CAM You can Use: Preventing Headaches,Kathi J Kemper, MD, MPH General Pediatrics, Integrative Medicine 2nd Opinion Clinic (Monday mornings) kkemperwfubmc.edu 716-9640,Disclaimer,I have no conflicts of interest to report regarding this presentation; I published a CME article on this topic with MedScape for which my institution received payment The presentation includes no description of any proprietary items for screening, diagnosis, or treatments,Objectives,By the end of this session, participants will be able to Counsel patients on dietary modifications to prevent headaches Discuss the scientific evidence about the effectiveness of stress management practices in preventing headaches Find evidence-based resources about the effectiveness of acupuncture in preventing headaches (See AAP Section for Complementary and Integrative Medicine; join the listserv) NOT focused on diagnosis or medications,Headache,Common! (in teens, 4 HA in past month by 6% males; 14% females) (Linet. JAMA, 1989) 90% Migraine or Tension-Type Headache 10% other : sinusitis, eye, trauma, ice cream, cervicogenic, myofascial pain, TMJ, hemorrhage, infection, pseudotumor, vasculitis, tumor,CAM Use for Tension-Type HA,40% used CAM 60% did not tell MD (how many MDs asked?) Types of CAM Chiropractic 21% Acupuncture 17% Massage 17% Rossi et al. Headache 46:622-631, 2006,* CAM Complementary or Alternative Medicine, somewhat outdated and useless term,CAM at UNC for Headache,Biofeedback (thermal, muscular, heart rate variability, autonomic) Hypnotherapy Osteopathy Acupuncture Mindfulness Meditation Herbal and supplement counseling,Prevention options,Patient-Centered Care,LIFESTYLE,Biochemical,Biomechanical,Bioenergetic,Prevention/health promotion lifestyle,Avoid triggers! Nutrition and supplements Exercise/sleep Environment Stress management,Lifestyle AVOID TRIGGERS,Non-modifiable: genetics, gender, weather Semi-modifiable: air pollution (including tobacco smoke, CO, SO2, NO2), menses Modifiable - Lack of sleep - Missing meals Allergens Foods tyramine containing, nuts, cheese, smoked fish, artificial sweeteners, nitrate preservatives, MSG, caffeine withdrawal Stress physical, psychological!KEEP A HEADACHE DIARY!,Diet: Avoid Food Allergens,Clinical trial of 43 patients Allergy skin testing 69% responded to diet modification (p impaired O2 utilization Riboflavin (B2) is the precursor to key molecules in the electron transport chain in the mitochondria 200 mg BID with meals for 3 months - 68% reduction in migraine attacks in RCT (next slide) Side effect: yellow urine Schoenen. Neurology, 1998; Sandor. Headache, 2000; Magis. Headache, 2007B6 essential in converting tryp to serotonin More than 100 mg daily - nausea, abd pain, sleepiness, lower B12 levels; 1000 mg daily - sensory neuropathy,* High Dose Riboflavin vs. Placebo,Schoenen J et al. Effectiveness of high-dose riboflavin in migraine prophylaxis: a randomized controlled trial. Neurology 50(2): 466-70; 1998.,Supplements: Minerals,Calcium for PMS-related migraines 44% of boys and 58% of girls 6-11 insuff 64% of boys and 87% of girls 12-19 insuff Ensure 1200- 1500 mg daily Thys-Jacobs. J Am Coll Nutr, 2000Magnesium (1 gram iv acutely) or 300 500 mg daily po to prevent (soy beans, black beans, tofu, seeds, nuts, whole grains, shellfish) Mauskop. Headache, 2002; Pfaffenrath. Cephalgia, 1996 Mazzotta. Cephalgia, 1999; Wang, Headache, 2003 Peikert. Cephalgia, 1996; Facchinetti F, Headache, 1991,* Magnesium - mechanism,Ionized magnesium levels low in 50% of MHA patients Migraines associated with platelet aggregation, serotonin release Magnesium reduces platelet aggregation Magnesium decreases the affinity of serotonin for vascular receptor sites Magnesium acts as an NMDA receptor (glutamate receptor) antagonist NMDA receptors & pain transmission Inhibits one type of neuronal spreading depression in experimental models * OPTIONAL SLIDE for participant reference,* Consequences of Reduced Mg+,Vasoconstriction of scalp arteries Reduced affinity of serotonin receptors Lower threshold for activation of N-methyl- d-aspartate receptors Enhanced platelet aggregation and serotonin release,* Trials with Mg+ Supplements,An infusion of 1.0 g of magnesium sulfate in 40 patients with acute migraine 52% responded to therapy 86% of the responders had low serum ionized Mg+ levels 16% of the non-responders had low serum ionized Mg+ levels.,