Nutrition & Migraine Case
•
Mason Gasper
•
U Bridgeport
•
10/20/19
Case – Menstrual Migraines
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40 y/o female with recurrent
migraines that occur in the days preceding her menses for last 13 years
•
Usually onset is gradual, starting
with pressure behind eyes and progressing over hours to left temporal 8/10
pounding pain, with associated nausea and sensitivity to light and sound.
•
Abortive treatment has been
ineffective as she failed triptans, and other analgesics. Migraines may last
days so she tries to sleep them off and may miss work.
•
She notes that her menstrual cycle
is regular at 28-30 days with ovulation at midpoint.
•
PMS symptoms includes somatic
tenderness, irritable mood, and sometimes food craving.
•
Also notes sleep onset delay due to
rumination, and frequent wakes-up overnight. Often has low energy during the
day.
•
Her appetite is good, but diet is
variable and not consistent. Often, she misses breakfast as she is not hungry
and may not eat until noon. Primary source of protein has been some meat and
green vegetables. She doesn't consume dairy or eggs but has no problems with
these foods.
•
She is on no meds, has no other
medical issues, drinks alcohol occasionally, and does not smoke or use
marijuana.
•
Exam (normal BMI and Vital Signs
with forehead temp 97.4F and pulse 55), Neuroimaging, Basic Labs are
unremarkable.
Assessment: Menstrual Migraines
Overview:
Migraines headaches occur in about
20% of women and 5% of men. Although causes of headaches are likely due to many
factors, estrogen appears to be a significant influence due to the gender
difference. In a susceptible individual, headaches seem to be triggered by such
events as stress, ingestion of a particular foods, lack of sleep, experience of
somatic pain, and others.
Once the diagnosis of primary
headache disorder is made it is common to direct treatment towards prevention
and abortive treatment. Prevention often involves modifying triggers. For
instance, in a person with insomnia, it may be useful to provide education
regarding sleep hygiene improvement (e.g., regular sleep wake times, removal of
stimulation like tv and computers, avoidance of blue light and addition of red
light, meditation, Epson salt bath, adding soft soothing background noise) and
to offer options for sleep aids (e.g., teas, herbs, supplements). Neck pain and
other common somatic complaints with migraineurs (such as TMJ Syndrome, Bruxism,
back or shoulder pain) is another common trigger than when addressed may
significantly reduce frequency of headaches. Prevention may sometimes be
employed in the empiric use of supplements without testing, including
Riboflavin (vitamin B2), Vitamin B12, Magnesium, Butterbur and others. Additionally,
trial and error in elimination dieting often may help. Prescribed
medications (including the 1st line therapies of tricyclic antidepressants,
topiramate, and propranolol) are a consideration when the frequency and
intensity of headaches impacts ability to function in daily life.
One common scenario in cases of
daily headache is the overuse of abortive analgesics which triggers the
condition of Rebound Headache. In order to avoid Rebound, generally Abortive
Treatment should be limited to 2-3 days a week. Primarily this restriction is
expressly meant for pain relievers such as Ibuprofen, Tylenol, and other
prescribed medications and may not be true for alternative therapies. Overall,
the goal is minimizing headache by prevention to avoid abortive
treatment.
One focus for nutrition minded
clinicians is to address metabolism. There is substantial evidence that
migraines are related to metabolic disruption. This does not imply that
infection, vascular abnormalities, and other mechanisms of pain are not to be
considered, but once considered and deemed less likely, it is useful to examine
how efficiently food is being used in the migraineur.
Metabolism is extremely complex, and
finding a single cause of disruption is not usually possible. A general focus
on how liver and brain cells oxidize glucose is a good starting place, followed
by an assessment of basic factors that influence oxidation.
- Beneficial Factors: thyroid and its hormones, progesterone, magnesium, B-vitamins and fat-soluble vitamins
- Impairing Factors: estrogen, endotoxin (lipopolysaccharides), Serotonin, cortisol (chronic), parathyroid hormone, aldosterone
Central to this process of creating
a healthy environment for glucose oxidation is the liver. And this is of utmost
importance in educating patients experiencing headaches that would like a
"natural" solution. In patients with menstrual migraine, the liver is
even more so an issue which I will now describe.
During the menstrual cycle, there
are dramatic changes in the hormones in the uterus. Estrogen's main purpose is
to start new growth and in doing so must completely change the metabolic
environment of the tissues in which it acts. Its actions are varied but clearly
Estrogen promotes the uptake of water by cells (which provides the space and
nutrition for cell division to take place) AND through vasopressin prevents
water loss in the kidneys, while losing salt. Water, we are realizing since the
discovery of the MRI, when inside cells is Metabolic Water, a novel state,
which influences the state of proteins and molecules within it allowing for such
functions as memory. Thus, in a highly estrogenic state many people complain of
brain fog or memory disturbance - Estrogen is the biochemical eraser of
memory, but it molecular or personal memories.
And so, the body needs to quickly
dampen the impact of Estrogen, and it does so with Progesterone. Often in
displays of amount of Estrogen and Progesterone during menstrual cycle, one
gets the impression that there are relatively equal amounts of each. However,
looking at the units, Progesterone is vastly more concentrated in the body that
Estrogen with amounts 1000 times that of Estrogen. The body respects the power
of Estrogen to build as well as to destroy, so it has plenty of Progesterone
around to dampen this effect.
Analysis should then focus on
what is creating the ability of Estrogen's effect to escape the protection of
Progesterone? The answer may be The Third Ovary as it has been described in
older times, otherwise known as the Thyroid Gland. Thyroid and its hormones are
as critical for pregnancy to occur as it is for estrogen to be controlled. The
following are functions related to thyroid in this regard:
- Thyroid hormone (with Vitamin A) are critical for converting Cholesterol into Progesterone. For pregnancy to occur and to avoid miscarriage, it is vital that this PRO-GESTATIONAL hormone be present with minimal ESTRUS HORMONE. This cannot happen without thyroid hormone. Additionally, Progesterone inactivates Estrogen production and mobilizes Estrogen from within tissues to be removed by the liver.
- Thyroid hormone is essential for proper bowel motility and creating of Bile Salts. Estrogen is removed from liver via bile salts, which if insufficient slows down removal of Estrogen from blood stream. Additionally, with low thyroid intestinal motility slows and allows Estrogen back into the entero-hepatic circulation keeping blood Estrogen levels high. Bowel slowing also allows for bacterial overgrowth which can trigger endotoxin production. The intestines respond by discharge of Serotonin to cause intestinal contraction to urgently remove its contents, some of which escapes into circulation with Estrogen. Estrogen and endotoxin are known to interact and amplify their effects.
- Thyroid hormone requires the liver to convert the majority of inactive thyroid (T4) into active thyroid (T3). The liver has limits in its ability to handle the stress of toxin removal (Estrogen, endotoxin) as well as converting T4 to T3. In the setting where there is too much to detoxify, the proteins can bind and hold toxin in the blood as storage until the liver is capable of clearing. If toxin load is too high in conjunction with inadequate protein, B vitamins, and carbohydrates, the liver may sense a higher metabolic rate may not be handled in a healthy way and may choose to quickly deactivate T4 or T3 to reverse T3 as a storage form of thyroid.
- As Estrogen and endotoxin spill into the blood from the overwhelmed liver, Estrogen inactivates the thyroid at multiple levels, further allowing Estrogen to dominate the organism as Progesterone will be more difficult to make. A diet high in Polyunsaturated Fats will add to thyroid inactivation.
In a state of Estrogen Dominance
(over Thyroid and Progesterone), the individual is highly sensitized to any
noxious stimulation that can create headaches or other symptoms. The Estrogen
energetic state is characterized by gradients of more water in cells and less
in the blood causing the kidney to conserve as much water at the expense of
sodium as it can. The urine then becomes less dilute (specific gravity
decreases). Muscles will take up more water and cramping and fatigue more
easily, and over time may create fibromyalgia. Blood vessels and smooth
muscles take up water as well and resulting in high blood pressure, leakiness
of blood out of vessels into extracellular space causing orthostatic
hypotension, and breakdown of fibrin in the blood vessel walls leading to
inflammation (increased CRP) and blood clotting (e.g., DVT). Connective tissue
cells and nerves retain water leading to Carpal Tunnel type Syndromes,
inter-vertebral disc edema, and in the brain fatigue, sleep disruptions,
emotional changes and even seizure.
Looking at Estrogen - Thyroid -
Progesterone and the other factors mentioned, a clinician can begin to see the
larger picture that incorporates many common conditions. In examining a
patient, looking for signs of edema, nerve entrapment, delayed relaxation of
reflexes and other common clinical manifestation may help with assessment.
Work-Up
Further information and
tracking:
- Track yourself on cronomoter.com app 1-2 times a week:
- Food intake
- Body temperature: on waking, after lunch, before bed - look for increasing waking temperatures with better metabolism (dealing with stress hormones at night), steady increase after meals and slight drop before bed.
- Pulse rate should increase with metabolism; however, this should be gradual, and significant increases suddenly may be stress related.
- Volume of fluid taken in and urinated. As Estrogen creates high body water volumes, track amount of free water taken in and reduce steadily attempting to reset thirst set point.
- Also track:
- Fatigue levels & Response to exertion - efforts to avoid severe fatigue should be noted and minimized.
- Avoid fatigue in 7-10 range, gradually increase your ability to tolerate healthy activities
- With less FATIGUE at Rest and With Exertion to the body will begin to increase its metabolism
- Sleep efficiency. Provide sleep hygiene education:
- Build a consistent sleep pattern with a regular, fixed wake-up time, even on days off!
- Avoid computers, tv screens, phones (Blue Light) after sun goes down
- Exposure skin to Red Light for 20 minutes before bed
- Expose yourself to outside light (e.g., open curtains or blinds) upon waking to encourage wakefulness.
- Epson salt bath can create a calming feeling and can relax sore muscles
- Key to deep sleep is adequate carbohydrates and protein (eaten during the day, and small amount before bed)
- Avoiding naps during the day, maintaining a wakeful state during the day will enhance deep sleep
- Monitor digestion – constipation, hard or soft stools, bloating, heart burn
- Stress Level:
- Anticipate stress, prepare for it by getting rest and eating well. A small amount of sugar and protein (like cheese and fruit) can help you deal with a stress
- As you get older, life becomes more stressful and it becomes harder to relax and sleep becomes fragmented. Maintain enough calories to counter the stress
- Exercising TOO much can create significant stress. Avoid hyperventilation and perform short-set muscle building exercise instead of endurance exercise.
- As you start eating, getting sleep, and avoiding stress, your energy level and metabolism will begin to increase
- Seek help from a professional for extreme stress.
Aside from testing already completed
(CBC, CMP, TSH), diagnostic testing that may be helpful include:
A close look at energy production (mitochondria, oxygen delivery/methylation, thyroid):
· Urine test for organic acids –
o
Adipate, suberate, ethylmalonate (if
high, consider supplement with L-carnitine, riboflavin)
o
High Lactate to Pyruvate (use
this as a marker for dietary success)
o
HMG (if high, supplement with serum
CoQ10)
o
BCKA (expect low levels as estrogen
uses up BCAAs quickly (*) and supplement)
o
Xanthurenate (if high, supplement
with vitamin B6)
o
B-HIV (if high supplement with Biotin)
o
MMA, FIGLU (if high, consider B12,
FA supplements)
· Thyroid assessment:
total T3, reverse T3, T4, iodine, zinc, selenium levels (supplement minerals if
low, use thyroid as marker of diet success)
· Vitamin D panel,
with ionized calcium, RBC Magnesium
· Hydration:
Urine and RBC Potassium, Urinalysis (specific gravity will be low with
overhydration), Urine Sodium (increased with overhydration)
· If anemia with low MCV, Iron panel (ferritin, total
iron, TIBC, % saturation) - important for menstrual migraine patient
Assessment of factors for oxidative
stress –
· HPLA, 8OHdG, lipid peroxide levels, vitamin C and E levels
· Systemic inflammation: CRP, ESR, D-dimer (fibrin),
Hcy
Assessment of Liver/ Intestinal
function
· Lipid panel (elevated HLD indicates high endotoxin load)
· Assessment of liver function, including AST, ALT, bilirubin
(direct and indirect)
· If suspected SIBO (bowel issues), check Benzoate/Hippurate,
Indican, D-lactate, Tricarballylate, D-Aribintitol
· Neurotransmitters (if high 5-HIA, limit tryptophan in diet,
avoid excessive meats/grains, add glycine by gelatin; feverfew is a serotonin
antagonist**)
* Obayashi, Mariko, Yoshiharu
Shimomura, Naoya Nakai, Nam Ho Jeoung, Masaru Nagasaki, Taro Murakami, Yuzo
Sato, and Robert A. Harris. “Estrogen Controls Branched-Chain Amino Acid
Catabolism in Female Rats.” The Journal of Nutrition 134, no. 10
(October 1, 2004): 2628–33. https://doi.org/10.1093/jn/134.10.2628.
** Nutrition in the Prevention
and Treatment of Disease. Elsevier, 2001. https://doi.org/10.1016/B978-0-12-193155-1.X5000-4
Treatment
From big to little picture
- General Diet:
- Optimal Diet = “choose wisely among available food options”
- Aim for a Defensive Diet, find foods that work for you, increase slowly volume
- Depend on body size/activity level, goal is 2000-3000 calories a day (slow and smart)
- Maintain adequate protein and carbohydrates for liver function:
- Protein 0.9 g/kg
- Guide: Protein: 70g+: dairy (milk, yogurt, cheese), cooked green leafy vegetables, beef gelatin, small amount of muscle meat/chicken, non-fatty fish (cod, sole), shellfish (oysters, shrimp); have a serving of liver once a week.
- Carbohydrates - try to keep at 2 times protein level to avoid protein misuse as fuel
- Guide: Carbohydrates 150g+: fruit, orange juice, honey, rice, potato, dairy (milk, yogurt, cheese), Haagen-Dazs Ice Cream
- Avoid intestinal irritants:
- Consider reducing foods on Allergy testing
- Avoid uncooked vegetables or salads (one exception is a raw carrot which is recommended daily)
- AVOID food additives including strict avoidance of Carrageenan, Gums, Soy, Canola, etc. No processed food
- AVOID eating out as much as possible; supplement with vitamin E after eating if you do
- AVOID pasta, baked goods, bread, cereal, nuts or seeds. Sour Dough bread and popcorn ok in small amounts.
- Avoid thyroid inhibitors: No vegetable oils, seed oils, unsaturated fats, cruciferous vegetables.
- Reduce water intake empirically, if able attempt only small glass of free water with meals and then only if thirsty
- Diuretics appears to help migraines (acetazolamide, Topamax©), so increasing amount of cocoa* (dark chocolate) may be helpful
* Sentürk,
Murat, Ilhami Gülçin, Sükrü Beydemir, O. İrfan Küfrevioğlu, and Claudiu T.
Supuran. “In Vitro Inhibition of Human Carbonic Anhydrase I and II Isozymes
with Natural Phenolic Compounds.” Chemical Biology & Drug Design 77,
no. 6 (June 2011): 494–99. https://doi.org/10.1111/j.1747-0285.2011.01104.x.
- At some point, if fatigue and sleep issues remain and depending on labs, intake of 1/4 tablespoon of white sugar every 1-2 hours, and 1/4 tablespoon of salt in free water.
Sleep Recommendations:
- Before sleep, drink small glass of milk (warm) with 1-2 tablespoons of local honey, and 1/4 tablespoon of salt - this will counter cortisol, aldosterone, and PTH rise overnight.
- On waking, due to extreme stress state, due to elevated cortisol by 8am, have fluids with sugar immediately (best is OJ due to Calcium content as well).
Exertion
- For those having trouble with exertion, consider resetting fatigue set point by building up resting metabolic rate
- Walk 5 minutes then rest 15 minutes x 3 and repeat this in morning and evening
- This should raise the resting metabolic rate over time, slowly.
- Overall avoid excessive hyperventilation type exercise. Muscle building by lifting weights a few times a week for 20 minutes is probably ideal.
Supplements:
•
To combat fatigue:
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Thiamine 300 mg in the morning
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Magnesium citrate or glycinate: 250
mg 3 times a day
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Riboflavin: 200-400 mg daily
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CoQ10: 1-3 mg/kg/d
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For 5 days before and after menses
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Vitamin E - 400 IU daily (see
toxinless.com for best brand)
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Butterbur - standardized extract of
petasites (Petadolex®) 50 mg BID during menses
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For refractory headaches will
consider adding next visit:
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Feverfew
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Alpha-lipoic acid: 600 mg/d
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Folate
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Vitamin B6
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B12
Follow-up
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q4 weeks to assess headache
frequency/intensity
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Expect steady increase in waking
temps, improved fatigue/sleep
•
Monitor waist circumference
Stay alert for central weight gait
On this diet plan there will be shift in set points for
thirst, body fuel needs, and muscles/liver will become denser (weight
will increase)
•
Assess metabolic / oxidative stress
labs, and supplement as needed
•
Educate, if
needed, on Sympathetic – Parasympathetic inertia and path forward-thyroid
•
If failure to increase metabolism,
improve headaches, consider
Liver testing
Phase 1 conjugation tests – caffeine challenge
Caffeine clearance may be high if liver is dealing with
toxins and phase 2 may fall behind (supplement with glycine, vitamin C and E,
Zinc, Selenium, A-lipoic acid)
Caffeine clearance low if chronic estrogen exposure present
(*)
Phase 2 testing – benzoic acid challenge may urinary pyroglutamine if glycine low
Further Intestinal testing
Permeability screen
Food antibody testing (IgE/IgG)
* Abernethy, D. R., and E. L. Todd.
“Impairment of Caffeine Clearance by Chronic Use of Low-Dose
Oestrogen-Containing Oral Contraceptives.” European Journal of Clinical
Pharmacology 28, no. 4 (July 1, 1985): 425–28. https://doi.org/10.1007/BF00544361.
•
Assessment of hormonal levels and
related electrolytes/minerals (for markers of stress, potential areas that
may be limiting metabolism):
AM Parathyroid hormone, Vitamin K, Osteocalcin
AM Aldosterone, RBC potassium, AM Cortisol to measure
overnight stress (along with PTH and aldosterone and TSH)
Prolactin (marker for Estrogen levels)
•
Consider rechecking hydration status
labs, lactate/pyruvate ratio
Prognosis
•
Emphasize
that overall metabolic support important to overall health and that with proper
nutrition, many factors may improve.
Sources:
Texts:
Ingrid Kohlstadt (CRC Press). Advancing Medicine with Food and Nutrients,
Second Edition ISBN: 978-1-4398-8772-1
Richard Lord. Pathways to Health Series & Laboratory
Evaluations for Integrative and Functional Medicine.
Ray Peat. Nutrition for Women.5th Ed. Kenogen, P.O. Box
5764, Eugene, OR 97405
Articles:
Yorns, William R., and H.
Huntley Hardison. “Mitochondrial Dysfunction in Migraine.” Seminars in
Pediatric Neurology 20, no. 3 (September 2013): 188–93. https://doi.org/10.1016/j.spen.2013.09.002.
Avnon, Y. “Autonomic Asymmetry
in Migraine: Augmented Parasympathetic Activation in Left Unilateral
Migraineurs.” Brain 127, no. 9 (August 2, 2004): 2099–2108. https://doi.org/10.1093/brain/awh236.
