AYURVEDIC TREATMENT OF MIGRAINE HEADACHES Sara Manwiller November 2010 Migraine headaches are a debilitating condition which costs the United States billions of dollars in healthcare treatment every year. Approximately 12% of the population or more than 30 million people in the United States suffer from migraine headaches. (2, 13,24) Migraine prevalence peaks in middle life, between 30-50 years old, and migraines affect more women (17.1%) than men (5.6%). Migraines are much less common in children and after age 60, (24) ‘And, despite recent advances in healthcare, migraines continue to be a very difficult diagnosis for healtheare providers to treat, and they are a frustrating diagnosis for patients to have. It is for this reason that [ am going (o explore the treatment of migraines using the principles of Ayurveda, Migraine headaches are commonly defined as episodic or recurrent severe headaches, typically of a throbbing or stabbing nature, usually on one side of the head, the neck or behind the eye. They usually start as a dull ache and worsen within minutes to hours, and they commonly last 6-48 hours.(17) Migraines may or may not be preceded by an aura; the aura may cause visual disturbances such as flashing lights, “zig-zags”, sparkles, spots or blurring of the visual field. Sensitivity to light (photophobia), sensitivity to sound (phonophobia) and to strong, smells often accompanies migraines, Activity typically aggravates migraines. Other common symptoms of migraines are nausea and vomiting, dizziness and cognitive disturbances-including problems concentrating or finding words. Patients may also experience chills, sweating, fatigue, numbness, tingling and weakness. Often there is a postdromal period after a migraine during which the patient is exhausted and mentally “fogey.” (27)‘True migraine diagnosis by healthcare professionals is made difficult because of the overlapping of symptoms of migraines with tension-type headaches. So, for the purpose of this paper, many treatment principles that apply fo treatment of migraines may also apply to the treatment of tension-type headaches. (26) Prevalence of tension-type headaches in the United States is up to 40% of the population, and the symptoms of tension headaches may include all of the above symptoms plus neck and facial muscle tension and pain. (3, 26) ‘The cause of migraines is not completely understood, Migraine headaches are thought to be triggered by something that causes an inflammatory response or a sensitivity reaction of the blood vessels in the head. The vascular inflammation thus causes irritation of the nerves, which results in the headache and its associated neurological symptoms. Substances or activities that cause a sudden vascular dilation or constriction may trigger these inflammatory neurovascular reactions, ‘There also seems to be a strong genetic component to migraines; about 70-80% of migraine patients have a family member with the disorder. (27) Common migraine triggers include: weather changes, hot or spicy foods, chocolate, baked goods, processed, pickled, marinated, sour or fermented foods, citrus fruits, bananas, avocados, nuts, onions, dairy products, excessive caffeine MSG, alcohol, medications (including rebound reactions to migraine medications), allergic reactions, bright lights, strong odors or perfumes, hormonal fluctuations (as related to the menstrual cycle or taking birth control pills), excessive exercise, exposure to loud noises, missing a meal, smoking or exposure to smoke, too much or 100 little sleep. (15, 17, 18, 20) Foods containing tyramine, which include red wine, aged cheese, smoked fish, chicken livers, figs and some beans can also trigger migraines. Meats containing nitrates, like bacon, hot dogs, salami and cured deli meats can cause migraine symptoms as well.(17) Universally, most migraine sufferers report that physical or emotional stress ean also trigger a migraine headache. ‘There is no known cure for migraine headaches. The goal is to prevent symptoms by avoiding any known personal migraine triggers. Keeping a headache diary with specific, attention to foods eaten, environmental exposure, sleep patterns and, for women, where they are in their menstrual cycle, may help to identify patient's personal triggers. Westen medicine has found some pharmaceuticals to be more effective than placebos at prophylactically decreasing frequency and severity of migraines, Some of these medications inelude; antidepressants and serotonin reuptake inhibitors (SSRI’s), blood pressure medications such as beta blockers and calcium channel blockers, seizure medications, and norepinephrine reuptake inhibitors. Acute migraine attacks are commonly treated with Triptans, Frgots, non-steroidal anti-inflammatories, nausea medications, sedatives, narcotic pain relievers, and over the counter medications like ‘Tylenol and Excedrin Migraine, (17,27) And, although many medications help migraine sufferers, many people do not get relief from medications or dislike the side-effects of those medications. This has led to many people exploring alternative treatments for their migraines. Ayurvedic treatment is one of the forms of alternative treatment that has helped many people with headaches. In Sanskrit, Ardhavabhedaka means “pain in half the portion of the head.” Ayurveda primarily defines migraine headaches as an excess imbalance of the Pitta dosha, In some Ayurvedic texts, there are descriptions of Vata headaches (tension-type) and Kapha headaches (sims headaches), but Pitta imbalance seems to be the culprit in most migraines. ‘There may ‘even be a multi-doshie imbalance which is ultimately causing a combination of different types of headaches in the same patient, However, for the sake of simplicity, this paper will be focusingon factors to address Pitta-type imbalances and migraines, Ayurvedic treatment focuses on treatment of the dosha which is in excess. We will examine how Pitta imbalance can contribute to migraines, and how many Pitta-calming therapies, including diet, lifestyle and herbal remedies, can help with migraines, DIET People with the Pitta-domi ant mind-body constitution have a predominance of the fire element in their make-up. Pittas often have strong digestion (agni) and voracious appetite. However, with overeating or indulging in excessive sour, salty or spicy (pungent) foods, indigestion or hyperacidity can occur, Ifa Pitta person is unable to digest food properly, a toxic accumulation of waste (ama) builds up in the small intestine, moves into the liver and blood, and ultimately results in various Pitta disorders. Inflammatory conditions are ultimately caused by excess Pitta; migraines are inflammatory neurovascular conditions, By normalizing digestion and eliminating ama, inflammation can be decreased. (28, 29, 30, 31) Various foods that are Pitta aggravating are also known migraine headache triggers, These foods include overly processed foods (salty with chemical preservatives), spicy foods including, onions, sour foods (fermented, pickled, marinated foods), cheese (salty and sour tastes), sour us fruits, salted nuts, alcohol (sour taste) and caffeine (heating and acid-causing). So, raine management should include avoiding these heating or sour, salty and spicy foods and beverages. Poods which are Pitta calming or cooling in nature, or that have more of a predominance of sweet, bitter and astringent tastes, should be favored, As mentioned before, keeping a headache diary is helpful in determining a patient’s specific migraine triggers. According to Ayurveda, virechana, or laxative therapy is an effective way to reduce excess Pitta in the digestive tract. Because Pitta conditions like migr nes are considered “high agni” orheated conditions, virechana is a method for cooling the digestive fire. Taking a tablespoon of Castor oil occasionally before bed is a safe way to clean out the digestive tract and decrease Pitta, but laxatives should not be taken if there is any intestinal pain, ivitability or bleeding. (31) ‘Aloe gel and the Ayurvedic formula Triphala, and warm milk with ghee are also helpful as purgatives for excess Pitta conditions. (30) WEATHER Being the only hot dosha, hot weather ean aggravate Pitta, A study was performed in which headache prevalence was examined in emergency room visits and the outside temperature at the time of the visit to the ER. ‘The study showed that for every 9 degree inerease in outside temperature, the likelihood of getting a headache increased by 7%. ‘The atmospheric pressure tended to be lower when more people had headaches as well. (20) So, because excess heat aggravates Pitta, it is best to avoid overheatin, you are prone to headaches. Ayurveda suggests decreasing outside exposure and not exereising during the hottest part of the day (10am-2pm). ‘This is the time of day that Pitta dominates our daily cycles. EXERCISE and OBESITY Ayurveda recommends regular exercise as a part of a healthy, balanced lifestyle. Large population-based studies suggest obesity is a risk factor for migraines, (25) so weight management, including proper diet and exercise is an important concept in the Ayurvedic management of migraines, One of the theories about the connection between obesity ancl migraines has to do with clevated inflammatory mediators in obese patients, including interleukins and calcitonin gene-related peptides (CGRP). (25) These mediators may increase the severity and frequency of mige ines, ultimately causing central nervous system centralization, Centralization of pain can result in chronic sympathetic nervous systemdominance, ul imately resulting in increased frequency of headaches and poor pain modulation, (25) So, itis helpful to contro! obesity with a holistic Ayurvedic lifestyle approach to help control migraines. Exercise moderation is the key when dealing with migraines, Excessive exercise, which can cause profuse sweating and overheating, may aggravate the Pitta dosha, triggering a migraine headache, Sports with hard physical exertion or aggressive competition would also be contraindicated in persons with Pitta imbalance. Physiologically, hard physical effort without a gradual warm-up may cause vascular structures to dilate too rapidly, resulting in inflammation or spasm of the blood vessels. ‘This could result in a migraine or aggravation ofan existing headache. Il is recommended that migraine sufferers and those with a predominance of the Pitta constitution chose forms of moderate and cooling exercise and limit competition, Ayurveda recommends that moderate exercise (at about 50% of maximum capacity) is best for Pitta types. Specifically, brisk walking or jogging, skiing, hiking in nature and swimming are good exercise choices for Pittas. (31) Exercising in nature at cool times of the day and av ng the hottest part of the day is best. Yoga and light resistance (raining (heavy weight lifting may cause the same vascular irritation mentioned above) are also suitable for Pittas and migraine sufferers. Exercise should ultimately be something that is enjoyable and helps to relieve stress. YOGA Ayurvedic lifestyle including yoga therapy has proven effective in treatment of migraine hreadaches without aura. In a study performed in India in 2007, integrated yoga therapy was effective at decreasing frequency and intensity of migraine attacks over the control group. ‘The control group in the study received instruction on managing their pain by avoiding migraine triggers with diet and lifestyle changes. The other group had the same instruction, plus performed |gentle yoga postures, pranayama (breathing exercises), meditation and relaxation, 5 dayss a week for | hour a day over 3 months, (7) The study hypothesized that the calming effect of the integrated yoga therapy had a relaxing effect on the nervous system, and the participants in the study had improvement in symptoms of anxiety and depression, and used less migraine medication as well. (7) Specific yoga asanas are also thought to be helpful in preventing migraines. However, Ayurveda recommends evaluating the person as a whole prior to assigning certain postures to rule out aggravating existing problems. Here are some general suggestions: Moon salutation has been cited as being especially good for migraines. Boat pose, Bow pose, Spinal Twists, Tree pose and Standing on the Toes are thought to be helpful for migraines as well. (18) Pitta calming asanas performed in a slow, cooling and calming manner may be beneficial for migraine sufferers with Pitta aggravation. Postures that focus on releasing tension from the mid-abdomen (small intestine and liver) where Pitta accumulates are helpful. Additional poses that open the abdomen are Cobra and Fish poses. Inversions and excessive backbends typically increase Pitta and can aggravate migraines because of their heating properties and increased blood flow to the head, so these should be avoided or followed by cooling poses. Twisting postures help to detoxify the liver and are helpful for Pitta, (3) Ayurveda also recommends calming, cooling pranayama during a yoga practice for decreasing Pitta, and thus breathing techniques may be beneficial for migraines. PRANAYAMA ‘Another common praetice in Ayurveda is pranayama --which means the “expansion of the life force.” Prana is our life force, and breathing is one way of taking in prana and circulating it throughout our intemal physiology. Breathing is also a way that we exchange prana with ourenvironment, so it connects us to all living things in the universe, Ayurveda recommends certain balancing and cooling forms of pranayama for decreasing Pitta. Alternate nostril breathing or “Nadi Shodhana’ means “clearing the channels of circulation” and it is a balaneing technique that increases the absorption of prana in the head. Left nostril breathing specifically relates to the lunar or cooling nadis, and inhaling through the left side and exhaling through the ri help to dissipate heat in the head. (30) Alternate nostril breathing is helpfal to do prior to meditating or if you are unable to sleep, and is calming (o all the doshas, Dirgha pranayama or “the complete breath’ is another technique that is cleaning and balancing for all doshas, It involves consciously filling up 3 different areas of your lungs, beginning with the lower portion, then the middle and lastly the upper regions. (34) Ayurveda recognizes that painful conditions, like migraines, often cause ws to breathe rapidly and shallowly; improper breathing ean be detrimental to our flow of prana, By utilizing these balancing and calming breathing methods, migraine patients may be able to improve their circulation of prana, and thus decrease their pain, Cooling pranayama techniques are particularly helpful in decreasing Pitta conditions like migraines. An example of a cooling pranayama is the Shitali breath, which means “cooling breath”, Ayurveda believes that shitali clears heat from the head and helps to lower high blood pressure (Pitta disorders). It is done by inhaling through a rolled tongue and retaining the inhale as long as possible before exhaling through the nostrils. Another cooling pranayama technique is, called Sitkari. “Sit” means cold in Sanskrit. The Sitkati technique is as above with the Shitali breath, except that you make the sound “see” as you inhale and you do not retain the breath. (33) Because of their cooling properties, Shitali and Sitkari breaths may be helpful in treatment of migraines. Ayurveda recommends that performing 5 minutes of pranayama in the AM and PMate beneficial to a balanced lifestyle. (31) Research studies in this area of Ayurvedic treatment should be pursued, MEDITATION Meditation is the cornerstone of balancing mind, body and spirit in Ayurveda, It has been noted in many studies that meditating has a powerful effect on our physiology. (29, 31,33) By bringing oneself into a state of restful awareness, stress responses including heart rate, blood pressure and breathing rate decrease, Even cholesterol levels decrease over time, (31) A study by Dr. David Orme-Johnson looked at the frequency of doctor visits for health problems compared to non-meditators and have found that people who meditate visit the doctor up to 74% less than non-meditators. Admissions to the hospital for heart disease and cancer were 87.3% and 55.4% less for meditators respectively. (31) ‘Thus, it is indicated that meditating can have a positive effect on health, From this study, it can be extrapolated that meditation may have beneficial effects for migraine patients too. ‘A.2009 study evaluating the efficacy of biofeedback in the treatment of headaches found that simple relaxation techniques including meditation were effective in decreasing headache fiequency and intensity in 48-52% of patients in the study. (3) In 2008, a literature review of the effectiveness of mind-body interventions in neurology found that, based on results in 39 controlled trials, treatment guideline for migraines now should include cognitive and behavioral treatment recommendations, These recommendations included: relaxation/meditation training, thermal biofeedback (hand warming), EMG biofeedback and cognitive-behavioral therapy. (8) There has been noted a comorbidity of migraine and hypertension; hypertension prevalence is, higher in headache sufferers than in the general population. (4) A 2008 meta-analysis of ‘transcendental meditation and its effect on hypertension analyzed 9 controlled trials through2006. It was noted that meditation practice may reduce systolic and diastolic blood pressures by 4.7mm and 3.2mm respectively. (21) Given that anti-hypertensive medications are commonly presoribed for migraine symptoms, it may be noted that meditation could effectively lower blood pressure as well and have a positive effect on migraine pain, possibly decreasing the need for pharmaceutical intervention, SLEEP Ayurveda recommends an adequate amount of sleep to restore, heal and invigorate the body. Proper sleep requires being in tune with the rhythms of nature. It is suggested that bedtime should be around 9:30-10:30 pm and waking should be beforé sunrise around 5:30-6 am, Getting significantly more or less than 7-8 hours of sleep can be detrimental to health. A 2008 study on subjective sleep parameters and impact of headache showed that migraine sufferers had ‘more nocturnal awakenings, abnormal movements, and breathing problems than other headache patients and controls. About half of the migraine sufferers felt sleepy during the day and took naps during the day, Only 32.8% of the migraineurs reported refreshing sleep. Twas concluded that sleep disruption is more common in migraine patients than tension-type headache sufferers and the contro! group. (11) Therefore, patients with migraines my benefit from an Ayurvedic sleep-enhancing routine and lifestyle to better manage their headaches. This would inelude ‘eating a light dinner several hours before going to bed and limiting stimulating aetivity in the evening. Meditating in the evening and taking a relaxing bath before bedtime is hefpful as well, Limiting daytime sleep or naps may be of benefit to encourage an earlier bedtime. (29, 31, 33) NASYAUsing a neti pot to itigate the sinuses daily is an Ayurvedic method of removing ama or toxic build-up from the nasal and sinus cavities and for purifying the breathing passages. It has been purported to help with sinus problems and migraine headaches. (10) Nasal therapy or nasya makes it easier fo absorb prana through the head, and ultimately can assist in the benefits gained through pranayama, Different food-grade oils like olive oil or ghee can be used to moisturize or provide additional Pitta-calming benefit in the neti pot. Asa recommended Ayurvedic practice for anyone, nasya may be especially beneficial to those who have problems with headaches, (29, 31,33) AROMATHERAPY Different smells have different effects on the mind and body and have been used for centuries in Ayurveda to balance the doshas. By smelling an aroma that is calming, cooling and sweet, & Pitta person may have an immediate decrease in their mind-body stress reactions. ‘Therefore, by inhaling Pitia-calming fragrances, there is possible benefit of decreasing Pitia disorders like rigraines, Pitta calming scents that may be beneficial for migraine sufferers are typically flower fragrances that reduce emotions like iritablity and anger and can clear heat from the head. Examples of sweet and coo! Pitta calming aromas are: Gardenia, Honeysuckle, Iris, Jasmine, Lavender, Lemon Balm, Lemon Grass, Lily, Lotus, Peppermint, Plumeria, Rose, Saffron, Sandalwood, Vetivert, and Wormwood. (29, 33, 34) HERBAL REMEDIES Many patients do not get relief from the pharmaceutical medications that they take or do not like the side effects; so many migraine patients have tried different herbal remedies. Research on herbs and migraines is somewhat limited, and itis an area of science that should ultimately beated more rigorously, Ayurveda recognizes that some herbs may be effective despite the lack of clinical evidence because of an herb’s bioenergetic properties. (34) One herb that has been more thoroughly researched for its efficacy in treating headaches is Feverfew or Tanacetum Parthentum. The chemicals in Feverfow seam to block production of prostaglandins, inhibit spasm of blood vessels and influence the brain's production of neurochemicals that are involved in pain modulation, (32) It appears to act as an anti- inflammatory, but also keeps platelets from sticking together and releasing serotonin, Ayurvedically, Feverfew is bitter in taste and cooling in energy, and decteases Pitta, A systematic review of 5 randomized double-blind clinical trials in 2004 showed mixed results with the authors concluding that there is insufficient evidence to suggest an effect of Feverfew over placebo in preventing migraines. (22) However, a review of 5 earlier studies in 1998 indicated that in 3 of these studies, the frequeney and intensity of migraine headaches were significantly decreased with using Feverfew over a placebo, (32) Feverfew is most effective by taking it preventatively, not for acute migraine. Using it for at least a month is recommended to Judge its benefit. Clinical doses are between 5-100mg. It is cautioned that the herb may cause mouth sores, and it should not be taken during pregnancy, (32) Butterbur, or Petisites hybridus, is another herb that has been researched in the prophylaxis of ‘migraines. In 2 separate studies on the effectiveness of Butterbur on preventing migraines in 2001 and 2004, Butterbur was found to reduce the frequency of migraines by up to 60%. Clinical doses are between 50-150mg. (5, 12) And, although not an Ayurvedic herb, it was included in this research because of its proven efficacy. Many other Ayurvedic herbs have reported benefit in treating migraines, but have limited or no research backing their claims. However, these herbs should not be discounted if their benefithas been evaluated as part of a holistic treatment approach for migraines and each individual's imbalances. Some potentially beneficial herbs for the treatment of migraine include: clove- the aroma of clove can sooth the nerves and help with headaches; garlic-has pain-relieving properties and may help with headache (although may be Pitta aggravating, so use caution); ginger-extemal application of ginger can act as a painkiller; henna flowers-applied externally ean help alleviate heat from the head (14); chamomile and rosemary are herbs that can cool inflammation. (32, 16) Gotu Kola, or Centella Asiariea, is an Ayutvedic herb whose Sanskrit name, brahmi, means consciousness or wisdom, Its use ean improve mental clatity, and it is often used for headaches when detoxifying from alcohol or caffeine. (34, 32) Gingko Biloba has been reported to improve memory and circulation and is a balancing to all of the doshas and has an overall cooling effect which may explain its use with Pitta headaches, (16, 34) GENERALIZED AYURVEDIC TREATMENT ‘A recent 2010 study fiom the International Journal of Ayurvedic Research demonstrated a positive response to Ayurvedic therapy in the treatment of migraine without aura. In this study, the Ayurvedie protocol consisted of 5 Ayurvedic medicines (Narikel Lavan, Sootshekhar Rasa, Sitopaladi Churna, Rason Vati and Godanti Mishran) with a regulated diet, 8 hours sleep, regular exercise and abstention from smoking and drinking over 90 days. Of the 204 people who completed the study, 70.5% had marked decrease in migraine frequency and intensity, with 35.2% of patients demonstrating complete disappearance of headaches. (13) ‘Thus, it ean be concluded that Ayurvedie treatment can be effective in migraine treatment, ‘Another generalized Ayurvedic treatment study in 1989 showed improvement in 79% of the people in the study who had ten different chronic diseases including migraine. Each of the 126people in the study was given an individualized Ayurvedic treatment plan. This study also suggests that Ayurveda as a whiole system does have benefit, (9) CONCLUSION In conclusion, migraine headaches can be a complicated disorder to treat, However, by investigating cach individual’s prakruti vikruti, diet, lifestyle and current treatment for migraine, it is possible to invent an Ayurvedic lifestyle approach to achieve mind-body balance. 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General Ayurvedic References 28) Dash B, Junius MM, 1983.A Handbook of Ayurveda, New Delhi, India: Concept Publishing. 29) Frawley D, Lad V. 2001. The Yoga of Herbs, An Ayurvedic Guide to Herbal Medicine, Twin Lakes, Wisconsin: Lotus Press. 30) Frawley D, 2000, Ayurvedic Healing, A Comprehensive Guide, Twin Lakes, Wisconsin: Lotus Press. 31) Chopra, D, 2000, Perfect Health, the Complete Mind Body Guide. Now York, New rk: Three Rivers Press, 32) Simon D, Chopra D, 2000, The Chopra Center Herbal Handbook. New York, New York: ‘Three Rivers Press. 33) Frawley D, 1999, Yoga and Ayurveda: Self-Healing and Self-Realization, Twin Lakes, Wisconsin: Lotus Press, 34) Online component of Chopra Center’s Ayurvedic Certification Training, 2010,