The successful treatment of conditions ranging from the common cold to many cancers remains beyond the reach of modern medicine, despite its tremendous advances. It is not surprising, then, that patients seek a variety of alternative or complimentary therapies. Complementary techniques are those that lack definitive proof of efficacy and are not accepted by the medical mainstream. While many treatments widely used in modern medicine also lack scientific proof, they are not considered complementary or alternative because of their wide acceptance by the medical establishment.
Headaches and alternatives
While the experience of an occasional headache may be universal and usually is tolerable, chronic headache is an important cause of distress and disability. The vast majority of people who suffer from headaches have either tension-type or migraine headaches. Headache only recently began to receive attention from the pharmaceutical industry and organized medicine. Selective serotonin-agonist drugs like sumatriptan have revolutionized treatment of migraines and dramatically changed the lives of millions of people. However, even these "designer" drugs do not work for at least 30% of patients. Unpleasant side effects may occur, and a very small proportion of patients can suffer serious side effects. These concerns encourage many patients who have tried conventional therapy for migraines to explore complementary therapies. Most headache sufferers, however, have never seen a physician for their headaches and may turn directly to complementary treatments, which seem cheaper, safer (though this may not always be the case), and more holistic.
In numerous double-blind treatment trials, a large proportion (30-40%) of headache patients respond favorably to placebo. This "placebo effect" can account for completely useless therapies being effective in some patients. If a particular therapy appears to be clearly ineffective, but at the same time is harmless and inexpensive, I would not discourage an interested patient from trying such an approach, in hopes of a favorable placebo response.
Types of complementary therapies
This ancient method has recently received a boost in popularity because of the consensus statement by a panel convened by the National Institutes of Health. This statement strongly suggests that acupuncture is a legitimate therapy proven to be effective for some conditions and deserving additional studies for others. The panel concluded that nausea and acute dental pain clearly respond to acupuncture, while many painful conditions, including headaches, may respond to acupuncture but require additional studies.
Acupuncture treatment is done using very thin disposable needles, which cause very little discomfort or pain. In patients with chronic headaches treatment involves ten or more weekly 20-minute sessions. Electrical stimulation of the needles is frequently used instead of the traditional twirling of the needles.
Double-blind study of acupuncture is very difficult because blinding for insertion of a needle is impossible, and inserting needles into non-acupuncture points has been shown to relieve pain.
A large number of animal studies indicate that different mechanisms of action (involving different chemical substances) may be involved in pain relief from acupuncture. Only about 70% of humans and animals respond to acupuncture. Patients with chronic headaches who did not respond to acupuncture were shown to have low endorphin levels.
Despite the lack of definitive proof of its efficacy, acupuncture has a significant potential to help some patients with headaches. Issues of cost, convenience and patient preferences should be taken into the account when deciding on this treatment.
Biofeedback is another therapy where definitive proof will be hard to obtain. Most specialty headache clinics offer biofeedback, which strongly suggests that a large number of patients benefit from it (but does not prove its efficacy).
Biofeedback is only one of many relaxation and stress management techniques which can be equally effective if strictly adhered to. This is a big "if." Biofeedback is a preferred technique because it gives the patient a structure and a therapist, who acts as a coach.
The essence of biofeedback, which is often combined with behavior modification, is to teach a patient how to encounter stress without adverse physiological effects. A typical course of biofeedback consists of 8-10 weekly 30-45 minute sessions. Learning to control body functions such as temperature can be achieved only by first learning to relax the skeletal muscles. This is achieved through progressive relaxation, visualization and breathing techniques. Most important though is the daily practice of these techniques. The practice sessions can be only a few seconds or minutes long, but have to be very frequent. A conscious effort is required in the first few weeks of training, but gradually self-monitoring and very brief relaxation techniques become a subconscious habit. This appears to allow many patients to lower tension throughout the day and this results in fewer headaches. Children are especially adept at biofeedback. They can often learn not only how to prevent their headaches in 4 to 5 sessions, but at times can learn how to stop their headache once it begins.
Dietary approaches to the treatment of migraines are widely advocated, but have very little scientific basis, which places them in the category of complementary methods. Dietary avoidance is a widely-advocated strategy. Migraine can be triggered in susceptible individuals by tyramine-containing foods, some food additives and sugar substitutes, as well as by skipping meals. Some patients report that their headaches get better with elimination of wheat, sugar, or milk products from their diets. While we do not have scientific proof, it is possible to speculate on why these dietary changes may work. If the patient is so inclined there is no reason to discourage her from trying these dietary changes, which are usually safe and inexpensive. Strict vegetarian and other unusual diets, on the other hand, can lead to vitamin B12 and other deficiencies, which can make headaches worse and cause other health problems.
Magnesium is a vital element which plays an important role in the pathogenesis of migraines. Many studies have found low magnesium levels in the serum and tissues of migraine patients. In one study, an intravenous infusion of 1 gram of magnesium sulfate was given to 40 consecutive patients with acute migraine. Twenty-one (53%) had very good and sustained relief of their headache. Of the responders, 86% had low serum ionized magnesium levels, while of the non-responders only 16% had low values. A study of intravenous magnesium in the treatment of cluster headaches suggests a possible 40% success rate in this difficult-to-treat disorder. Oral magnesium supplementation was attempted as preventive therapy of migraines in three double-blind trials. Two of the three trials were positive, while one was negative. The negative study might have used a more poorly absorbed salt of magnesium. The absorption of various salts of magnesium has not been studied, so it is difficult to recommend a specific product to patients interested in trying magnesium for their headaches. Magnesium oxide, magnesium diglycinate and slow-release magnesium chloride seem to work for some patients when used in 400-600 mg daily dose.
Wider availability of serum ionized magnesium testing may enable us to identify patients who have low ionized magnesium levels and who are most likely to benefit from magnesium supplementation. In order to remove magnesium from the list of complementary therapies and move it into the mainstream we need large trials unequivocally proving its efficacy.
Riboflavin or vitamin B2 has been reported to relieve migraine headaches better than placebo. The maximum effect was achieved after three months of daily intake of 400 mg of riboflavin. The study involved only 55 patients, but the treatment is very benign and potentially very effective, which makes riboflavin a good candidate for further extensive trials.
Feverfew is the only herbal remedy studied in double-blind fashion. In a trial of 24 patients, a daily dose of feverfew was found to be better than placebo as prophylactic therapy for migraines, though the difference was not dramatic. Because feverfew is fairly safe and may help some patients, this is the herb to recommend to patients interested in herbal remedies. Migra-Lieve is a product made by Natural Science Corporation of America which contains magnesium, riboflavin and feverfew in one tablet. Having these three ingredients in one tablet greatly improves compliance and has been effective for many of my patients. To be fair, I must disclose that I have a financial interest in the success of this product. However, my involvement started only after I became convinced that it helps my patients.
Guarana is a relatively recent import from Brazil, which is being used for headache relief. It may very well have some analgesic properties because of its high caffeine content. However, daily caffeine consumption is one of the leading causes of rebound headaches (see article on Rebound Headaches). Guarana and all other caffeine-containing foods, drinks and medications should be avoided in patients with frequent headaches.
Anecdotal reports suggest that ingestion of ginger, gingko or valerian root, all of which are well tolerated, may help some patients with headaches.
Aromatherapy may not appear as far fetched if we consider how much of our brain is devoted to olfaction and that strong odors can almost instantly induce a migraine.
A double-blind study of healthy volunteers showed that an external application of peppermint extract raises pain threshold and has strong relaxing effects, while eucalyptus has calming and relaxing effects and improves cognitive performance without analgesic effect. Another study which used peppermint oil for tension headaches showed positive results. This gives some scientific support to a variety of topical products being promoted for the treatment of headaches.
Homeopathy is based on an unproved concept of using extremely small amounts of substances (usually herbal), which in large amounts can induce a symptoms which are being treated. Since the treatment is extremely benign and relatively inexpensive it can be tried by patients who believe that it may help.
Regular and frequent aerobic exercise as a treatment for headaches is impossible to study in a double-blind trial and would require a very large comparative trial to confirm efficacy. However, there is little doubt that it offers effective relief for many stress-provoked conditions, including headaches. Other unsubstantiated but anecdotally effective modalities include application of heat and cold, massage and many other similar techniques. As long as they are safe and affordable, patients should not be discouraged from trying them.
Chiropractic manipulation has several potential benefits, which must be weighed against possible complications. Controlled trials in tension headache have yielded mixed results, while small trials looking at migraine prevention have been encouraging. More than 100 cases of serious complications of this approach have been reported. The number of unreported complications must be certainly much larger. Most of the complications involve neck manipulation resulting in a stroke. Because there is no proof that this treatment works, and in view of the potential for very serious complications it seems prudent to strongly discourage headache patients from trying chiropractic treatment.