Botanical treatment strategies: migraine case studies.
Article Type: Reprint
Subject: Migraine (Care and treatment)
Migraine (Risk factors)
Alternative medicine (Methods)
Authors: Stansbury, Jill
Faass, Nancy
Pub Date: 02/01/2012
Publication: Name: Townsend Letter Publisher: The Townsend Letter Group Audience: General; Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 The Townsend Letter Group ISSN: 1940-5464
Issue: Date: Feb-March, 2012 Source Issue: 343-344
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 282825223
Full Text: An integrative approach to the treatment of any health condition typically begins with an assessment of the underlying cause(s), rather than the symptoms alone. In cases of migraine headache, treatment focuses on causal factors that trigger vascular phenomena. The following three cases exemplify common migraine presentations and how each might be treated specifically using botanicals:

* allergy-induced migraines

* muscle-tension migraines accompanied by anxiety

* hormonally triggered migraines

Allergy-Induced Migraines

When treating patients with migraines, the initial step is to ascertain whether the complaint might be related to allergic hypersensitivity. A simple history and review of physiological systems will typically reveal concomitant allergic and/ or atopic phenomena. If there are symptoms of chemical sensitivity, hay fever, skin reactivity, food allergies, or bowel reactivity, the migraines are likely to be an allergic phenomenon and should be treated accordingly.

History - The first case involves a 30-year-old woman who experiences migraines weekly, sometimes with no apparent trigger, and sometimes following exposure to perfumes or fumes. She also has exercise-induced asthma, hay fever, eczema, and irritable bowel syndrome.

Diagnosis - Hypersensitivity allergy-induced migraines.

Treatment - The herbal formula includes antioxidant agents with antiinflammatory effects, known to be helpful in cases of allergies, asthma, blood histamine phenomena, and related conditions:

* Tanacetum parthenium (feverfew)

* Curcuma longa (turmeric)

* Ginkgo biloba

* Crataegus oxyacanthaor or monogyna (hawthorn)

Outcome - Allergy-related migraine symptoms usually improve over 2 to 3 months' time as the allergic phenomena gradually lessen. Typically, the patient who has weekly headaches finds that the headaches decrease to every other week within the first month or so. It may take a few months for the full effects of dietary changes to become apparent.

Botanicals for Allergy-Induced Migraines

Tanacetum parthenium (Feverfew)

This herb is classic for migraine headaches, particularly those that involve hyperreactive blood cells such as occur in allergies. Tanacetum is less effective for headaches that are triggered by hormonal stress, or muscular tension.

Anti-inflammatory - Tanacetum has known effects on prostaglandins.

Vascular phenomena - Tanacetum is useful for any kind of vascular phenomenon that involves acute hypersensitivity or allergic response. The research on this botanical indicates that it stabilizes platelets, histamine release, and reactivity of blood vessels.

Curcuma longa (Turmeric)

Curcuma is the Latin name for the whole herb, while its active constituent, a flavonoid, is referred to as curcumin.

Anti-inflammatory - Curcuma has been well researched and is documented to decrease inflammation via a number of prostaglandin pathways and supports liver function, helping to cleanse the blood of proinflammatory substances.

Liver support - Curcuma supports the detoxification of antigens and oxidants via the glutathione pathway, which converts fats and fat-soluble toxins and wastes into a more water-soluble form, assisting their elimination from the body.

Blood cleansing - Curcuma provides benefits in blood cleansing, a term from traditional herbalism that implies supporting the organs of elimination and digestive function: the pancreas, gall bladder, liver, and intestinal tract. This also entails promotion of beneficial bacteria and the health of the intestinal ecosystem, as well as the mucous membranes of the gastrointestinal tract, which all play a role in removing toxins.

Curcumin, one of the most studied active constituents of curcuma, is sometimes concentrated and dispensed in capsule form or included in lesser quantities in formulas for liver and antioxidant support.

Ginkgo biloba

Historically, this circulatory herb has been used for millennia in China, where it is indigenous.

Anti-inflammatory and blood thinner - There is extensive molecular research on ginkgo's effect on inflammatory phenomena via platelets. It has been found to inhibit PAF (platelet activating factor), a type of messenger chemical that induces platelets to clump together. Because platelets often initiate both clotting and the inflammatory cascade, inhibiting PAF frequently reduces allergic hypersensitivity and has been found to moderately thin the blood.

Circulatory effects - Gingko is well documented to improve circulation to the brain, heart, and limbs, and is given for cerebral vascular insufficiency as well as other circulatory and cardiac applications. For the elderly it is indicated for complaints related to poor cerebral circulation, ringing in the ears, dizziness, loss of focus, confusion, senility, and Alzheimer's. Gingko has also been used as a heart tonic, for blood pressure, and to improve poor circulation in the limbs in conditions such as Raynaud's syndrome or arterial insufficiency.

Vascular stabilizer - The blood vessel lining, the endothelium, also plays a role in allergic phenomena by reacting to antigens or other offenders in the blood. Gingko has been shown to have a stabilizing effect on the endothelium through numerous mechanisms, primarily affecting nitric oxide and its associated enzymes housed in blood vessel walls.

Crataegus oxycantha (Hawthorn)

This nourishing herb is a tree in the rose family, native to Europe. The bright red berries have powerful effects as anti-inflammatory, antioxidant, and tissue stabilizers, particularly for the heart and blood vessels.

Circulatory effects - Crataegus was historically used as a tonic for heart or circulatory complaints. It improves circulation to the heart and coronary arteries, strengthening the heart muscle and lowering blood pressure. It is included in this formula because it also decreases the inflammatory process in the blood and reactivity in blood vessel walls. This botanical can be used for people who are prone to varicosities or fragile veins. Although it is difficult to reverse varicosities, research on the bioflavonoid content of Crataegus has found that it strengthens blood vessel walls, through collagen-stabilizing effects. Crataegus also helps to strengthen connective tissue elsewhere in the body and protects it from oxidative damage.

Effects on allergic phenomena - This herb decreases endothelial reactivity to some degree, stabilizing platelets, histamine, and mast cells. Crataegus has been found to prevent the conversion of histidine to hyperinflammatory histamines, although this effect tends to be weaker than the action of other herbs known for this effect, and it is not a pharmaceutical-like antihistamine,

Improving endothelial dysfunction - Crataegus is utilized for allergic phenomena that occur when microcapi Maries become hyperpermeable. If bioflavonoid levels are insufficient to repair connective tissue, these tissues develop weakened areas that leak blood and its components into the body's tissues. The result can be swelling or a tendency to bruising; this phenomenon can also trigger asthma, eczema, irritable bowel syndrome, or other inflammatory phenomena. The resultant scarring of the microendothelia decreases circulation over time. This type of endothelial dysfunction has been implicated in many forms of chronic vascular and inflammatory disorders and may be an underlying factor that sustains these conditions.

Adjunctive Protocol for Allergies

Antioxidant protection - The intervention for allergic patients also typically includes the use of antioxidants, the primary nutrients responsible for subduing free radicals (oxidizing agents) in our bodies. When toxins bind onto any type of cellular membrane, the toxins usually destroy the cell. The body frequently combats these toxins with oxidants. In a sensitive individual, both the toxins and the oxidants can trigger the release of histamines and serotonin from blood platelets and initiate allergic and inflammatory reactions throughout the body. When our bodies have plentiful levels of antioxidant nutrients, toxins to which we are exposed in our daily environment are less likely to trigger the allergic inflammatory cascade.

Minimizing allergic reactivity - Antioxidants provide nutritional support to stabilize blood vessels and decrease allergic phenomena. Some of the most powerful antioxidants are flavonoids, found in botanicals that are brightly pigmented, with beneficial effects on vasculature and blood cells. For example, the botanical turmeric is an intense yellow-orange color, high in antioxidant flavonoids with anti-inflammatory activity. Colorful vegetables and fruits are also rich sources of the compounds, including beets, cabbage, spinach, squash, and berries.

Lowering levels of allergens-Specific food sensitivities can be a factor in migraines, so allergy testing or an elimination diet can be beneficial.

Promoting detoxification - Since the skin functions as a secondary organ of elimination, activities that open the pores and cleanse the body will tend to remove toxins and lighten the burden on the kidneys and liver. Effective approaches include exercise, skin brushing, and saunas.

Stress-Related Migraines

Headaches associated with stress usually involve acute muscular contraction due to physical tension or an emotional trigger such as anxiety. Tension in any of its forms in the mind or body can cause a shift in brain biochemistry and the balance of neurotransmitters. Herbs specific for this type of headache can be taken to address muscular tension, reduce elevated Cortisol levels, and produce a calming effect on the mind and emotions. For many patients, these herbs can be used in times of stress, on an as-needed basis for insomnia or tension. For individuals who are prone to stress and headaches, some of these herbs can be taken in low doses on an ongoing basis.

History - The second case involves a 30-year-old woman who has episodic migraines that are extremely incapacitating, associated with tightness in the back, shoulders, neck, and scalp, and throbbing pain in the entire crown and forehead. The headaches do not occur in association with her menses or any pattern other than stress. She also suffers from frequent insomnia and occasional panic attacks.

Diagnosis - Stress/anxiety-related muscular tension that extends to the muscular layer of the vasculature.

Treatment - Botanicals indicated for stress:

* Cimicifuga racemosa (black cohosh) - Counters anxiety (anxiolytic) and is an antiinflammatory specific for muscular contraction headaches

* Piper methysticum (kava) -Anxiolytic, antispasmodic, pain relief (anodyne)

* Withania somnifera (ashwagandha) - Adrenal support for chronic stress reaction, gamma-aminobutyric acid (GABA) agonist, improves insomnia

Outcome - These herbs can be used in combination, periodically when stress is elevated, or they can be taken in smaller doses long-term to moderate tension for anxiety-prone individuals. This formula is appropriate for acute tension, such as muscle contraction headaches, because it is fast acting and relaxes the mind as well as the muscles. Kava may be omitted and other botanicals substituted, using muscle relaxers such as valerian or nervines such as Hypericum, depending on the patient and the circumstance.

Botanicals for Stress-Related Migraines

Cimicifuga racemosa (Black Cohosh) This herb is well known in botanical medicine as a woman's herb. Cimicifuga has documented hormonal effects due to its isoflavone constituents. This herb is effective for menopausal symptoms, including hot flashes, and has been investigated for osteoporosis, due to its weak estrogenic-like effects. In this particular formula, cimicifuga is used due to its effects in moderating muscular contraction headaches and anxiety. Molecular research has shown it to affect neurotransmitter levels as well.

Piper methysticum (Kava)

Kava has been used in the US in herbal medicine for decades without problem. Many people appreciate it as an aid in relieving stress, nervous tension, or muscle cramping.

Contraindications - Liver cautions associated with kava are a concern. Use of kava should be avoided for patients with known liver disease such as hepatitis C and those on liver-toxic medications. In the Fiji Islands, where kava is used as alcohol or coffee is in the West, heavy consumers are known to develop elevated liver enzymes and in some cases jaundice and scaly rashes. At high doses, kava's hepatic effects are comparable to those of alcohol. However, at moderate doses, many individuals can use kava safely. When used occasionally for concerns such as acute muscle tension and headaches, al most everyone can tolerate it for a day without harm.

Pain management - Kava can be a useful tool for addressing chronic pain; for example, in cases of spinal injury that causes muscle pain and contractions. For these pain patients, narcotics, sedatives, morphine, or opiates would be the primary pharmaceutical options, so kava offers a reasonable alternative. For a few specific patients, kava may be appropriate for long-term use. These patients should be monitored frequently and their liver enzymes checked every 3 to 6 months or annually. All known hepatotoxins should be avoided. Certainly kava can be omitted altogether whenever it does not seem like a wise choice for the patient.

Anxiolytic - Kava can be used at the time of an emerging headache, when the patient begins to experience muscle tension, stress, or anxiety. This herb is somewhat like a pharmaceutical in its action, in that it comes on rapidly (within a half hour or so) and wears off rapidly. For an occasional bad day, it can be taken every half-hour to relax muscles and prevent a headache.

Stress management - In general, kava is taken as needed. This herb can also be taken at a lower, adjusted dose or combined with black cohosh or other nervines and used in moderation long-term for stress management. The mild calmative effects are indicated for people who are prone to stress associated with physical tension, particularly muscle tension.

Nervine - In traditional herbology, a nervine is a plant having a tonifying effect on the nervous system. Kava appears to decrease nerve excitability, which may be why it seems to moderate stress, anxiety, and pain. It is known to decrease the excitability of nerves through the potassium-gated channels on the nerves themselves. The research on kava indicates that it also binds to GABA receptors in the brain. It can be used in combination with other herbs depending on the circumstances, to provide a calming, relaxing, anxiolytic effect.

Withania somnifera (Ashwagandha)

Withania is the Latin name for the Ayurvedic herb Ashwagandha. Interestingly, Ashwagandha has been used to both improve sleep and promote energy. This herb is sometimes referred to as Indian ginseng, although it is not a true ginseng. Like ginseng, it is thought to be useful in managing stress.

Adaptogen - Ashwagandha is an adrenal tonic, moderating adrenaline and Cortisol responses. Herbs that provide this type of balancing effect on adrenal function are described as adaptogens. When we are under long-term stress and function constantly in the sympathetic mode, the increased production of Cortisol and adrenaline helps us sustain the pace. However, if that pace is maintained month after month, year after year (the way in which many of us live), the adrenal glands eventually "downregulate," becoming less responsive to ACTH (adrenocorticotropic hormone) and other stress-induced chemicals released by the brain. Then one is less able to tolerate stress, energy output tends to wane, and steroid output decreases as well.

Like other adaptogens, Ashwagandha can improve energy by increasing adrenal output. It is also known to bind to GABA receptors; consequently, it provides a balance between managing adrenalin and Cortisol output, while calming the mind and emotions.

Tonic - Ashwagandha is known as a tonic herb, and the term ashwagandha means "like a horse." A debate within the herbal community is whether that implies that it makes one strong as a horse, provides the stamina of a horse, or supports the fertility or virility of a horse, as is often attributed to adrenal tonics and adaptogens.

Hormonally Triggered Migraines

Migraines triggered by hormonal phenomena are experienced by some women premenstrually. Although they may also experience these symptoms at other times in their cycle, typically these responses are associated with the menses. Research has not fully confirmed the factors that cause the blood vessels to constrict, dilate, and then progress to the entire inflammatory cascade (the sequence of events that precedes migraines). However, a hormonal trigger to migraines is logical, since we now know that there are estrogen receptors on the blood vessels and adrenergic receptors on both the blood vessels and the uterus.

History - The third case involves a 30-year-old woman who experiences headaches premenstrually. Her headaches are accompanied by abdominal heaviness, some bloating, and breast tenderness. Headaches are typically right-sided and accompanied by sensitivity to light, visual changes, and mild nausea. She has never had a migraine away from her menses.

Diagnosis - Vasomotor phenomena with a hormonal trigger.

Treatment - Botanicals indicated:

* Vitex agnes castus - A progesteronic fluid retention may trigger migraines and progesterone may reduce this; estrogen receptors on blood vessels may be implicated.

* Taraxicum officinalis - Promotes diuresis and liver metabolism of estrogen.

* Sanguinaria canadense - Specific for vasomotor disorders, used only in small doses because it is potentially caustic.

Outcome - We tend to see symptoms of fluid retention most frequently in women who have high estrogen relative to progesterone, since estrogen tends to promote fluid retention. In selecting a botanical protocol for these patients, two strategies come to mind. One approach is to assist the body in excreting estrogen more efficiently. The other is to improve hormone balance by supporting the body's production of progesterone when estrogen levels are normal, but progesterone is low or suboptimal.

Botanicals for Hormonally Triggered Migraines

Vitex agnes castus (Chasteberry)

If progesterone is insufficient, the herb Vitex may be appropriate. This is a classic herb mentioned in herbals hundreds of years old for menstrually related migraines and women's hormone issues in general.

Promoting progesterone production - For many women with hormonal concerns, normalizing low progesterone can balance out excessive estrogen and abolish symptoms of PMS and fluid retention. Vitex has been shown to affect the release of gonadotropins via dopamine. Gonadotropins are hormonelike agents released by the pituitary (LH - luteinizing hormone, and FSH - follicle stimulating hormone). Gonadotropins act on the ovaries and adrenals (and testes in men) to stimulate estrogen, progesterone, and testosterone output. Overall, Vitex affects the brain in a manner that promotes LH and supports increased progesterone levels; this serves to "oppose" estrogen, which is commonly in excess.

Systemic support - Vitex is typically taken all month to increase a woman's progesterone, rather than simply taking it at the time of a headache. Symptoms such as headaches or fluid retention are less likely to develop if progesterone-enhancing herbs are taken on an ongoing basis.

Taraxicum officinalis (Dandelion)

The other approach to hormonal migraines is to lower excessive estrogen in the tissues by assisting the body in excreting or metabolizing it more efficiently. Many herbs are known to have this effect-particularly the alterative roots, which are somewhat bitter and act on the liver.

Taraxicum is a classic remedy with liver-supportive effects, like many roots in the aster or Compositae family. Although burdock and chicory have similar mechanisms, Taraxicum is also known to be a diuretic and a cholagogue, promoting bile release from the liver.

Improving estrogen metabolism - Any substance that promotes bile production tends to enhance liver activity, particularly the ability of the liver to emulsify fats. Estrogens, like all steroids, are built on cholesterol molecules, so estrogen metabolism can be promoted by supporting bile production. This improves not only fat metabolism, but also more efficient excretion of estrogen from the system through liver detoxification (via the process of conjugation).

Supporting estrogen detoxification - The normal life of estrogen in the body is quite short: It is released from the ovaries into the bloodstream and removed from systemic circulation as soon as that blood reaches the liver. Once estrogen is conjugated, it is less active, and is transported to the intestines for elimination from the system. Estrogen disposal can be compromised if there is constipation or poor elimination of wastes.

Minimizing toxic load Estrogen detoxification may also be compromised when the liver is inundated with substances to process and detoxify, which is quite common. Detoxification is necessary whenever we take medication, have too much to drink, do heavy housecleaning, or spray the garden with pesticides. A slowdown in detoxification can lead to excessive levels of estrogen in the body. Furthermore, many chemicals and pesticides are known to bind to estrogen receptors and elicit an estrogenic effect. This is another reason why so many people have elevated estrogen levels. In this particular botanical protocol, dandelion or some other bitter herb is selected to enhance estrogen elimination from the system via the liver and promote better hormone balance. Minimizing exposure to environmental chemicals and toxins can also help the liver and actually reduce the estrogen load in the body.

Sanguinaria canadense

In cases of hormonal migraine, the ideal formula includes an herb specific for vascular phenomena, such as Sanguinaria.

Addressing vascular phenomena-Sanguinaria is indicated for vasomotor blood vessel activity such as hot flashes and migraines. It is specific for heat, perspiration, or flushing and associated headaches. This is also the herb of choice when there is acute vascular phenomena, such as blind spots in the visual field.

One-sided headaches - This herb is especially appropriate for one-sided headaches, associated with certain types of migraines.

Formulation

Both Vitex (chasteberry) and Taraxicum (dandelion) are typically taken all month long. For the convenience of the patient, Sanguinaria could also be taken all month, but in extremely small amounts. This botanical is so strong and caustic, it can burn the mouth when taken repeatedly over time. Consequently, it is only appropriate for use in highly dilute form, in a formulation prepared by a skilled herbalist. In this migraine protocol, Sanguinaria is combined with Vitex and Taraxicum, but in extremely small amounts. A 2 ounce bottle holds approximately 64 ml, so a good ratio would be 30 ml Vitex, 30 ml Taraxicum, and 4 ml Sanguinaria. In that concentration, the Sanguinaria would be diluted to a safe dosage that could be used during the entire month.

Outcome - Typically women will see improvements after a month of use, by the next menses. If no changes are observed within 2 or 3 months, the formula should be changed.

Conclusion

These are sample formulas - the author customizes formulas for all patients individually, depending on their needs and the causal factors involved (for example, adrenal issues, muscle spasms, vasomotor phenomena, hormonal triggers, or stress and tension). For allergy-induced migraines, herbs that stabilize the blood vessels are very specifically selected to assure that they do not cause allergenic effects as well. All these formulas can be amended or fine tuned, depending on the requirements of the individual.

The more we learn about botanicals, the more we come to realize their subtlety and complexity, which is the beauty and mystery of biochemistry and organic phenomena.

This article was excerpted from StansburyJ. In: Rakel D, Faass, NJ. Complementary Medicine in Clinical Practice. Jones & Bartlett, Burlington, MA; 2006. www.jblearning.com. Reprinted with permission.

by Jill Stansbury, ND, with Nancy Faass, MSW, MPH

Jill Stansbury, ND, received her doctorate from National College of Naturopathic Medicine; she is currently chairwoman of the Botanical Medicine Department and has been a professor there since 1991. Licensed as a naturopathic physician in Washington State, she has maintained a private practice in southwestern Washington for more than 20 years. She also writes, lectures, teaches workshops, and serves on the editorial and advisory boards of several publications and organizations. Courtesy of Jill Stansbury, ND, Battle Ground, Washington.

Nancy Faass, MSW, MPH, is a writer and editor in San Francisco who has worked on more than 40 books, including The Pocket Guide to Bioidentical Hormones (Alpha/Penguin), The Everything Raw Food Recipe Book (Adams Media), Boosting Immunity (New World Library), The Germ Survival Guide (McGraw-Hill), and Complementary Medicine in Clinical Practice (Jones & Bartlett). She is director of the Writers' Group, available on the web at www.HealthWritersGroup.com.
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