Introduction: 'Migraine' by Justyna Skowronski
"It’s not just a headache...it’s a migraine. This isn’t just another one of your wake up after a night of endless drunkenness hangover-type migraines. But the problem is that the word “migraine” gets tossed around so much in our everyday vocabulary that people begin to forget that it is an actual chronic illness. There isn’t enough research done on migraines, and the main reason is that the word gets tossed around and used interchangeably with headaches to the point where we forget that it is an actual medical condition. Migraineurs suffer at least 15 days a month with the headache most hungover people experience for a few hours.
Imagine this…
You’re sitting in a classroom and all of a sudden you start seeing white lines in your vision as everything begins to blur.
You get dizzy and your head starts spinning as the fluorescent lights above become unbearable to look at.
You turn to look away from the lights and stare at the floor, but now the professor’s voice is amplified. So loud you might as well be at a rock concert in the front row right by the blasting speakers.
You look up hoping nobody notices you squinting. Trying to draw attention away, you try to participate and raise your hand just as the nausea hits.
Stomach-revolting, gut-wrenching turbulence and you think you’re gonna hurl, right as you're called on.
It seems like the whole world is looking at you as your body starts to go numb from the pain, almost paralyzing.
As you start to ask the question, you feel your words jumbled together and your speech turns into a mumble.
You wonder- can anyone tell? Can anyone see? Can anyone feel what I’m feeling? Is it obvious that I’m struggling.
You excuse yourself to go to the bathroom. After class you go home, and become a potato. Not the lazy kind of couch potato, but the kind that is so paralyzed with pain that you cannot move.
Seeking shelter in a dark room, forcing yourself to try to fall asleep and make the pain go away you lay down.
Your neck becomes stiff, body immobile in excruciating pain, stomach nauseous, pins and needles in your head, razor-swords poking behind your eyes, and no relief in sight.
You’re uncomfortable in your own skin.
After finally forcefully falling asleep, you wake up realizing you missed two classes and go to email your professors, but the migraine has still not gone away, and the light from the laptop is unbearable. It hurts too much.
Alone-in pain. Behind-in school. Anxious-about everything. Depressed- by the situation.
Nobody talks about this seemingly “silent sickness.” This neurological condition that I cannot control.
I cannot control the struggle I have with migraines, but I can control the way we speak about them. I cannot make this chronic illness go away, but I can choose to exercise cura personalis. Care for the self that requires going beyond just what’s at the surface, to a full connection of mind, body, and spirit. They all need to be connected, and “self-care” involves making sure that the entire person is taken care of as a whole.
I cannot create medications that will work, but I can change the conversations to include more funding for researching solutions. I cannot find the medical help and research it will take to finally find something that works for migraines, but I can change the context in which we talk about migraines.
Let’s change this endless cycle once and for all. Let’s be more compassionate, empathetic, and understanding of those around who are suffering. Let us be men and women for others simply by changing the way we speak. We can unite with those suffering by being flexible and adaptable in the way we carry on our conversations.
When was the last time you saw someone struggling and asked: How can I help you? We cannot control the way we feel, but we can control the way we respond to things. I cannot control my migraines, but I can control the way I respond to them."
Background
This essay was written by my now wife, Justyna (Skowronski) Coppus, when she was in college at the height of her migraine suffering. While preparing for the writing of this blog post, I stumbled upon this essay saved in my Google docs, but couldn't remember where it came from. Upon initial reading, my wife could not identify it either, but remarked at how accurately it portrayed her struggles with migraines. It was only upon further inspection and digging that we realized she had written this for a class as an account for her experiences at the time. She told me she has little memory of writing this essay because she was so heavily medicated at the time, while on her migraine medication. She felt like a zombie, barely recalling this time in her life.
When the migraines were at their worst, she was experiencing 20+ migraines/month. She tried every medication, supplement, and dietary recommendation that her neurologist threw at her, none leaving a dent in the frequency or severity, only leaving her numb and muted.
I met her early on in my career, and was able to utilize what I had learned about migraine treatment to help her. Using non-invasive and individualized therapies, diet, hormone regulation, and musculoskeletal techniques we were able to lower her 20+ migraine days/month down to once a week, then to once a month, and eventually one every 3-4 months. She will always be predisposed and have a higher likelihood than most to develop migraines, but they are now so much more manageable and less frequent that she is able to enjoy and engage in her life more fully.
What is a Migraine?
Migraine is the 6th most common cause of disability in the world, directly and indirectly costing the US $19.6 billion dollars each year. 38 million people in the US alone who suffer with migraine headaches. Less than half of migraine sufferers feel they are currently being treated effectively.
An updated definition of migraine from The National Institute of Neurological Disorders and Stroke describes migraine as "a type of headache characterized by recurrent attacks of moderate to severe pulsating pain on one side of the head". Migraine can be preceded by an aura, varying from patient to patient, and typically is accompanied by nausea and light/sound sensitivity.
Physiologically, people who suffer with migraines have altered ion channel function, most of which occurs in the brainstem, and can manifest itself in the vestibular nuclei, midbrain, pons, or medulla. Typically there are many autonomic findings that present with migraines (autonomics relating to blood pressure, heart rate, breathing, sweating, pupillary constriction/dilation, digestion, etc.). Anxiety, depression, and altered sleep are common co-morbidities of chronic migraine headache sufferers, as well. Migraine can be considered as a brain state of hyper-excitability. Migraine is caused by activation of the nociceptors (pain fibers) innervating the blood vessels, which originates from the three branches of the trigeminal ganglion.
Four Phases of Migraine
There are four classic phases to a migraine: Premonitory, Aura, Headache, and Postdrome. The full cycle of a migraine could last from a few minutes to a few days, maybe longer.
The symptoms of the premonitory phase could include the following: mood changes, irritability, fatigue, food cravings, repeated yawning, stiff neck, and light and sound sensitivity. During this phase there is increase in hypothalamic blood flow, which is the area of the brain responsible for many of the previously described premonitory symptoms.
The aura phase is experienced by 1/3rd of migraine sufferers, which can last up to 72 hours in some cases. Typically the aura is visual in nature; however, sensory, motor, speech retinal, and various brain stem auras may be experienced. During this time, a transient wave of neuronal depolarization of the cerebral cortex is occurring, known as: "Cortical Spreading Depression", which is thought to be the hallmark clinical phenomenon of migraine. This is a slow spreading wave of neuronal activation, which is prolonged by inhibited cortical activity for a period of 15-30 minutes. This eventually leads to activation of pial mater pain fibers in the cortex, neurogenic inflammation, vasodilation, and mast cell degranulation.
The headache phase then follows, which can last anywhere from 4-72 hours. This period is usually accompanied by nausea and light/sound sensitivity. Migraine headaches are classified as one sided, pulsatile or throbbing, moderate to severe headaches, which tend to get worse with physical and mental activity.
The postdrome phase concludes the migraine cycle. Symptoms of the postdrome phase can include: fatigue, neck stiffness, and focus/concentration difficulty. This is often an overlooked phase of the migraine cycle, and the symptoms felt during this phase are often attributed to the medication that reduced their head pain.
Understanding Triggers and the Bucket Theory
Most people who suffer with migraines are aware of certain triggers that tend to precipitate them. Some common triggers people may be familiar with are: stress, fluctuating hormones, disrupted sleep, poor diet, caffeine, alcohol, dehydration, loud noises or bright/flashing lights, certain odors, and more. Just because these things are common to trigger a migraine, it doesn't necessarily mean that they are the cause of the migraine.
A concept that was introduced to me by Dr. Adam Harcourt is the 'Bucket Theory'. The Bucket Theory states that we all have a metaphorical bucket. Some of us may have larger buckets than others, and can subsequently hold more water. Those with migraine tend to have smaller buckets and can hold less liquid as a result. If we consider what we initially discussed in the beginning of this post, a person with migraine has altered ion channel function, leading them to be more susceptible to the accumulation of triggers and stressors on the brain, leading to what is knowns as 'cortical spreading depression' in the brain and the migraine cycle. In this analogy, the liquid would represent the stressors in our life, such as the hormonal shifts, sleep disturbances, and alcohol, as examples. Eventually someone with migraine is going to reach the maximum amount of liquid, or stress, that they can hold in their bucket. Once the hypothetical bucket overflows, a migraine is bound to occur. This is why approaching migraine needs to be multifactorial. Not only do we want to reduce the stressors from filling up our buckets, we want to improve the brain's neurophysiology to increase the amount of stress that our brains can handle.
Four Key Considerations with Migraine
Because migraine is a multifactorial condition, our examination process needs to be that much more in depth. If we neglect to cover all our bases, our chances of success begin to diminish.
There are four key things that we consider when evaluating an individual who wants to improve their migraines:
Neurophysiology
Diet & Lifestyle
Hormones
Musculoskeletal System
Not all four categories are inherently issues in those struggling with migraine; however, if you address one of these and neglect the others, your likelihood of success is considerably lower.
Neurophysiology:
The approach that we implement in our office, and the one that has been most effective for my wife and many other patients is that of Functional Neurology. Functional neurology relies on a deep understanding of neurophysiology and the interplay it has on disease and neurologic based symptoms. Using the concept of neuroplasticity, meaning the brain has the ability to adapt and change given the appropriate stimulation and environment, we can create positive changes and ultimately achieve the desired patient outcomes.
When assessing someone's neurophysiology, we start with a comprehensive neurological examination in our office. We are trying to determine where the patient's neurological strengths and weaknesses are. Using standardized testing, we can perform different evaluations of different regions of the brain that may be the weak link in the chain, making migraine more likely.
Our neurological exam process includes a cognitive screen, video eye movement testing, a detailed balance assessment, and comprehensive bedside neurological testing. Once we're able to gather all of these key data points from our exam, we can begin to create a customized and individualized treatment plan to address each patient's specific needs.
Once the problem areas are identified, the next step is to create a treatment plan in order to rehabilitate and strengthen these regions and networks. In our practice, and most other functional neurology practices, non-invasive and therapeutic modalities are utilized to improve these regions. Based on the principal of neuroplasticity, we know that the brain has the ability to adapt and change given the appropriate stimuli, and that's exactly what we aim to do. First, find what needs to change, and second, create that change using appropriate stimuli.
Many times, I am asked "what do therapies look like?". This can be tough to answer, as everyone's treatment plan is going to be unique to their individual needs and metabolic state. In general, our therapies incorporate eye movement exercises, light peripheral nerve electric stimulation, vestibular therapy, musculoskeletal work, somatosensory therapies, and more. Nothing should ever be painful or invasive. Our goals with therapy are to be therapeutic in nature to reduce the frequency and severity of migraine. We also aim to stop migraine in its tracks without medication using individualized techniques to bring a migraine down in real time. Once we can determine what these strategies are, we can teach you, the patient, how to perform these at home so you don't need to rely on a medication that oftentimes makes you feel groggy and foggy.
Once we are able to see what has been helpful and positive for your symptoms and objective findings, we then pass the torch onto you to perform these exercises at home. We aim for every patient to feel empowered and become self-sufficient, never relying too heavily on us, any other doctor, or any thing (be that a supplement or medication).
A general suggestion that will help reduce neurophysiological burden in migraine sufferers, and is applicable to many people in today's modern age, is to reduce screen time. And if you can't reduce screen time because of work or school, at least invest in blue light blocking glasses, a flicker free / blue light blocking monitor, or change the settings on your device to be more eye friendly. I've included links to brands I personally like, but feel free to shop around based on your needs and budget.
Diet & Lifestyle
In working with patient's with migraine, diet and lifestyle seem to be something that is often overlooked in traditional care they tend to receive; however, this can be a hugely important factor in improving the outcome of their care. While there is no specific diet that I recommend for every patient with migraine, there are important principals that tend to hold true for most sufferers.
The ketogenic diet has been shown to be helpful; however, it is not my opinion that all migraine sufferers need to be on the ketogenic diet, but rather understand the underlying mechanism by which the diet is helpful. Therefore, an important principle when considering diet and migraine is to regulate blood sugar. We can do this by making sure we have adequate protein and healthy fats at each meal, and are not overly reliant on carbohydrates. Consuming foods that are lower glycemic index vegetables and fruits is also very important to consider. Also, eating small meals every 2-3 hours and getting plenty of sleep (7-9 hours) will help keep your blood sugar consistent.
Often times when we think of dietary considerations, we think of all the things we can't eat; however, I want to continue to emphasize foods that may be helpful to move towards, and not just away from.
Keeping healthy proteins in your diet, such as organic free range chicken and turkey, organic grass fed beef, wild caught cold water fish (especially as source of omega-3 fatty acids), and nuts (that you aren't sensitive or allergic to) will be great things to lean towards.
Healthy fats, such as olive and coconut oils, avocado (in moderation due to higher histamine levels), nuts (non-allergenic/sensitivity), seeds (such as flax, hemp, and chia), eggs, and more.
Raw and steamed organic vegetables, especially brussel sprouts, broccoli, and asparagus. I also love recommending cauliflower, chicory, carrots, mushrooms, radishes, spinach (in moderation because of histamine), zucchini, cucumber, garlic, pumpkin, bok choy, and onion.
Organic low glycemic fruits, especially berries, consumed with healthy fats and proteins.
When it comes to carbohydrates and grains, try to keep them to a minimum and gluten free, but when you do consume them, try to stick to: quinoa, sweet potatoes, yams, beans, brown rice, millet, oats, and legumes. It is always important to not solely consume these carbohydrates alone, and to pair them with healthy fats, proteins, and vegetables.
Lastly, make sure to drink plenty of water and be mindful of your electrolyte balance, using simple at home recipe (Himalayan salt, clean water, lemon juice, and a little bit of honey to taste) or sugarless electrolyte drinks (such as LMNT).
This is a general list, and non-specific for each person, as some people may be sensitive to some of these foods (which we will discuss later), but is a good framework to work within.
Foods that are an absolute no for my migraine patients include: caffeine, alcohol, gluten, nitrites, MSG, artificial sweeteners, and dairy. Foods that I try to have migraine patients reduce and consume in moderation include: chocolate, citrus fruits, fermented foods, and foods high in histamines. In some cases, histamine can be a major factor. For these patients, we have them reduce or cut out the following: cured meats, fermented foods, vanilla, certain fruits (dried fruits, avocado, kiwi, pineapple, and strawberry), certain vegetables (spinach, tomato, and eggplant), eggs, and high histamine containing nuts.
With each migraine patient, it is important to cut out the known trigger foods, first. But then, we often need to perform further testing to see if there are other food sensitivities that could be unknown or subtle triggers of your migraine. Once identified, our goal is to then eliminate those foods that each patient is sensitive to.
Supplements, vitamins, and minerals that tend to be important and helpful for migraine sufferers include: B vitamins (especially 2, 6, 9, and 12), Vitamin E, Vitamin D, Omega-3, magnesium, turmeric, curcumin, and CO-Q10. This is not an exhaustive list, but an accessible list for many. Consult with your clinician for dosages, frequencies, and specific supplements for your unique needs.
Finally, from a lifestyle standpoint, important considerations to implement include: sleeping 7-9 hours a night at a consistent time, getting 150 minutes of moderate intensity exercise per week and regular HIIT exercise, reducing screen time and blue light exposure, managing stress through prayer and meditation, and limiting chemical and environmental stressors.
Hormone Balance
Demographically, migraine suffering women outnumber men 3:1, which makes sense given the cyclical nature of their endocrinology. Women go through ebbs and flows of estrogen and progesterone throughout the month. If her monthly cycle results in a consistent migraine headache, she may need to consider regulating her hormones to aid in the reduction of her migraine attacks.
Estrogen and progesterone are the two main players in a woman's hormonal cycle. Estrogen being the primary hormone to spike after the start of her cycle leading into ovulation, during the follicular phase. As ovulation is approaching progesterone rises and becomes the dominant hormone during the luteal phase of her cycle. Sometimes our estrogen and progesterone spikes may be blunted or accentuated. In other times, we may have imbalanced estrogen, meaning not enough good estrogen, and possibly too much 'bad' estrogen. These things can be affected by diet, sleep, stress, genetics, and environment.
An important test that I have found helpful in getting a good idea of where the hormone cycle is breaking down is by running a Complete Cycle Map through the DUTCH test. This testing will show us exactly how estrogen breaks down, how estrogen and progesterone fluctuate throughout the day, as well as many other important data points surrounding your endocrine function. Once the problem is identified and brought to light, then we can start addressing it.
As a general guide and resource, I have found the book "In the Flo" by Alisa Viti to be incredibly informative and helpful for those who stick to her suggestions. In her book, she gives suggestions on how to structure your meals, exercise, work, and social life to optimize each phase of your menstrual cycle.
Musculoskeletal System
The last of the four main considerations, but certainly not the least, is the musculoskeletal system. The musculoskeletal system is comprised of the muscles, bones, joints, ligaments, and tendons of the body. Most importantly, the cervical spine and sub-occipital regions. Whether from injury, posture, etc., if the muscles, bones, ligaments, and tendons of the body, especially the cervical spine and sub-occipital region, are out of alignment or too tense, a migraine may be more likely to occur.
In order to manage this element of managing the potential of a migraine, there are many interventions that are readily available in most communities. The modalities that I'm most familiar with and have seen the best results from include: chiropractic care, physical therapy, myofascial work, massage, acupuncture, cupping, taping, scraping, and various electric stimulation to name a few. Our clinic offers a majority of these services, and also has a great referral network for those seeking alternatives. This is not an exhaustive list, and there may be something that you've found to be especially helpful with managing your musculoskeletal system, and that's great! Do what works best for you and your body. Even amongst practitioners, such as chiropractors and physical therapists, there are a large number of variations and approaches that each individual practitioner could take. So, if you don't like something, there's always something else out there that might work better for you and your body.
Keeping your body strong and flexible is important for musculoskeletal integrity. Mindful posture during work and play is crucial. Taking adequate breaks from screens is important to consider. My golden rule is for every hour of screen time, its best to take at least a ten minute break to look off in the distance.
Special Considerations
While the previously four listed considerations are comprehensive, and for most sufferers all they need to worry about, there are still other special considerations that I have found in practice to be important to address with some migraine sufferers. I will not go into depth on these individual special considerations, because to do so would be multiple blogs worth of information, so I will merely list them so you are aware of potential other factors that could be perpetuating your migraine. These things could include: previous head injury, mold exposure and/or toxicity, Lyme disease, carbon monoxide poisoning, other chronic infection (such as Epstein Barr Virus or COVID-19), and more. Presence of one or more of these special considerations can worsen the severity and/or frequency of migraines.
Conclusion
In this article, we delved into the cellular and neurologic mechanism underlying migraine. We explored the four key components essential for holistic and natural migraine treatment. Armed with this knowledge, I hope you feel empowered to steer your care in the direction that suits you best. My hope is for you to find a practitioner who considers all these factors in your treatment, leading to significant relief from this debilitating condition.
To learn more or to schedule a free consultation to see how we can help you, check out our website or call (614)-706-2093.
