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0019 - Behavioural and physical treatments to control migraines

This is the last chapter of my series on migraines, where I cover other non-medicated solutions that have been proven to work.


Once you have identified your migraine triggers, eliminated the foods that don't agree with you (These foods could trigger your migraines), added some healthy natural supplements (The best natural remedies for migraines) and prioritised sleep quality and stress management, you should have already noticed a reduction in the frequency, duration and severity of your headaches. If this is not enough, there are a few more options that you can try: behavioural treatments (biofeedback and relaxation training for instance), physical treatments (acupuncture, chiropractic adjustments...) or a few other solutions that you can try in the comfort of your own home. These treatments help address several factors that can play a role in migraines, including stress, muscle tension but also behaviours and emotions.


Less than 5% of adults use complementary and alternative medicine to treat their migraines. As there is high quality evidence that behavioural and physical treatments work for the prevention of migraine, many migraineurs could benefit from trying one of these practices.


This article is for educational purposes only. It is not a substitute for professional medical advice and is not intended to diagnose, treat, cure, heal or prevent any disease or medical condition. See full Disclaimer here. I encourage you to do your own research and to discuss with a qualified healthcare practitioner the options that could work the best for your specific circumstances.


1- Behavioural treatments or mind-body practices


Behavioural treatments, also called mind-body practices, teach migraineurs how to identify and mediate the effect of triggers such as stress or muscle tension. These skills can be acquired in a few sessions with a specialist and then practiced at home, at work or when needed. They can be used stand-alone, or in combination with other treatments or migraine medication, to maximise the results.


The US Headache Consortium has confirmed the efficacy of such treatments for the prevention of migraines, including relaxation training, biofeedback and cognitive behavioural therapy, based on "Grade A" evidence. This means that multiple well-designed randomised clinical trials consistently showed significant benefits.


- The relaxation training the most commonly used for migraine is called "progressive muscle relaxation". It consists in scanning for any tension in the body, deep breathing and imagining each tense muscle relaxing. Once learned, these skills can be used regularly to help prevent migraines. Other relaxation techniques include meditation, visualisation / guided imagery and diaphragmatic ("deep") breathing for instance. I have covered them in my blog Mastermind your stress - The power of the thoughts. With regular practice, these techniques can become automatic, effortless and very efficient to reduce your stress levels, whether you suffer from migraines or not.


One study showed that relaxation techniques can be as simple as using a smartphone app to reduce the number of migraine attacks, with progressive muscle relaxation techniques and deep breathing exercises. There are many free apps available for guided relaxation or meditation (such as Headspace). Try one during your daily commute, when you are unwinding at home or whenever you have 5 to 10 minutes to spare.


On average, the research showed that relaxation training yielded an improvement of 41% in migraine index or frequency. Not bad!


- Biofeedback is a technique that works well for pain management. It involves monitoring certain metrics (such as skin temperature, blood‐volume‐pulse or muscle electrical activity), whilst the patients try to relax and actively manage their pain with diaphragmatic breathing or visualisation. The real-time feedback helps the patients improve the outcomes and regain some control over their pain. Once the patients have learned to control their physiologic response, they no longer need the monitoring device and can practice on their own when needed.


On average, biofeedback showed a 38% improvement (one study yielded 56%) in headache activity and received a level 4 evidence (i.e. "efficacious", on a scale of 5) from organisations specialised in psychophysiology, biofeedback and neurofeedback. A few studies showed even better results when biofeedback is combined with medication.

This technique can also reduce the feeling of depression and anxiety that often comes with migraines. It empowers the migraineurs and increases their feeling of self‐efficacy, which seems to be key for controlling stress and tension. Moreover, the benefits tend to increase overtime for those who practice regularly and continue to develop their skills.


- Cognitive behavioural therapy helps patients recognise the situations that make them feel stressed, anxious and trigger migraines. It focuses on identifying and challenging dysfunctional thoughts or behaviours and limiting beliefs that may trigger or fuel migraines. This therapy works well for those experiencing chronic stress or anxiety, mood issues, depression, panic attacks, eating or sleep disorders.


Indeed, research has shown that the mere belief that nothing can help a migraine can actually prevent the efficacy of any migraine treatment. This is the nocebo effect. Negative thinking or limiting beliefs induce a sense of hopelessness that undermines migraine management, increases perceived migraine severity and reduces the quality of life. This is why it is so important for migraineurs to understand how treatments work, that their efficacy has been proven by the research and clinical experiences, so that they can trust the process and realise that there is a lot that they can do to improve their situation. So if you believe that migraines run in your family and that there is nothing you can do about it, read my blogs and the research and start to actively manage your headaches with dietary interventions, supplementation, lifestyle modification, relaxation and stress management...


The research has observed that cognitive behavioural therapy can decrease headaches by 38 to 68% and that adding relaxation training, medication or supplements can further increase its efficacy.


2- Physical treatments


Physical Treatments for migraine management include acupuncture, physical therapy, massage, chiropractic or osteopathic manipulations, for instance, mostly to relieve the neck pain, muscular tension or postural issues that are frequently associated with migraines.

In 2000, The US Headache Consortium concluded that evidence was still insufficient to recommend the use of physical treatments for migraines: the available studies were either of low quality or had only found a modest benefit of physical treatments. Since then, these treatments have been further researched, with very good results.

- Acupuncture has been used for a few thousand years in China. Nowadays, it is used in the treatment of many conditions and has been proven to work well for pain relief. It may also reduce stress and tension in migraineurs. Headache treatments account for about 10% of visits to acupuncturists.


The Chinese medicine believes that acupuncture helps restore the flow of qi, the life energy that flows through our organs and meridians. The Western medicine, on the other hand, considers that it works on the body's neurophysiology and that the placebo effect is likely to play an important role in its efficacy. Anyhow, they both agree that it provides an analgesic effect useful for migraine treatments.


Many recent studies have found consistent evidence that acupuncture provides more benefit than conventional care and that it is as effective as beta-blockers or migraine medication, with fewer side effects.


Here are just some of the benefits observed in the studies: Both the acupuncture and the migraine medication prevented a full migraine attack in about 35% of patients. 41% of patients experienced complete pain relief. Acupuncture was effective in reducing pain 2 to 4 hours after treatment. Migraine frequency was reduced by up to 53%. After 3 months, monthly headache days decreased from 8.4 to 4.7 and were also less intense. Monthly migraine days were reduced by 2.3 days with acupuncture and by 2.1 days with medication. 22 fewer days of headache per year, 25% fewer visits to GPs, 15% less medication and days off sick...


Well, even if you don't particularly like needles, acupuncture is definitely worth considering, especially if you are not satisfied with or do not respond well to standard migraine medication.


- Chiropractic manipulations aim at correcting the alignment, motion and/or function of a vertebral joint and at correcting bad postures that could trigger or worsen migraines.


Several studies have shown that spinal manipulation may be as effective as common medication, with significant improvements in migraine frequency, intensity and duration. More specifically, one study found that 22% of migraineurs had a 90% reduction in the number of attacks and that 49% reported a significant reduction in pain intensity after chiropractic manipulation.


However, select your chiropractor carefully, as cervical spinal manipulations have also been associated with an increased risk of certain strokes (although association does not mean causation...).


- If you want to try something completely different, there are a few studies and a lot of clinical evidence showing that oxygen therapy is effective in the treatment of migraines. The treatment requires a small portable cylinder to breathe pure oxygen during a migraine attack. Not very practical you may say, but those who tried reported a reduction of pain (in 24% to 46% of cases), nausea (in 42% of cases) and visual symptoms (in 36% of cases). On average, 66% of patients responded positively to the treatment.


The theory is that impaired oxygen utilisation is implicated in migraines and that increasing blood levels of oxygen can alleviate migraine pain. It might work by stimulating serotonin (a neurotransmitter) and by reducing inflammation and constricting blood vessels. However, this treatment only works during attacks and does not have any prophylactic effect.


- Reflexology could also be helpful to ease migraine pain and nausea and you can try it at home. There are several pressure points that you can massage: (1) between your big toe and the second toe on the foot opposite to the side of your migraine; (2) the top of your foot, also on the opposite side or both feet if your migraine in on both sides; (3) the outer edge of the top of the foot; (4) the top of the big toes. If you are confused, this diagram can help.


One study showed that nausea was reduced by 85% 4 hours after treatment and that 84% of migraineurs found it beneficial. Another study found that acupressure was more efficient that muscle relaxation for pain reduction (33 and 56 on the pain scale, respectively).


- For migraine, convincing evidence is still lacking to support physical therapy as a stand-alone treatment, but it seems to help when combined with other treatments, including relaxation therapy or biofeedback, exercise and stretching, and ergonomics training, as part of a multimodal treatment plan.


If you like the idea of physical treatments for additional relaxation or well-being, you are likely to feel a benefit for the management of your headaches. Otherwise, the mind-body practices or one of the other options listed below might be more beneficial for you.


3- Other options


There are other options that do not require you to visit a specialist. We have seen that stress, muscular tension, blood flow and blood pressure can all play a role in migraines. So, any practice that can address these factors could be beneficial.


- Mild to moderate exercise increases the production of neurotransmitters that make us feel good, more relaxed and it also reduces pain signalling. Physical activity is good for the cardiovascular, inflammatory and neurovascular processes involved in migraines. It also helps migraineurs regain control of their own health: they can decide when and how to exercise to control their headaches.


Several studies have shown that regular low-intensity exercise can reduce the number of migraine days (-22 to -50%), the attack duration (-20 to -67%), pain intensity (-16 to -80%) and the use of migraine medication (-24%). The results vary a lot depending on the study and once again, you will have to find the amount, intensity and type of exercise that works for you.


Walking, yoga, gardening, cycling, swimming or any other physical activity that you enjoy and help you unwind can be great options. However, more strenuous exercise could trigger migraines and moderation is key, as well as proper warm up, hydration and balanced blood sugar levels. In any case, stop exercising or reduce the intensity if you feel the headache coming.


- Stretching and moving during the day, especially if your job requires you to sit for hours at a time, is a quick and easy practice to release tension in the neck and shoulders. Also, spending hours hunched over a phone adds more than 10 kilos / 20 pounds of pressure to your neck, which can well be another migraine trigger. When you look at your phone, it is better to raise it to eye level. In any case, if your job is sedentary, take a break every hour. Go to the kitchen to make a tea, stand up to make a phone call or during a meeting. Check for muscular tension in your neck, shoulders and jaws and stretch. Or stretch in the evening when you are waiting for the dinner to cook or watching telly.


It may not seem like much, but a study showed that a stretching program resulted in a 37% decrease in headache frequency and intensity, and in a 69% decrease when strength training exercises were added to the stretching routine. Pretty good! Another great reason to start strength training 3 times a week for 30 to 45 minutes. See the benefits of exercise in my blog Exercise to get fitter, smarter and healthier.


- During a migraine attack, put a hot or cold / ice pack or compress on your head and at the back of your neck and apply some pressure for 5 to 10 minutes. Repeat every couple of hours. Alternatively, a hot bath, hot shower or a sauna could work as well to release muscular tension, ease pain and help you relax, assuming that heat is not one of your migraine triggers. Add essential oils (lavender, peppermint, lemongrass, frankincense or sandalwood oil for instance, diluted in almond or olive oil) to your bath to maximise the relaxing effect.


The cold tends to work better for migraine and the heat for tension-type headache, but both could offer some pain relief. The cold seems to work by constricting the blood vessels, by reducing swelling and by slowing nerve conduction, which inhibits our ability to feel the pain. It may also decrease metabolic and enzymatic activity, reducing local tissue demand for oxygen.


The studies agree that cold packs or compresses are effective for migraine management and that the efficacy is improved when pressure is applied. A pain reduction of about 1/3 was observed and 64 to 75% of patients considered the treatment effective. The frozen neck wrap got the best results, with 87% of "optimally effective" and 13% of "moderately effective." Another study observed that headaches last for 0.7 to 2.8 hours with the pressure and heat/cold treatment, versus 2 to 8 hours with medication.


As mentioned in my previous blog, different treatments can have different mechanisms of action on migraines and research shows that the best results are typically achieved with a multimodal approach. So, maximise your chance of controlling your migraines by avoiding or minimising the triggers (foods, beverages, stress, insufficient sleep, medication overuse...), by supplementing nutrient deficiencies (with magnesium, B vitamins, plant extracts...) and by including a behavioural or physical treatment to your life. And remember that taking control of your own health might be the most efficient way to manage your migraines, whilst reaping additional benefits in terms of general well-being!


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