If you suffer from migraines, you’re no stranger to the often debilitating symptoms that can keep you out of work, pleasure, and life for days at a time when a migraine strikes. Many of my patients tell me that with a bad flare, they might have to crawl into bed for as long as three days and lay there in a dark, quiet room just to cope.
Women account for 75% of the of the 36 million people who experience migraines in the United States, which are three to four times more common in women than in men. In this article I'm going to walk you through migraine prevention.
Once thought to be initiated by vascular changes in the brain, more contemporary studies have shown us that migraines occur as a result of triggers changing the brain's “migraine threshold” (which can be genetically based and then hormonally or environmentally triggered) due to temporary abnormalities in brain signaling in turn leading to a cycle of events involving the brain's nerve circuits, neuropeptides, neutrotransmitters (including serotonin), changes in the brain's small arteries, and the brain stem which houses our nausea and vomiting centers, for example. They can start at any time – in childhood, our teen years, or as adults, and tend to diminish or disappear once we go through menopause, largely because one of the triggers for migraines is estrogen, explaining the large numbers of women who experience menstrual (or sometimes ovulatory) migraines, and the overwhelming number of women migraine sufferers compared to men. Pregnancy and oral contraceptives (OCP) can each either increase, decrease, or not change migraines at all. Of note, migraines, especially with aura, suggest an increased risk of stroke for OCP users – so if you have migraines please read this before starting an OCP
Despite the known physical origins of migraine headaches, too often women feel their migraines – and the impact they are having on their lives – are underestimated by the medical community. In fact, one study of over 1200 patients seeking care for headache from a primary care provider, 94% of the 377 who turned in a headache diary met criteria for migraines, yet at least 25% did not receive a diagnosis of migraine. This common reality is highlighted in an article in the New York Times with the title, Women's Emotions Do Not Cause Migraines, emphasizing this phenomenon, which is not uncommon in western medicine where many of women's symptoms are dismissed as being emotional in origin. Further, among women who do receive treatment, only about half of patients achieve a 50% reduction in the frequency of their attacks, despite the availability of pharmaceutical options for prevention, and sadly, only 3-5% of chronic migraine sufferers receive adequate prophylaxis therapy. And half of women who have headaches, in one study, had migraines, but did not recognize them as so.
If you have migraines you know you may have had to miss school, work, and social engagements. Some of my patients have come to me with such severe migraines that they've become depressed and anxious – worrying when the next will strike and having to constantly rearrange their lives to accommodate the unwelcome headache's intrusion. Read this article (or watch the video!), to learn how I prevent migraines naturally and how you can, too.
6 Steps to Preventing Migraines, Naturally
Here are the key recommendations I give to all of my patients. I recommend incorporating all of these tips into an overall migraine prevention plan.
Note that it can take up to several months to really make a dent in your migraine frequency and severity, so don’t give up if you don’t notice a change immediately, or even in just a couple of weeks. It doesn't usually happen over night, but it can happen!
Step 1. Identify migraine triggers with a migraine diary
The first step to migraine prevention lies in identifying and removing possible underlying triggers:
The most common triggers are:
- Red wine, alcohol
- Aged cheese
- Nitrites (found in hot dogs and deli meats)
- Food additives (for example, MSG)
- Low blood sugar
- Neck and shoulder tension
- Allergies leading to sinus congestion
- Hormonal changes
- Perfume odors
To keep a migraine diary:
When you get a migraine (I know you won’t feel like doing it, but do it anyway because if you wait until the headache passes, you’ll forget the important details!) to note: what you ate and drank in the last 12 hours, what you were doing (i.e., were you doing a certain kind of exercise, did you fall asleep on a plane if you travel regularly) that might have affected you, and where you were that you might have had an exposure (did you have to go to Home Depot or the supermarket and walk through the aisle with heavily scented detergents, perfumed products, or chemicals; were you at a party where a lot of people were wearing perfume or were smoking?, were you a few days away from getting your period?) Try to identify trends in when you get your headaches – notice what triggers you. Here is a super helpful headache diary from the University of Wisconsin Integrative Medicine Center. I give this to all of my patients. You can download it and start to track your migraine patterns. Use it to monitor your progress once you get started on your headache prevention plan. Please note that just because you might be susceptible to triggers, migraines are not ‘your fault.' And while stress may also be a trigger for you – it's important not to blame yourself – but if there is an association, stress reduction practices like meditation, deep breathing, and biofeedback can help..
Step 2. Do an Elimination Diet
The first thing I do with all of my patients is an elimination diet diet for 3 weeks. For 21 days during remove all of the common triggers as well as gluten, dairy, and sugar, and during the elimination diet, keep your blood sugar steady with regular meals that contain good quality fats and protein – and drink enough water. Ideally, an elimination diet for migraines is about 4-6 weeks long; as you reintroduce foods, pay close attention to headaches or migraines that creep up. If a food that you add back in causes a headache, eliminate it completely, and see the 4R program for when and whether to reintroduce it.
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Step 3. Get your Bowels Moving
In my clinical experience, constipation and migraines go hand in hand so if they're not, make sure your bowels are moving every day. Increasing you daily intake of veggies to 6-10 servings, reducing flour products, pastries, and pasta, and getting a total of about 30 gm of fiber daily (i.e., 2 TBS ground flax seed), can help tremendously. A probiotic can also be very effective. If more help is needed, you can add in 600 mg of magnesium citrate before bed, or up to b600 mg in the morning and before bed if the nighttime dose isn't enough. Bitter herbs can also help you to ‘get a move' on.
Step 4. Reduce Pain Medication Use (for real!)
Most people don’t know this, but there is a phenomenon called medication overuse headache (MOH). When you take pain medications for headaches, including narcotics, Tylenol, aspirin, caffeine, and ibuprofen, on a regular basis, these medications actually start to cause headaches, and make your headache and migraine frequency and severity worse, creating a vicious cycle where you rake more and more of the meds that are making you worse! So as crazy and scary as this might seem to you to try, stop all of your pain medications for a few months. You might be surprised to find that you are actually having fewer headaches! The triptan drugs and propranolol do not fall into this category, however they have their own side effects. Instead, try these pain relieving herbs that I discuss here.
Step 5. Reduce Inflammation
Reducing the pro-inflammatory foods in your diet, particularly sugar, red meat and poultry, and processed foods, while adding antioxidant rich fruits and vegetables and good quality oils can reduce your headache frequency. Oils I recommend include olive oil, walnut oil, and coconut oil, all of which can be eaten raw or cooked. Also, avoid low blood sugar by eating healthy meals at regular times, and eating healthful snacks such as vegetables with hummus, a small handful of nuts or seeds, or an apple with almond butter. If you struggle with inflammation or blood sugar problems read my book, The Adrenal Thyroid Revolution to help you learn to cool down the heat and keep your sugar steady and stay tuned for the next 28 Day Gut Reset program which walks you through the Elimination Diet and teaches you how to follow a low inflammation diet and balance blood sugar. .
Step 6. Try Herbal & Nutritional Supplements
I recommend taking Riboflavin, Magnesium, Ginger and Fish oil daily as a core set of migraine prevention supplements, and then after 4-6 weeks if more support is needed, adding in your choice of one or several additional choices. Most of these options take 4-6 weeks to begin to have a notable impact, so give them time – it's not like a typical magic bullet. The exception is ginger, mentioned below, which can be taken daily for prevention, but can also work acutely for stopping a migraine in its tracks. These supplements are safe with your other migraine medications, though a few other cautions are noted.
Continue for 4-6 weeks even if you don’t notice improvement right away, as it can take several weeks or more, to reduce or relieve symptoms.
Start with this combination (which is also safe in pregnancy and breastfeeding as noted):
- Riboflavin (Vitamin B2) 400 mg/day: An under-recognized contributor to migraines may be decreased mitochondrial function (mitochondria are the ‘energy power houses of the cell'). Riboflavin has been shown to safely prevent recurrent migraines by 50% compared to 15% for placebo – that’s a lot! Its benefits are likely a result of increased efficiency of the mitochondria. It may take about a month to notice results, but hang in there. It’s often very effective. If you are on a beta-blocker for migraine prevention, riboflavin has been shown to enhance the benefits so it may allow you to lower your dose or get better results from the dose you are taking. CAN BE TAKEN DURING PREGNANCY and in fact is considered a migraine prevention of choice during this time.
- Magnesium glycinate (600-1200 mg daily): can help prevent migraines generally, and may be especially helpful in preventing migraines associated with your period (hallelujah sister!) Dose 600 mg daily. It may take as long as 3 months to see results, but hang in there wit this one, too. CAN BE TAKEN DURING PREGNANCY; take care and discuss with your prescribing provider if you are on a beta-blocker or other blood pressure medication as high-dose magnesium can lower blood pressure).
- Ginger: In a study of 100 migraine sufferers, both sumatriptan (50 mg), a common drug used to stop migraines at their onset, and ginger powder (250 mg) equally decreased the severity of attacks within 2 hours, with equal satisfaction with pain relief in both groups, and far more side-effects in the Sumatripan group. Ginger is traditionally used to treat pain and inflammation, and up to 1 gm/day is considered safe even for use during pregnancy.
- Fish Oil (1500-3000 mg daily): also effective anti-inflammatory, supplementing with fish oil (750 mg/day EPA and 500 mg/day DHA), which is anti-inflammatory, has been shown to reduce headache frequency, length, and severity. CAN BE TAKEN DURING PREGNANCY!
Then add in one of more of the following if needed;
- Melatonin (3 mg): Results from a multicenter, randomized, double-blind, placebo-controlled trial showed that 3 mg of melatonin was more effective than placebo and had efficacy similar to that of 25 mg of amitriptyline, was safer, and better tolerated. It was associated with lower rates of daytime sleepiness and no weight gain. It is likely working through the pineal gland, the circadian rhythm, and improving sleep quality. I have no safety data on melatonin during pregnancy but safe during breastfeeding. It may take a few weeks of daily use to really have an impact.
- 5HTP (200 mg/day) has been shown to be helpful in preventing migraines in several studies with better effects than pharmaceuticals. It probably works by regulating serotonin levels and increases endorphin (a natural pain reliever produced in the body) levels. It is safe for use while breastfeeding. Take for at least 6 months for best results. I have no safety data on melatonin during pregnancy but safe during breastfeeding
- Co-Enzyme Q 10 (50-200 mg/day in the form of ubiquinol): this supplement has helped many women overcome chronic migraines – it's primary activity also being to enhance mitochondrial function. Safe for use in pregnancy.
- Feverfew (25 mg daily): Feverfew is an herb that acts as a natural anti-inflammatory. It reduces migraine frequency and severity, as well as lessening migraine-associated symptoms. Dose: 25 mg daily. If you are on blood thinners, feverfew is not for you – it can interfere with your medication and increase bleeding. NOT FOR USE IN PREGNANCY.
- Butterbur (also called Petasites, (purchase the “PA-free: type only!): is also anti-inflammatory and has been shown to lead to a significantreduction in headache frequency. The dose is 75 mg twice daily. It may take several months before you notice major improvement, but give it a whirl. Because it also helps with symptoms of allergic rhinitis, this is an especially useful herb if you have allergy-associated headaches. NOT FOR USE IN PREGNANCY.
- These supplements are generally safe for most women; even if you are on other medications, however, talk with your doctor before starting feverfew if you are on blood thinners. Feverfew and butterbur are not appropriate for use in pregnancy, but can be taken while breastfeeding.
I have seen these migraine prevention tips work for so many patients! If you have suggestions for things you have found helpful in migraine prevention, please let me know – I’d love to know what methods work for you!
Wishing you speedy migraine relief!