stop migraine dr deb

Can the ketogenic diet help prevent migraine headaches?

Can the ketogenic diet help prevent migraine headaches?

stop migraine dr deb

Migraine headaches are characterized by recurrent episodes of moderate to severe throbbing pain that are typically associated with nausea, vomiting, along with light and sound sensitivity. Currently, it is estimated that between 12-14% of the population, or over 37 million people in the United States suffer from migraine headaches. Migraines are more common in females of childbearing age. One out of four women will have a migraine sometime during their lives. Despite the fact that it is the 3rd most prevalent and the 6th most disabling illness in the world, there are still very few effective treatment options.

As a headache specialist I am always looking for better treatment options for migraine headaches. For those who know me, know that I prefer conservative treatment options, such as exercise or dietary changes. For the past two years I have been doing research on all the potential neurological benefits of ketones and the ketogenic diet (KD).

The ketogenic diet mimics fasting by restricting the amount of carbohydrates that are eaten. This triggers the break down of fats, producing ketones. Research has shown that ketones have many beneficial effects both for the brain and the body. Specifically, research has shown that ketones decrease inflammation, decrease brain cortical excitability, improves mitochondria function, and decrease the amount of reactive oxygen species (ROS) thus reducing oxidative stress.

So why would the ketogenic diet or having ketones potentially help with migraine headaches?

Ketogenic diet has been used since the 1920’s for treatment for epilepsy. Many of the same medications are used to treat both conditions. Specifically, the anti-seizure medications, Topamax and Depakote are also used to prevent migraine headaches. Both migraine headaches and seizures involve paroxysmal excitability of the brain. So measures that decrease this excitability may improve both conditions. Ketones have been found to decrease the levels of the excitatory neurotransmitter glutamate. (Stafstrom, C. 2016) Decreasing glutamate levels decreases cortical excitability and decreases central sensitization. Central sensitization is a condition of the nervous system that is associated with the development and maintenance of chronic pain syndromes such as chronic migraine headaches and fibromyalgia.(Pomeror, 2017)

Decreased cortical excitability has also been shown in rat models looking at cortical spreading depression (CSD). CSD is a wave of cortical excitability that is thought to correlate with migraine aura and may be a trigger for the start of a migraine. (Stafstrom, C. 2016) It has been shown that rats treated with a KD had decreased CSD. (Di Lorenzo C. , 2015) Why CSD occurs is unclear but one hypothesis is that it is due to dysfunctional mitochondria. Mitochondria are where the cells produce ATP needed for cellular energy. When the mitochondria are dysfunctional, this lead to decreased ATP production. This decreased ATP then increases the occurrence of CSD and potentially migraines. (Sparaco, 2006) Thus, another reason ketones may be beneficial in preventing migraines is that ketones have been shown to improve mitochondrial function. (Di Lorenzo C. , 2013)

Another reason that ketones or being on the KD would be helpful in prevention of migraines is because of the anti-inflammatory effect of ketones. Neuroinflammation is inflammation medicated by the release of neuropeptides of the nerve fibers in the brain. It is the physiological mechanism of a migraine attacks. Indirect evidence that inflammation is the mediator of a migraine attack is during a migraine attack is based on the increased levels of inflammatory peptides during a migraine and the fact that non-steroidal anti-inflammatory drugs are often effective treatment for acute migraine headache.(Pietrobon, 2013)

There are several different mechanisms for the anti-inflammatory effects of ketones.   First of all, compared to glucose metabolism, ketone metabolism produces fewer reactive oxygen species (ROS). ROS contribute to inflammation. Secondarily, the neurotransmitter Adenosine is increased with the KD. Adenosine has been shown to decreases both central and peripheral inflammatory. (Masino, 2013) (Dupuis, 2016) Lastly, ketones have been shown to block the NLRP3 inflammasome. Activation of NLRP3 inflammasome leads to the release of pro-inflammatory cytokines. (Youm, 2015)

So what does this mean clinically? Can the KD decrease the frequency of migraine headaches?

The first report of using the KD for migraine was in 1928. That study, 9 of the 28 patients reported some improvement, despite the fact that there was low compliance with the diet. (Stafstrom, 2016) More recently a larger observational study was done in 96 obese females. In this study, the females were randomized to either eat a KD or standard diet (SD) for 1 month. During the month on the ketogenic diet, there was a significant decrease in the frequency of migraine, the number of days with migraine, and medications used to treat migraine headaches. After that month all were transitioned back to a SD, during which their headaches again worsened. (Di Lorenzo C. , 2015) 

headache study

So, if you have migraine headaches, and would like to try something conservative as a means to decreasing the frequencies of your headaches consider starting a ketogenic diet. If starting making this significant dietary changes scares you, consider jumping in the easy way by starting a ketone supplement*. Other benefits that you might notice when you have ketones in your system include fat loss, improved energy, and improved mental focus. When was the last time you heard those ‘side effects’ when discussing medication options for migraines?!?

Bibliography

Di Lorenzo, C. (2013). Diet transiently improves migraine in two twin sisters: possible role of ketogensis. Functional Neurology, 28 (4), 305-308.

Di Lorenzo, C. (2015). Migraine improvement during short lasting ketogenesis: a proof of concept study. European Journal of Neurology, 22, 170-177.

Dupuis, N. P. (2016). Anti-inflammatory Effects of a Ketogenic Diet. In S. Masino (Ed.), Ketogenic Diet and Metabolic Therapies (pp. 147-155).

Masino, S. (2013). Ketogenic Diet and Pian. Journal of Child Neurology, 28 (8), 993-1001.

Pietrobon, D. M. (2013). Pathophysiology of Migraine. Annual Review of Physiology, 75, 365-91.

Pomeror, J. L. (2017). Ketamine Infusion for Treatment Refractory Headache. Headache, 57 (2), 276-282.

Sparaco, M. (2006). Mitochondrial dysfunction and migraine: evidence and hypotheses. Cephalalgia, 361-372.

Stafstrom, C. (2016). Dietary Therapy for Neurolgical Disorders. In S. A. Masino (Ed.), Ketogenic Diet and Metabolic Therapies. Oxford.

Stafstrom, C. (2012). The ketogenic diet as a treatment paradigm for diverse neurological disorders. Frontiers in Pharmacology, 3, 1-8.

Youm, Y.-H. (2015). Ketone body Beta Hydroxybutrate blocks the the NLRP3 inflammasome-mediated inflammatory disease. Nature Medicine, 21, 263-269.

 

The medical information on this site is provided as an information resource only. This information does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.
*These products are not intended to are not intended to diagnose prevent treat or cure any disease. If you are under medical supervision for any allergy, disease, taking prescription medications or you are breastfeeding contact your medical provider before adding any new supplements to your daily regimen.

 

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Obesity increases risk of migraines

Yes, being obese can actually increase your risk of having more migraines headaches!

Obesity affects one and a half billion adults worldwide, with estimates of a third of adults in United States being obese. Obesity is associated with many health issues including heart disease, stroke, diabetes, and cancer, making obesity is a significant health problem.  Obesity also has a negative effect on quality of life due to increased back and joint pain. What may be surprising to some people is the fact that obesity is also associated with an increased risk of migraine headaches.

Studies have shown obesity is a strong risk factor for having migraines. Being overweight or obese is associated with a two-fold increased risk of having migraines. As the BMI increases so does the risk of having migraine headaches. Additionally, obesity is also associated with having greater than five times the risk of developing chronic migraines. By definition, a chronic headache is having >15 migraines a month, which are typically more difficult to treat.

The fact that obesity increases the risk of both chronic and episodic migraines has been shown in multiple studies.   The first was in 2003 by a study by Ann Scher.  This study showed that not only that the risk of having migraines increased with obesity, but also that compared to those with normal weight, individuals with episodic headaches who also had obesity at baseline were at increased odds of developing chronic migraine at follow up. These results have since been confirmed in several other studies.

What is the mechanism?

The cause of increased migraine in obesity is not exactly known, but most likely it is related to the pro-inflammatory properties of adipose tissue. Adipose tissue is more than just fat that piles up where we don’t want it; it is also a functioning active endocrine organ. Adipose tissue produces and releases pro-inflammatory cytokines including tumor necrosis factor and interleukin-1. Additionally, several hypothalamic peptides adiponectin and orexin, typically felt to be anti- inflammatory, are low in people who are obese.   This increased systemic inflammation has been implicated in the pathogenesis of migraine headaches.  Increased inflammation also is associated with increased central sensitization, which then lead to more frequent and harder to treat migraines.

Can weight loss help prevent migraines?

Currently the only studies on the effects of weight loss in adults were in people who underwent surgical treatment for weight loss. The two small clinical studies that looked at headache frequency after weight loss from bariatric surgery, found that at 6 months after surgery the frequency of migraine did indeed decrease from a pre-surgery average of four per month down to 1-2 per month. There was also an improvement in headache duration, pain severity, disability, and use of pain medications.

The only study looking at non-surgical intervention for weight loss to date was in adolescents. This study looked at whether a behavioral weight loss intervention would reduce migraine frequency. The behavior intervention consisted of encouragement of exercise program and dietary education of the adolescent and their parents. This study showed that a decrease in BMI was associated with a reduction in migraine frequency. With the greater decrease in BMI was a greater decrease in migraine frequency.

How can weight loss cause an improvement in migraine headaches?

Just as obesity is associated with pro-inflammation, weight loss is anti-inflammatory. Weight loss decreases pro-inflammatory cytokines (TNF and IL-1) and the peptides leptin.   Weight loss also increases anti-inflammatory peptides; Orexin A, and adiponectin. Thus with weight loss, there is less neurogenic inflammation resulting in less frequent migraines but also less central sensitization and decreased severity of those migraines.

Additionally, there are also the benefits of physical activity on prevention of migraines. Several studies have been published that have reported beneficial effects on both migraine frequency and severity. Also a study showed that exercise might be just as beneficial as topiramate in the prevention of migraines. Exercise is also felt to be anti-inflammatory and also increases the feel good, pain-reducing chemicals in your brain. In addition, people who exercise, tend to eat better, sleep better and have less stress which all can also decrease migraines.

WHY NOT GIVE IT A TRY?

Given that there is proven benefits seen with both exercise and weight loss in improvement in both frequency and severity of migraines, what is stopping you from giving it a try. I would love to help find an exercise and weight loss program that is right for you.

Your Name: *

Email Address: *

How may I help?

Please leave this field empty.


Bibliography:

Evan, R. W. (2012, February). The Association of Obesity with Episodic and Chronic Migraine. Headache .

Lockett, D. C. (1992). The effects of aerobic exercise on migraine. Headache, 32 (1), 50-54.

Peterlin BL, R. A. (2010). Migraine and obesity: Epidemiology, mechanisms, and implications. Headache, 50, 631-648.

Varkey, E. e. (2011). Exercise as migraine prophylaxis: A randomized study using relaxation and topiramate as controls. Cephalalgia, 31 (4), 1428-1438.

Verrotti, A. e. (2013). Impact of a weight loss program on migraine in obese adolescents. Euroean Journal of Neurology (20), 394-397.

2014Scottsdale-head

What is new in migraine

What is new is in Migraine?

My top 5 take away from:

2014 American Headache Society Scottsdale Headache Symposium

 

  1. Migraine facts: One billion people on this planet have migraine headaches. One out of every four households has someone who suffers from migraines. 10% of children have migraines. Between 1-3% of people who have migraines will develop chronic migraines. Less than 50% of people who have migraines seek medical treatment.
  1. Neuromodulation:  Neuromodulation via either direct transcranial magnetic stimulation of the brain or stimulation peripherally, is the new wave of future treatment options for both migraine and cluster headaches. They are not yet ready for prime time but the future looks promising. Some of the most promising include the sphenopalatine ganglion stimulator for cluster headaches and the vagal nerve stimulator for both migraine and cluster headaches.   Currently available for purchase is a transcutaneous supraorbital neurostimulator (cephaly). In the studies it was reported to have a responder rate of 38% with 1/3rd of responders having a 25% reduction in headaches and decrease in headache severity. The most common side effect was strong paresthesias.
  1. Nutraceuticals: More and more people are reaching for a more natural treatment options for migraines. However, just because it is natural does not mean it that is always safe. Butterbur (petasites hybridus) is a popular nutraceutical often given for migraine prevention. Butterbur in its natural plant form contains pyrrolizidine alkaloids, which are hepatotoxic if not processed correctly.   Petoladex formulation of butterbur previously had the most trusted processing standards to which the butterbur was purified to contain less than the detectable limit of this hepatotoxic alkaloid.   Because Petoladex safety has recently come to be questioned it has been taken off the market in Europe and is no longer recommended by the AHS.
  1. Food Sensitivities:  The scientific community is slowly coming around to what my patients have been telling me for a while now.   That is, that the foods that we are eating may be triggering our migraines. Some foods have long been associated with triggering migraines such as MSG or Red Wines.   New triggers or food sensitivities can be found by testing for IgG sensitivities instead of relying on food diaries or IgE skin testing.   Removal of those food sensitivities from the diet may make significant difference headaches frequency.  (For more information on food/gluten sensitivities check out my recent post).   Also discussed was that a specific diet i.e., a diet in high Omega 3 vs Omega 6 has been shown decrease the frequency of migraines.  (For more information on this study of high omega 3 diet see my recent post).
  1. Obesity: Obesity is a strong risk factor for both having migraines and progressing into chronic migraines (>15 migraines a month). As your BMI increases so does the risk of having migraines, specifically, up to 2 times the risk of having migraines and 5.28 times the risk of developing chronic migraines.   The reason why is probably multifactorial but one interesting theory is based on the fact that adipose tissue produces cytokines that are pro- inflammatory (IL-6 and TNF alpha). Studies currently are under way looking at the potential benefits weight loss might have on the treatment of migraines.

This information is for education only, it is not intended to replace the advice of your physician .

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Migraine Headaches

 What are migraines and how can I prevent them?

As a Neurologist with a specialty in Headache Medicine;  This is what I tell patients with migraine headaches

What are migraines?  Migraines are a primary headache disorder of recurrent attacks of moderate to severe pain.  The pain is often described as a throbbing or a pulsing pain which is typically located on one side of the head.  This can be accompanied by light and noise sensitivity, upset stomach, and visual changes (aura).  Migraines may present in different ways and maybe misdiagnosed by as tension headaches or sinus headaches.

What causes migraines? For many years it was believed that migraine attacks were due to changes in the blood vessels in the brain.  It is now believed that migraines are probably genetically induced hypersensitivity of the neurons in the central nervous system. This results in the brain neurons being more sensitive to their environment and thus has a lower threshold for developing a headache. Hormones, foods, noises, smells, lights, and stress all play a part in causing headaches.

How are migraines diagnosed? Migraines are diagnosed clinically by talking with your doctor. There are no x-rays or blood tests that will diagnose migraines. Generally, no tests are needed when migraine is suspected.

Who gets Migraines? Migraines affect 12 % of the U.S. population. Men and women of any age can get migraine headaches. However, migraines are most common in women in their teens to menopause.  Migraines often run in families.

Why did I get migraines? Every person has a headache threshold.  For a lucky few, it may take a sledgehammer to give them even a mild headache.  However for those with frequent headaches, something as simple as a missed meal may lower their headache threshold enough to start a disabling migraine.  Everyone has different migraine triggers to increase their headache threshold. The way I like to describe migraine is to think of it like a cup; once the cup is full = migraine.  Some people start with a cup that is already almost full and only one other trigger such as hormonal issue can make the cup full and thus trigger a migraine.  Other people have very little in the cup to begin with so it takes multiple triggers before the cup is full, and thus harder to trigger a migraine.

What are some common migraine triggers?

  1.     Sleep pattern changes, either too much or too little
  2.     Increased stress in everyday life
  3.     Menstrual cycles or hormonal changes (for women)
  4.     Weather changes/fronts
  5.     Foods; There a lot of foods that has been reported to trigger migraines in some people.  Some of the most commonly reported causes include
    1. Caffeine
    2.  Aspartame
    3.  MSG from Chinese food
    4.   Nitrates and nitrites
    5.   Red wines and alcohol
  6.  Dehydration

For more information on migraine triggers see recent blog post on triggers.

Conservative ways to prevent/decrease migraines:

  1. Get good restorative sleep; try to wake up and go to sleep at about the same time every day.  If you snore please seek medical evaluation and treatment for this, it may be sign of obstructive sleep apnea which can cause headaches, and also other medical problems such as high blood pressure, heart attack, and strokes.
  2. Stress reduction; obviously it is hard to get rid of all the stress in your life, but you need to find ways to better deal with the stress.  Such as: talking about problems, relaxation, messages, and exercise.
  3. Make exercise a routine part of your life.  Migraine may worsen when you exercise with a headache.  Recent studies however show that participants who routinely exercise had a decrease in the frequency and severity of their migraines.  I recommend exercising 5-6 times a week.  Exercise also help to decrease other migraine triggers such as anxiety and stress. It can improve sleep, decrease weight, increases natural pain reducing chemicals, and increases natural endorphins (feel good chemicals) in the brain.  For more information see “Exercise to prevent your migraines” post.
  4. Practice relaxation exercises on a daily basis. Whether it is through biofeedback, deep breathing, mediation, guided relaxation, cognitive-behavioral treatment, yoga, or Tai Chi, these practices can help decrease the hyperexcitation of the brain, thus decreasing likelihood of getting a migraine, help you deal with the migraine better, and help you deal with other outside stressors.
  5. Weight loss: Obesity is associated with an increase in frequency of migraines in people with migraines.  It is unclear why, some feel it is due to the higher levels of inflammation in the body.
  6. Hydration:  Drink at least eight 8 ounces of water daily, this may need to be increased in the summer months, if exercise regularly, or drink dehydrating fluids such as caffeine or alcohol.
  7. Limit or stop drinking caffeine: If suddenly stop drinking caffeine may get caffeine withdraw headache.  If must drink caffeine try to drink less than two servings a day.
  8. Eat regularly: do not skip meals, especially breakfast. I also recommend eating smaller more frequent meals.  (See addition information in “Migraine Diet” blog)
  9.  Maintain a headache diary: this helps you keep track of any possible triggers (lack of sleep, food, hormones, stress) that might have trigger but also shows if migraine frequency is improving or worsening.

Medical treatment for migrainesThere are medications that can decrease the frequency of your migraines and also medication to take when you have a migraine.  For more information please discuss with your Neurologist.

This site is purely informative and should not be considered medical advice. It is not intended to be used to diagnosis or treat any disease.  Please consult your physician before starting any fitness program or new supplement.