Although scientific evidence supports several natural and cognitive–behavioral therapies, four of five specialists do not routinely use alternative medicine in their practice.

To better treat patients, headache specialists should consider integrative medicine alongside traditional allopathic strategies, said Robert Cowan, MD, at the Fifth Annual Winter Conference of the Headache Cooperative of the Pacific (January 27-28, 2012, Ojai, Calif).

Integrative medicine complements conventional treatments with unconventional, nonallopathic, and alternative medical techniques that have been accepted as scientifically valid according to Western standards. These techniques should be a “fourth option” in addition to acute, preventive, and lifestyle strategies, said Dr. Cowan, Professor of Neurology at Stanford University School of Medicine in California.

Patients are using alternative medicine, but physicians are not
Between 50% and 82% of patients with severe headache use alternative medicine together with conventional therapy, often when they believe that the latter is ineffective or too expensive, said Dr. Cowan. These patients do not use alternative medicine to treat their headache, however, and more than half of patients who use alternative medicine do not discuss it with their physicians.

“That’s probably partially our fault,” said Dr. Cowan. Although about 93% of headache specialists ask their patients if they use alternative medicine for their headaches, about 19% of these specialists routinely use alternative medicine in their practice, according to a survey that Dr. Cowan conducted. In consequence, most specialists give patients the impression that alternative medicine is “not really kosher,” he said.

Two views about when to use alternative medicine
One approach to alternative medicine is to use it with the most appropriate patients, such as those who prefer not to take drugs, said Dr. Cowan. Alternative strategies also should be considered for patients who are intolerant to medication, do not respond well to conventional treatment, have medical contraindications, or who have high stress or poor coping skills.

But using alternative medicine as a last resort is akin to “loading the deck,” said Dr. Cowan. “You’re skewing against the patients who are more likely to respond … and … you’re not really opening the door to complementary and alternative approaches,” he added. Another strategy might be to consider alternative medicines as a starting point or as a complement to drugs. Alternative medicine could be part of every patient’s treatment plan, Dr. Cowan said.

Nature’s ways of treating headache
Natural products such as vitamins, minerals, and herbs may be the first treatments that come to mind in a discussion of alternative medicine, and magnesium probably is the best known among them, said Dr. Cowan. Physicians can easily measure ionized magnesium levels or magnesium in red blood cells. Clinical studies have shown that magnesium deficiency is common in migraineurs—especially in menstrual migraineurs. Data indicate that a daily dose of 600 mg of magnesium is an effective preventive measure, but data are unclear about whether it is an effective rescue therapy, said Dr. Cowan.

Studies also indicate that riboflavin, or vitamin B2, is effective as a preventive treatment for migraine. About 60% of patients in one randomized controlled trial experienced a 50% improvement when they took 400 mg of riboflavin daily, compared with 15% of the patients who took a placebo. Riboflavin’s pathophysiology and chemistry are well understood, and it is a safe and easy complementary medicine to administer, said Dr. Cowan.

In addition, coenzyme Q10 (CoQ10) has provided significant benefits in several studies. In a pediatric trial involving 1550 patients, a daily dose of 1 to 3 mg/kg of CoQ10 reduced headache frequency from about 19 days per month to about 12 days per month. Roughly 46% of the patients experienced a 50% reduction in headache frequency, and their pain scores decreased by more than half.

Marijuana has been shown to be of benefit for patients with migraine, and psilocybin has aided patients with cluster headache. Studies of these drugs have been small, however, and more information is needed, said Dr. Cowan.

Scientific justification is weak for other natural products, however. A small trial of patients who took 600 mg of alpha lipoic acid daily failed to meet its primary endpoint of 50% improvement. No evidence has shown that the herb feverfew is more effective than placebo, and a 2010 study of melatonin failed to show the benefit of a 2-mg daily dose.

Mind over matter
Mind–body therapies are another component of alternative medicine. The US Headache Consortium reviewed 39 controlled trials of various mind–body therapies and concluded that biofeedback, relaxation training, and cognitive–behavioral therapy were effective treatment options for migraine prevention, in combination with medication. These treatments are about equally effective, and physicians can choose the best one for the patient’s personality, said Dr. Cowan.

In biofeedback therapy, patients monitor their body functions through various instruments and attempt to control them at will. A meta-analysis of 53 outcome studies found biofeedback to be superior to relaxation therapy and placebo in reducing headache frequency and analgesic consumption. A 2007 meta-analysis concluded that biofeedback could be recommended as a nonmedical treatment for and prevention of chronic migraine.

Cognitive and behavioral therapies, also known as stress management techniques, can reduce tension-type headaches by more than 50%, said Dr. Cowan. Combining cognitive and behavioral therapies with drugs such as amitriptyline may be more beneficial than either treatment alone, he added.

Treating migraine by manipulating the body
Some patients with migraine use practices that manipulate the body, but the science that supports these techniques’ efficacy is not strong, said Dr. Cowan. The US Headache Consortium has not endorsed acupuncture, cervical manipulation, or occlusal therapy as treatments for migraine because of insufficient evidence.

Evidence indicates that other manipulative practices may be beneficial, however. Some data support spinal manipulation as a treatment for cervicogenic headache, and preliminary findings suggest that massage therapy can reduce migraine frequency and improve sleep quality.

Integrating alternative techniques Into medical practice
“I think that it’s important for all of us as headache specialists to develop some integrative medicine skills,” said Dr. Cowan. Physicians should choose a technique that interests them and learn enough about it to be comfortable using it, he added. “In the same way that we don’t all have the same armamentarium of drugs, we’re not all going to have the same armamentarium of complementary and alternative approaches. But I think it’s something we need to be aware of if we’re going to be of full service to our patients. And I think it’s something that should be discussed openly and up front with your patients, rather than when everything else has failed.”

Physicians also must determine how to be reimbursed for alternative medical practices, said Dr. Cowan. Techniques such as biofeedback and hypnosis are usually billable as psychotherapy when they are performed by PhDs. “There actually are ways of incorporating these into your practice,” he concluded.

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Suggested reading
Hershey AD, Powers SW, Vockell AL, et al. Coenzyme Q10 deficiency and response to supplementation in pediatric and adolescent migraine. Headache. 2007;47(1):73-80.

Sun-Edelstein C, Mauskop A. Alternative headache treatments: nutraceuticals, behavioral and physical treatments. Headache. 2011;51(3):469-483.

Wells RE, Bertisch SM, Buettner C, et al. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51(7):1087-1097.