraine frequency from 4.76 by 1.9 attacks per month in the MIG-99 group and by 1.3 attacks in the placebo group (P = 0.0456). Logistic regression of responder rates showed an odds ratio of 3.4 in favour of MIG-99 (P = 0.0049). Adverse events possibly related to study medication were 9/107 (8.4%) with MIG-99 and 11/108 (10.2%) with placebo (P = 0.654). MIG-99 is effective and shows a favourable benefit-risk ratio.(G.2) while others insisted that there are insufficient evidence from randomised, double-blind trials to suggest an effect of feverfew over and above placebo for preventing migraine.(G.3)
3. Butterbur
Butterbur is a creeping underground plant, genus Petasites of 15 -20 species, belonging to the family Asteraceae, native to Northern Hemisphere. In a comparison in a three-arm, parallel-group, randomized trial comparing Petasites extract 75 mg bid, Petasites extract 50 mg bid, or placebo bid in 245 patients with migraine conducted by Albert Einstein College of Medicine, Petasites extract 75 mg bid is more effective than placebo and is well tolerated as a preventive therapy for migraine.(G.4)
4. Ginkgo biloba
Ginkgo biloba is oldest living tree species, genus Ginkgo, belonging to the family Gink-
goaceae, native to China. Some researchers suggested that Gingkolide B, a herbal constituent extract from Ginkgo biloba tree leaves, seems to be effective as preventive treatment in reducing migraine attack frequency and in attenuating the use of symptomatic medication in our small series of children with primary headache in a small sample of 30 young patients(G.5). Other found that Ginkgolide B is effective in reducing MA frequency and duration. The effect is clearly evident in the first bimester of treatment and is further enhanced during the second(G.6)
5. Cannabis
Cannabis is a herbal plant with three putative varieties Cannabis sativa, Cannabis indica and Cannabis ruderalis, native to Central Asia, and South Asia. clinical cannabis indicated that Migraine has numerous relationships to endocannabinoid function. Anandamide (AEA) potentiates 5-HT1A and inhibits 5-HT2A receptors supporting therapeutic efficacy in acute and preventive migraine treatment. Cannabinoids also demonstrate dopamine-blocking and anti-inflammatory effects. AEA is tonically active in the periaqueductal gray matter, a migraine generator and suggested that Migraine, fibromyalgia, IBS and related conditions display common clinical, biochemical and pathophysiological patterns share an underlying clinical endocannabinoid deficiency that may be suitably treated with cannabinoid medicines(G.7)
6. Lavender
Herbalist suggested that rubbing a little lavender oil on your temples, or dropping some in the bath water can be extremely soothing. For the migraine associated with depression or poor digestion, it may be result of the relaxation and coronary circulative effects of the oil(G.8)
7. Others
Many herbs such a Fenugreek, Black willow, Marjoram, St. John's wort, fennel or caraway seed tea hane been used to relieve pain or symptoms of migraines, but they are not mention here because lack of studies.
For information of The World Most Popular Herbs - Health Benefits and Side Effects, visit
http://theworldmostpopularherbs.blogspot.ca/2011/10/world-most-popular-herbs-health.html
H. In traditional Chinese medicine (TCM)
X. Traditional Chinese Medicine
H.A. According to Flaws & Sionneau, 2001,p.346; Yin & Liu, 2000, p.370; Blackwell, 1991 Migraine Headache is as a condition of tou feng (Wind in the head) or pian tou tong(pain in one half of the head), and is mainly due to emotional factors causes of Liver Yang hyperactivity and sometimes may be influenced by exterior Wind-Cold factors, common cold and allergy(H.A.). In the report the author indicated that differetiation of the MH depending to the patient’s pathology and the pathodynamics underlying any particular clinical case is likely to be complex. As pain is the single most important clinical feature, Blood stasis should beaddressed in all cases. Thus, one of the formulas described under thesubheading of Blood Stasis will be included in all acute stage treatments. In addition, Interior Wind is also a common feature and this often occurs due to Liver Fire or stagnant Heat in the Liver. In some cases there is also Phlegm,which binds with Wind to exacerbate the symptoms.(Part 2MIGRAINE HEADACHE IN TCM)
H.B. Migraine headache caused by Liver Yang rising with Interior Wind
1. Symptoms
a Visual disturbance
b. Dizziness
c. Irritability
d. Red tongue
e. Wiry pulse
f. Etc.
2. Formula Liver Yang rising with Interior Wind - Tian Ma Gou Teng Yin
a. Gastrodia and Uncaria formula has been used in TCM for hundred of years to treat the symptoms of headache and migraine as a result of ascendant Liver Yang with internal movement of Wind, caused by Liver and Kidney Yin deficiency and exuberant Liver Yang. This formula is best used during the early stages of a Migraine and combines well with Corydalis H for a strong, double strike against Migraine pain.
b. The ingredients including
b.1. Tian Ma (Rhizoma gastrodiae elatae)
b.2. Gou Teng (Ramulus cum uncis uncariae)
b.3. Shi Jue Ming (Concha haliotidis)
b.4. Zhi Zi (Fructus gardeniae jasminoidis)
b.5. Huang Qin (Radix scutellariae baicalensis)
b.6. Yi Mu Cao (Herba leonuri heterophylli)
b.7. Chuan Niu Xi (Radix cyathulae officinalis)
b.8. Du Zhong (Cortex eucommiae ulmoidis)
b.9. Sang Ji Sheng (Ramulus sangjusheng)
b.10. Ye Jiao Teng (Caulis polygoni multiflori)
b.11. Fu-shen (Sclerotium poriae cocos pararadicis)
H.C. Liver Fire
1. Symptoms
a. Red face and eyes
b. bitter taste in the mouth
c. thirst
d. dark and scanty urine
e. constipation with dry stools
f. red tongue with a yellow coat
g. rapid pulse
b. Formula Long Dan Xie Gan Tang
The formula Long Dan Xie Gan Tang has been used in TCM to treat pain in the hypochondriac region, headache, dizziness, red sore eyes, trouble with hearing, ear swelling or infection, traveling the Liver and Gallbladder meridians to relieve liver heat and fire
b.1. Long dan cao (Radix gentianae longdancao)
b.2. Huang qin (Radix scutellariae)
b.3. Shan zhi zi (Fructus gardeniae jasminoidis)
b.4. Ze xie (Caulis mutong)
b.5. Mu tong (Semen plantaginis)
b.6. Che qian zi (Rhizoma alismatis orientalis)
b.7. Chai hu (Radix bupleuri)
b.9. Sheng di huang (Radix rehmanniae glutinosae)
b.10. Gan cao (radix glycyrrhizae uralensis)
b.11. Dang qui (Radix angelicae sinensis)
Author note the formula may damage the Kidney due to the presence of Herb Mu Tong
H.D. Liver qi stagnation
1. Symptoms
a. Chest distention
b. Hypochondriac pain
c. Nausea, vomiting
d. Poor appetite
e. Diarrhea
f. Depression
g. Mood swing
f. Normal tongue
g. Wiry pulse
h. Etc.
2. Formula as a result of Liver Qi deficiency: Xiao Yao San (Bupleurum and Dang-gui Formula)
The formula has been used in TCM to treat anxiety, irritability, stress, and depression due to the challenge of a daily life or premenstrual tension, as a result of liver Qi deficiency
a. Chai Hu (radix burpleuri)
b. Dang Gui (radix angelicae sinensis)
c. Bai Shao (radix paeoniae lactiflorae)
d. Bai Zhu (rhizome atractylodis macrocephalae)
f. Fu Ling (sclerotium poriae cocos)
g. Zhi Gan Cao (honey fried radix glycyrrhizae uralensis)
H.E. Excess syndrome-pattern with Liver Blood stasis:
1. Symptoms
a. Palpable masses in the abdomen
b. Irregular a/or painful menstruation possible with dark clots,
c. purple nails,
d. purple lips
e. Tongue Purple, possibly w/purple spots
f. Wiry pulse
b. Formula for Excess syndrome-pattern with Liver Blood stasis: Chai Hu Shu Gan Tang
The formula has been used in TCM to treat sighing and flank pain due to emotional stress or premenstrual tension, headache as a result liver Blood stasis.
a. Chai hu (Radix Bupleuri Chinensis)
b. Chen pi (Pericarpium Citri Reticulatae)
c. Bai shao (Radix Paeoniae Lactiflorae)
d. Zhi ke (Fructus Aurantii)
f. Chuan xiong (Rhizoma Ligustici Chuanxiong)
g. Xiang fu (Rhizoma Cyperi Rotundi)
h. Gan cao (Radix Glycyrrhizae Uralensis)
H.F. Headache Migraine caused by Wind Phlegm
1. Symptoms
a. Excessive sputum
b. Nausea,
c. Fullness of the chest and/or epigastrium
d. Greasy tongue coat
e. Etc.
2. Wind Phlegm With Heat (if tongue is red tongue with a yellow coat): Wen Dan Tang (Bamboo & Hoelen Formula)
The formula has been used in TCM to treat disharmony between the gallbladder and stomach causes of Qi is blocked in flow transformed phlegm and form of rebellion Qi in the stomach that lead to fear, restlessness, dreaminess and anxiety
a. Zhi Ban Xia (Rhizoma Pinelliae Ternatae)
b. Zhu Ru (Caulis Bambusae In Taeniis)
c. Chen Pi (Pericarpium Citri Reticulatae)
d. Fu Ling (Poriae Cocos)
f. Lian Qiao (Fructus Forsythiae Suspensae)
g. Jin Yin Hua (Flos Lonicerae Japonicae)
h. Yu Jin (Radix Curcumae)
i. Zhi Shi (Fructus Aurantii Immaturus)
3. Formula Wind Phlegm With Cold (if tongue is pale with a white coat): Er Chen Wan (Citrus & Pinellia Combination), ingredients include
The Formula has been used in TCM to treat nausea and abdominal fullness, dizziness and vertigo, etc., as a result of Withe Phlegm with cold causes of phlegm accumulation, spleen-damp, rebellion qi and unharmonization of the center.
a. Chen Pi (Pericarpium Citri Reticulatae)
b. Ban Xia (Rhizoma Pinelliae)
c. Fu Ling (Poriae Cocos)
d. Gan Cao Glycyrrhiza (Radix Glycyrrhizae Uralensis)
f. Sheng Jiang Zingiberis (Rhizoma Zingiberis)
H.F. Blood Stasis
1. Symptoms
a. Fixed pain,
b. Palpitation
c. Pulse appears tense and fast
d. Tongue is purple -
f. bluish-purple
2. Formula for migraine headache caused by blood stasis
Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination)
The formula has been used in TCM to treat heavy bleeding of dark, purplish, sticky menstrual blood sharp and fixed abdominal pain before or during the menses, dizziness, dull headache, etc. as a result of blood stasis
a. Shu di huang (Rehmannia glutinosa root-prep)
b. Dang gui (Angelica sinensis root)
c. Bai shao (Paeonia lactiflora root)
d. Tao ren (Prunus persica seed)
e. Hong hua (Carthamus tinctorius flower)
f. Chuan xiong (Ligusticum wallichii rhizome)
H.G. Invasion by Exterior Wind Cold
1. Symptoms
a. Generalized body aches
b. Aversion to cold
c. Chills
d. Mild fever
e. Nasal congestion
f. Thin white coat
g. Floating, possibly a little tight
2. Formula for mihraine headache caused by Invasion by Exterior Wind Cold: Chuan Xiong Cha Tiao Wan (Ligusticum & Tea Formula)
The formula has been used in TCM to treat headache, migraine, or headache on the top, aversion to cold and fever, dizziness, nasal obstruction as a result of Exterior Wind Cold
a. Bo he (Herba Menthae Haplocalycis)
b. Chuan xiong (Rhizoma Ligustici Chuanxiong)
c. Jing jie (Herba Schizonepetae Tenuifoliae)
d. Qiang huo (Rhizoma Seu Radix Notopterygii)
e. Bai zhi (Radix Angelicae Dahuricae)
f. Gan cao (Radix Glycyrrhizae Uralensis)
g. Fang feng (Radix Saposhnikoviae Divaricatae)
For more information of Chinese herb in Western view, please visit http://chineseherbsinnutrientsperspective.blogspot.ca/2011/10/chinese-herbs-in-western-view-health.html
10. Etc.
E.B Nutritional Supplements for Migraine Headache
1. Magnesium
Some studies indicated that deficiency of magnesium is associated with patient with migraine headache as may promote cortical spreading depression, affecting serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters and suggested that empiric treatment with at least oral magnesium is warranted in all migraine sufferers.(E.B.1)
2. Calcium
Calcium deficiency can lead to Hypocalcemia, a serum level of calcium that is below normal, it is manifested by increased neuromuscular irritability, leading to neuromuscular hyperexcitability, anxiety, dysautonomia, oculofrontal headache and migraine(E.B.2)
3. DLPA (DL-phenylalanine)
DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(E.C.9)
4. Vitamin B2
Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (E.C.7)
5. Melatonin
Serotonin, a type of neurotransmitter, passes messages between nerve cells, low serotonin levels in the brain may increase the risk of the process of constriction of the blood vessels as it alters levels of dopamine and stress hormones, and may be part of a complex cellular membrane trafficking dysfunction involving not only the serotonin transporter but also other transporters and ion channels of which trigger a migraine (B.A.7)
6. Coenzyme Q 10 (CoQ10)
In some studies found that deficiency of CoQ10 are common in pediatric and adolescent migraine, but determination of deficiency and consequent supplementation may result in clinical improvement and involving more scientifically rigorous methodology to confirm this observation.(E.B.3)
7. Omega 3 fatty acids Diet with long-chain n-3 polyunsaturated fatty acids might reduce frequency and severity of migraines in adolescents in astudy conducted by Divisions of Adolescent Medicine. Dr. Harel Z, and the team also sadi that results of this preliminary study suggest that both fish oil and olive oil may be beneficial in the treatment of recurrent migraines in adolescents. Further studies are warranted to compare each of these treatments with other interventions.(E.B.4)
E.C. Diet for Migraine headache
Certain diet may trigger the attack of migraine headache as a result of allergic reaction in certain people, but it may be helpful to people who are experience migraine headache with no allergic effects
1. Water
Water, an essential for the body’s proper functioning, and dehydration may trigger the migraine attack. Un a study of Fifty migraineurs were asked if insufficient fluid intake could provoke their migraine attacks conducted by The City of London Migraine Clinic, twenty replied "yes," 7 were doubtfully positive, and 23 said "no." In addition 14 of 45 migraineurs at a meeting of the British Migraine association (UK) also recognized fluid deprivation as one of their migraine triggers.(E.C.1) Adding fluid deprivation to migraine patient may reduce the numbers of migraine attacks.
2. Fish oil and Olive oil
Omega-3 PUFA, from fish oil-eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been studied to consist anti-inflammatory properties of which are useful in the management of inflammatory and autoimmune diseases, including rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis, lupus erythematosus, multiple sclerosis and migraine headaches.(E.C.2)
3. Broccoli
Broccoli is a very good source of magnesium and a good source of calcium. Magnesium, plays an essential in many intracellular processes and in migraine pathogenesis, low levels of magnesium may promote cortical spreading depression, hyperaggregation of platelets, affect serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters of which can trigger migraine headache(B.A.8)
4. Sardines
Sardines contain measurable amount of Omega 3 fatty acid, calcium and CoQ10 of which can be helpful in reducing the frequency of migraine headache (E.B.3)(E.B.2)
5. Spinach
Spinach is an excellent source of both calcium, magnesium, vitamin B2 (riboflavin)
Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (E.C.7)
6. Mustard Greens
The World's Healthiest Foods recommends mustard greens as an excellent source of calcium and a very good source of magnesium of which are important in preventing and treating migraine headache (See E.B.1 and 2)
7. Fish
Beside rich in Omega 3 fatty acids, all fish contain more or less DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(E.C.9)
8. Etc.
For The World Most Healthy Foods, please visit http://healthy-foods-index.blogspot.ca/2011/03/healthy-foods-list.html
Certain diet may trigger the attack of migraine headache as a result of allergic reaction in certain people, but it may be helpful to people who are experience migraine headache with no allergic effects
1. Water
Water, an essential for the body’s proper functioning, and dehydration may trigger the migraine attack. Un a study of Fifty migraineurs were asked if insufficient fluid intake could provoke their migraine attacks conducted by The City of London Migraine Clinic, twenty replied "yes," 7 were doubtfully positive, and 23 said "no." In addition 14 of 45 migraineurs at a meeting of the British Migraine association (UK) also recognized fluid deprivation as one of their migraine triggers.(E.C.1) Adding fluid deprivation to migraine patient may reduce the numbers of migraine attacks.
2. Fish oil and Olive oil
Omega-3 PUFA, from fish oil-eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have been studied to consist anti-inflammatory properties of which are useful in the management of inflammatory and autoimmune diseases, including rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis, lupus erythematosus, multiple sclerosis and migraine headaches.(E.C.2)
3. Broccoli
Broccoli is a very good source of magnesium and a good source of calcium. Magnesium, plays an essential in many intracellular processes and in migraine pathogenesis, low levels of magnesium may promote cortical spreading depression, hyperaggregation of platelets, affect serotonin receptor function, and influence synthesis and release of a variety of neurotransmitters of which can trigger migraine headache(B.A.8)
4. Sardines
Sardines contain measurable amount of Omega 3 fatty acid, calcium and CoQ10 of which can be helpful in reducing the frequency of migraine headache (E.B.3)(E.B.2)
5. Spinach
Spinach is an excellent source of both calcium, magnesium, vitamin B2 (riboflavin)
Riboflavin therapy supplemented may be appropriate alternatives in patients with migraine disorder as it significant decreases in headache frequency, intensity, duration and medication intake (E.C.7)
6. Mustard Greens
The World's Healthiest Foods recommends mustard greens as an excellent source of calcium and a very good source of magnesium of which are important in preventing and treating migraine headache (See E.B.1 and 2)
7. Fish
Beside rich in Omega 3 fatty acids, all fish contain more or less DL-phenylalanine, an essential amino acid of which is important for our body converts phenylalanine to tyrosine, another amino acid then to epinephrine and norepinephrine, which are important brain chemicals called neurotransmitters. Some researchers suggest that DL-phenylalanine (DLPA) appears to potentiate pain relief and also ease depression in patients receiving opiates for chronic non-malignant pain(E.C.9)
8. Etc.
For The World Most Healthy Foods, please visit http://healthy-foods-index.blogspot.ca/2011/03/healthy-foods-list.html
Treatments in conventional medicine
F. A. Types of therapy (Non medication treatment)
1. Biofeedback and Cognitive-behavioral therapy
Some studies find that following sequence: blood-volume-pulse biofeedback followed by cognitive behavioral therapy (Group I) or were given the treatment in reverse order (Group II). The application of biofeedback helps the patient to recognize the influence of thoughts and emotions on bodily reactions and therefore prepares the way for successful cognitive treatment.(F.A.1)
2. Relaxation training/thermal biofeedback (RTB)
Relaxation therapy is a technique helped to enhance the relaxation response with an aim to relieve stress, control anxiety, improve sleep, and have a better quality of life in general. In the study conducted by University of Pittsburgh Medical Center, found that 41.3% of patient reported a significant headache reduction in relaxation training/thermal biofeedback (RTB).
(F.A.2).
3. Etc.
F. B. Medication
F.B.A. Medication to relieve acute migraine pain
Depending to the severity of the disease, acute attacks may be best prescribed by a prescription version of an NSAID, of which have a potent vasoconstricting action (constricting blood vessels) and patients are instructed to take them during or at the onset of a migraine. including
1. Triptan
a. Triptan are a family of tryptamine-based drugs used in the treatment of migraine headache and cluster headache. In the comparison of subcutaneous sumatriptan and oral administration formulation, subcutaneous formulation has a faster time of onset and high rate of efficacy when compared with the oral formulation, but the oral formulation appears to be better tolerated.(F.B.A.1)
b. Side effects of Triptan are not limit to
b.1. Nausea
b.2. Dry mouth
b.3. Tingling
b.4. Burning,
b.5. Dizziness
b.6. Drowsiness
b.7. Warm or cold sensations
b.8. Feelings of heaviness, pressure, or tightness
b. Other severe symptoms include coronary spasm, heart disease, shortness of breath, changes in vision, etc.
2. Ergotamine
Ergotamine has been used to treat migraine for a century and is still considered to be the most effective therapeutic agent for acute attacks andt good responses of the medication are associated with plasma concentrations of 0.2 ng/ml or above within one hour of administration.
In the same study, researchers also emphasized the principal adverse effects of ergotamine include nausea, vomiting, weakness, muscle pains, paraesthesiae and coldness of the extremities and suggested dosage must therefore be limited to no more than 10mg per week to minimise toxicity.(F.B.A.2)
3. The oral calcitonine gene-related peptide antagonist telcagepant
In a recent study conducted by University of Liège, in comparison of the oral calcitonine gene-related peptide antagonist telcagepant(CGRP) and triptans, found that its efficacy is almost comparable but its tolerance is superior. The same is true for the 5HT-1F agonist lasmiditan, another agent devoid of vascular effects. Researchers also said that the drugs with a better efficacy or side-effect profile than triptans may soon become available for acute treatment. The future may also look brighter for some of the very disabled chronic migraineurs thanks to novel drug and neuromodulation therapies.(F.B.A.3)
4. Etc.
F.B.B. Medication to prevent migraine pain
Medication used to prevent migraine pain are normal prescribed for patient who are experience frequent migraine attacks, severe side effects from acute treatment drugs or ineffectiveness of acute treatment drugs and together with behavioral therapy and lifestyle adjustments.
1. Beta-blocker (usually propranolol [Inderal] or timolol [Blocadren])
a. Beta-blocker are also known as beta-adrenergic blocking agents, use to block norepinephrine and epinephrine from binding to beta receptors on nerves to prevent migraine headache. Some researchers suggested that the addition of combined β blocker plus behavioural migraine management, but not the addition of β blocker alone or behavioural migraine management alone, improved outcomes of optimised acute treatment.(F.B.B.1)
b. Side effects are not limit to
b.1. Beta-blocker may interact with other medicines, such as thioridazine, chlorpromazine, etc.
b.2. Most common side effects include dastrointestional discomfort such as stomach cramps, nausea and vomiting.
b.3. The medication may also increase nervous symptoms, including headache, depression, confusion, dizziness, etc.
b.4. Etc.
2. Anticonvulsants (usually divalproex [Depakote] or topiramate [Topamax])
a. Anticonvulsants or anti seizure are medication used to treat epileptic seizures, bipolar disorder as mood stabilizers and neuropathic pain. In the study conducted by Department of Neurology, Canisius Wilhelmina Ziekenhuis, anticonvulsants, considered as a class, reduce migraine frequency by about 1.3 attacks per 28 days compared with placebo, and more than double the number of patients for whom migraine frequency is reduced by > or = 50% relative to placebo.(F.B.B.2)
b. Side Effects are not limit to
1. The medication may also increase central nervous symptoms such as dizziness, drowsiness, unsteadiness, feeling dull difficulty concentrating, focusing, mood swing, etc.
2. The medicine may cause gastrointestinal discomfort such as nausea, and vomiting.
3. Other side effects include liver or kidney damage and decrease the amount of platelets in your blood
4. Etc.
3. Tricyclic antidepressants (usually amitriptyline [Elavil])
a. Tricyclic antidepressants are also known as cyclic antidepressants, a chemical compound used to treat depression by affecting chemical messengers, neurotransmitters, in the brain. In the study conducted by Ohio University, Athens, found that amitriptyline is more effective than placebo for migraine and tension headache. Amitriptyline also seems to be more effective than serotonin reuptake inhibitors, although few direct comparisons are available.(F.B.B.3)
b. Side Effects are not limit to
b.1. The medication may cause central nervous symptoms, such as blurred vision, confusion, drowsiness, etc.
b.2. Loss of sexual desire
b.3. Lowered blood pressure
b.4. Tremors and sweating
b.5. Etc.
The doses and duration is depending to the nature of the migraine, but in general, patient started the medication at a low dose, and then gradually increased.
F.B.C. Medication for children
According to the recommendation of The American Academy of Neurologys practice guidelines
1. children Under 12 years old
a. Ibuprofen (Advil)
a.1. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used as as an analgesic for relief of symptoms pain as aresult of inflammation of certain diseases. In adult, researchers found that ibuprofen 200 and 400 mg are effective in reducing headache intensity and rendering patients pain-free at 2 hours. Photophobia and phonophobia improved with 400 mg dosing (F.B.C.1). Children should reduce the amount of medication according to the guideline.
a.2. Side Effects are not limit to
a.2.1. Common side effects include nausea, dyspepsia, gastrointestinal ulceration/bleeding, headache, dizziness, rash, etc.
a.2.2. Less common side effects include esophageal ulceration, heart failure, renal impairment, confusion, etc.
a.2.3. Etc.
b. Acetaminophen
b.1. Acetaminophen is a pain reliever to treat moderate to moderately-severe pain. Some researchers suggested that Tramadol/acetaminophen reduces the severity of pain, photophobia, and phonophobia associated with migraine headache, but does not reduce migraine-associated nausea. Tramadol/APAP might be an appropriate option for the management of moderate-to-severe migraine headache(F.B.C.2)
b.2. Side effects are not limit to
b.2.1. Common side effects include nausea, vomiting, sweating, diarrhea, irritability, etc.
b.2.2. Less common side effects include liver or kidney failure, heart problems, seizures, etc.
b.2.3. Etc.
2. Children 12 and older
a. Sumaptriptan (Imitrex) is a triptan sulfa drug used for the treatment of migraine headaches. some researchers found that nasal sumatriptan may be effective in aborting migraine in young children (aged 5 to 12 years). It also suggests that there may be subgroups for which it works well. This information suggests that double-blind, placebo-controlled studies are necessary to determine the overall effectiveness of nasal sumatriptan in this age group(F.B.C.3)
b. Side effects are not limit to
b.1. Most common side effects include flushing, sensations, weakness, drowsiness, or dizziness, etc.
1. Peppermint
Peppermint contains high amounts of menthol which have long been used in herbal medicine to treat various pain conditions including headache. In a randomised, triple-blind, placebo-controlled, crossed-over study conducted in the neurology Clinic of Nemazee Hospital, affiliated with Shiraz University of Medical Sciences, Shiraz, southern Iran, from March 2007 to March 2008. Menthol solution can be an efficacious, safe and tolerable therapeutic option for the abortive treatment of migraine(G.1)
2. Feverfew
Feverfew and it's ingredient parthenolide have shown the inhibition of the brain chemicals that dilate blood vessels and cause a migraine. Some researchers suggested that a CO(2)-extract of feverfew decreased the migraine frequency from 4.76 by 1.9 attacks per month in the MIG-99 group and by 1.3 attacks in the placebo group (P = 0.0456). Logistic regression of responder rates showed an odds ratio of 3.4 in favour of MIG-99 (P = 0.0049). Adverse events possibly related to study medication were 9/107 (8.4%) with MIG-99 and 11/108 (10.2%) with placebo (P = 0.654). MIG-99 is effective and shows a favourable benefit-risk ratio.(G.2) while others insisted that there are insufficient evidence from randomised, double-blind trials to suggest an effect of feverfew over and above placebo for preventing migraine.(G.3)
3. Butterbur
Butterbur is a creeping underground plant, genus Petasites of 15 -20 species, belonging to the family Asteraceae, native to Northern Hemisphere. In a comparison in a three-arm, parallel-group, randomized trial comparing Petasites extract 75 mg bid, Petasites extract 50 mg bid, or placebo bid in 245 patients with migraine conducted by Albert Einstein College of Medicine, Petasites extract 75 mg bid is more effective than placebo and is well tolerated as a preventive therapy for migraine.(G.4)
4. Ginkgo biloba
Ginkgo biloba is oldest living tree species, genus Ginkgo, belonging to the family Gink-
goaceae, native to China. Some researchers suggested that Gingkolide B, a herbal constituent extract from Ginkgo biloba tree leaves, seems to be effective as preventive treatment in reducing migraine attack frequency and in attenuating the use of symptomatic medication in our small series of children with primary headache in a small sample of 30 young patients(G.5). Other found that Ginkgolide B is effective in reducing MA frequency and duration. The effect is clearly evident in the first bimester of treatment and is further enhanced during the second(G.6)
5. Cannabis
Cannabis is a herbal plant with three putative varieties Cannabis sativa, Cannabis indica and Cannabis ruderalis, native to Central Asia, and South Asia. clinical cannabis indicated that Migraine has numerous relationships to endocannabinoid function. Anandamide (AEA) potentiates 5-HT1A and inhibits 5-HT2A receptors supporting therapeutic efficacy in acute and preventive migraine treatment. Cannabinoids also demonstrate dopamine-blocking and anti-inflammatory effects. AEA is tonically active in the periaqueductal gray matter, a migraine generator and suggested that Migraine, fibromyalgia, IBS and related conditions display common clinical, biochemical and pathophysiological patterns share an underlying clinical endocannabinoid deficiency that may be suitably treated with cannabinoid medicines(G.7)
6. Lavender
Herbalist suggested that rubbing a little lavender oil on your temples, or dropping some in the bath water can be extremely soothing. For the migraine associated with depression or poor digestion, it may be result of the relaxation and coronary circulative effects of the oil(G.8)
7. Others
Many herbs such a Fenugreek, Black willow, Marjoram, St. John's wort, fennel or caraway seed tea hane been used to relieve pain or symptoms of migraines, but they are not mention here because lack of studies.
For information of The World Most Popular Herbs - Health Benefits and Side Effects, visit
http://theworldmostpopularherbs.blogspot.ca/2011/10/world-most-popular-herbs-health.html
H. In traditional Chinese medicine (TCM)
X. Traditional Chinese Medicine
H.A. According to Flaws & Sionneau, 2001,p.346; Yin & Liu, 2000, p.370; Blackwell, 1991 Migraine Headache is as a condition of tou feng (Wind in the head) or pian tou tong(pain in one half of the head), and is mainly due to emotional factors causes of Liver Yang hyperactivity and sometimes may be influenced by exterior Wind-Cold factors, common cold and allergy(H.A.). In the report the author indicated that differetiation of the MH depending to the patient’s pathology and the pathodynamics underlying any particular clinical case is likely to be complex. As pain is the single most important clinical feature, Blood stasis should beaddressed in all cases. Thus, one of the formulas described under thesubheading of Blood Stasis will be included in all acute stage treatments. In addition, Interior Wind is also a common feature and this often occurs due to Liver Fire or stagnant Heat in the Liver. In some cases there is also Phlegm,which binds with Wind to exacerbate the symptoms.(Part 2MIGRAINE HEADACHE IN TCM)
H.B. Migraine headache caused by Liver Yang rising with Interior Wind
1. Symptoms
a Visual disturbance
b. Dizziness
c. Irritability
d. Red tongue
e. Wiry pulse
f. Etc.
2. Formula Liver Yang rising with Interior Wind - Tian Ma Gou Teng Yin
a. Gastrodia and Uncaria formula has been used in TCM for hundred of years to treat the symptoms of headache and migraine as a result of ascendant Liver Yang with internal movement of Wind, caused by Liver and Kidney Yin deficiency and exuberant Liver Yang. This formula is best used during the early stages of a Migraine and combines well with Corydalis H for a strong, double strike against Migraine pain.
b. The ingredients including
b.1. Tian Ma (Rhizoma gastrodiae elatae)
b.2. Gou Teng (Ramulus cum uncis uncariae)
b.3. Shi Jue Ming (Concha haliotidis)
b.4. Zhi Zi (Fructus gardeniae jasminoidis)
b.5. Huang Qin (Radix scutellariae baicalensis)
b.6. Yi Mu Cao (Herba leonuri heterophylli)
b.7. Chuan Niu Xi (Radix cyathulae officinalis)
b.8. Du Zhong (Cortex eucommiae ulmoidis)
b.9. Sang Ji Sheng (Ramulus sangjusheng)
b.10. Ye Jiao Teng (Caulis polygoni multiflori)
b.11. Fu-shen (Sclerotium poriae cocos pararadicis)
H.C. Liver Fire
1. Symptoms
a. Red face and eyes
b. bitter taste in the mouth
c. thirst
d. dark and scanty urine
e. constipation with dry stools
f. red tongue with a yellow coat
g. rapid pulse
b. Formula Long Dan Xie Gan Tang
The formula Long Dan Xie Gan Tang has been used in TCM to treat pain in the hypochondriac region, headache, dizziness, red sore eyes, trouble with hearing, ear swelling or infection, traveling the Liver and Gallbladder meridians to relieve liver heat and fire
b.1. Long dan cao (Radix gentianae longdancao)
b.2. Huang qin (Radix scutellariae)
b.3. Shan zhi zi (Fructus gardeniae jasminoidis)
b.4. Ze xie (Caulis mutong)
b.5. Mu tong (Semen plantaginis)
b.6. Che qian zi (Rhizoma alismatis orientalis)
b.7. Chai hu (Radix bupleuri)
b.9. Sheng di huang (Radix rehmanniae glutinosae)
b.10. Gan cao (radix glycyrrhizae uralensis)
b.11. Dang qui (Radix angelicae sinensis)
Author note the formula may damage the Kidney due to the presence of Herb Mu Tong
H.D. Liver qi stagnation
1. Symptoms
a. Chest distention
b. Hypochondriac pain
c. Nausea, vomiting
d. Poor appetite
e. Diarrhea
f. Depression
g. Mood swing
f. Normal tongue
g. Wiry pulse
h. Etc.
2. Formula as a result of Liver Qi deficiency: Xiao Yao San (Bupleurum and Dang-gui Formula)
The formula has been used in TCM to treat anxiety, irritability, stress, and depression due to the challenge of a daily life or premenstrual tension, as a result of liver Qi deficiency
a. Chai Hu (radix burpleuri)
b. Dang Gui (radix angelicae sinensis)
c. Bai Shao (radix paeoniae lactiflorae)
d. Bai Zhu (rhizome atractylodis macrocephalae)
f. Fu Ling (sclerotium poriae cocos)
g. Zhi Gan Cao (honey fried radix glycyrrhizae uralensis)
H.E. Excess syndrome-pattern with Liver Blood stasis:
1. Symptoms
a. Palpable masses in the abdomen
b. Irregular a/or painful menstruation possible with dark clots,
c. purple nails,
d. purple lips
e. Tongue Purple, possibly w/purple spots
f. Wiry pulse
b. Formula for Excess syndrome-pattern with Liver Blood stasis: Chai Hu Shu Gan Tang
The formula has been used in TCM to treat sighing and flank pain due to emotional stress or premenstrual tension, headache as a result liver Blood stasis.
a. Chai hu (Radix Bupleuri Chinensis)
b. Chen pi (Pericarpium Citri Reticulatae)
c. Bai shao (Radix Paeoniae Lactiflorae)
d. Zhi ke (Fructus Aurantii)
f. Chuan xiong (Rhizoma Ligustici Chuanxiong)
g. Xiang fu (Rhizoma Cyperi Rotundi)
h. Gan cao (Radix Glycyrrhizae Uralensis)
H.F. Headache Migraine caused by Wind Phlegm
1. Symptoms
a. Excessive sputum
b. Nausea,
c. Fullness of the chest and/or epigastrium
d. Greasy tongue coat
e. Etc.
2. Wind Phlegm With Heat (if tongue is red tongue with a yellow coat): Wen Dan Tang (Bamboo & Hoelen Formula)
The formula has been used in TCM to treat disharmony between the gallbladder and stomach causes of Qi is blocked in flow transformed phlegm and form of rebellion Qi in the stomach that lead to fear, restlessness, dreaminess and anxiety
a. Zhi Ban Xia (Rhizoma Pinelliae Ternatae)
b. Zhu Ru (Caulis Bambusae In Taeniis)
c. Chen Pi (Pericarpium Citri Reticulatae)
d. Fu Ling (Poriae Cocos)
f. Lian Qiao (Fructus Forsythiae Suspensae)
g. Jin Yin Hua (Flos Lonicerae Japonicae)
h. Yu Jin (Radix Curcumae)
i. Zhi Shi (Fructus Aurantii Immaturus)
3. Formula Wind Phlegm With Cold (if tongue is pale with a white coat): Er Chen Wan (Citrus & Pinellia Combination), ingredients include
The Formula has been used in TCM to treat nausea and abdominal fullness, dizziness and vertigo, etc., as a result of Withe Phlegm with cold causes of phlegm accumulation, spleen-damp, rebellion qi and unharmonization of the center.
a. Chen Pi (Pericarpium Citri Reticulatae)
b. Ban Xia (Rhizoma Pinelliae)
c. Fu Ling (Poriae Cocos)
d. Gan Cao Glycyrrhiza (Radix Glycyrrhizae Uralensis)
f. Sheng Jiang Zingiberis (Rhizoma Zingiberis)
H.F. Blood Stasis
1. Symptoms
a. Fixed pain,
b. Palpitation
c. Pulse appears tense and fast
d. Tongue is purple -
f. bluish-purple
2. Formula for migraine headache caused by blood stasis
Tao Hong Si Wu Wan (Persica, Carthamus & Dang-gui Combination)
The formula has been used in TCM to treat heavy bleeding of dark, purplish, sticky menstrual blood sharp and fixed abdominal pain before or during the menses, dizziness, dull headache, etc. as a result of blood stasis
a. Shu di huang (Rehmannia glutinosa root-prep)
b. Dang gui (Angelica sinensis root)
c. Bai shao (Paeonia lactiflora root)
d. Tao ren (Prunus persica seed)
e. Hong hua (Carthamus tinctorius flower)
f. Chuan xiong (Ligusticum wallichii rhizome)
H.G. Invasion by Exterior Wind Cold
1. Symptoms
a. Generalized body aches
b. Aversion to cold
c. Chills
d. Mild fever
e. Nasal congestion
f. Thin white coat
g. Floating, possibly a little tight
2. Formula for mihraine headache caused by Invasion by Exterior Wind Cold: Chuan Xiong Cha Tiao Wan (Ligusticum & Tea Formula)
The formula has been used in TCM to treat headache, migraine, or headache on the top, aversion to cold and fever, dizziness, nasal obstruction as a result of Exterior Wind Cold
a. Bo he (Herba Menthae Haplocalycis)
b. Chuan xiong (Rhizoma Ligustici Chuanxiong)
c. Jing jie (Herba Schizonepetae Tenuifoliae)
d. Qiang huo (Rhizoma Seu Radix Notopterygii)
e. Bai zhi (Radix Angelicae Dahuricae)
f. Gan cao (Radix Glycyrrhizae Uralensis)
g. Fang feng (Radix Saposhnikoviae Divaricatae)
For more information of Chinese herb in Western view, please visit http://chineseherbsinnutrientsperspective.blogspot.ca/2011/10/chinese-herbs-in-western-view-health.html
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As a life long sufferer of Migraines it was life changing at the age of 56 to find a solution that actually worked. I had an Occipital Nerve Stimulator Implant. I went from 20 or more migraines monthly to maybe 1 every couple months.
ReplyDeleteThank you Neuro Surgeon Dr. Abood.