Ask the Experts: Kiran Rajneesh, MD and Joy Derwenskus, DO

I’ve read that CBD can help with pain in general. Could it ease migraine pain?

Dr. Rajneesh: There aren’t a lot of studies on CBD (cannabidiol) for migraine, so the data is not robust. A lot of patients do say it helps their headaches. But we need randomized, controlled trials on CBD—they’re the gold standard, and they are lacking.

Dr. Derwenskus: There is some evidence for CBD for the treatment of pain, which may include headaches and migraines. But, as Dr. Rajneesh notes, we are lacking good randomized, controlled studies testing CBD in migraine.

Can nutritional supplements help cut the number of migraine attacks?

Dr. Rajneesh: Riboflavin (vitamin B2) helps if you take it daily. There’s no concern about toxicity because it’s water-soluble. The reason you need to take a separate B2 supplement is because B-complex vitamins don’t have enough riboflavin to help prevent migraines. Magnesium can help, but it can also cause diarrhea or softening of the stool for a day or two until your body gets used to it. Vitamin E is helpful for preventing menstrual migraines, but you should only use it with a doctor’s supervision, because taking too much can cause problematic side effects.

Dr. Derwenskus: Probably the best data is for riboflavin supplements. There’s also some research to support magnesium, feverfew, coenzyme Q10, and melatonin. Some small studies have looked at vitamin E as a preventive for menstrual migraines, and magnesium may also help menstrual migraines. Ask your doctor before you try any of these.

My irritable bowel syndrome (IBS) often flares when I have a severe migraine attack. Is that a fluke?

Dr. Rajneesh: There is a link between migraine and the gastrointestinal system. A lot of people say they feel like they have the stomach flu for a few hours with a migraine. You may experience something called cortical spreading depression—a wave of brain activity involving dramatic changes in nerves and blood flow—when you have a migraine. This can cause GI effects even without IBS. When you have IBS, your GI function is already abnormal, so this can make it worse. For prevention, avoid foods that make your IBS or migraine worse, and get plenty of good sleep.

Dr. Derwenskus: IBS is common in people with migraines, and migraines are prevalent in people with IBS. The gut-brain axis is a two-directional interaction that is thought to play a role in both. And both diseases are thought to alter gut microflora, which may affect the gut-brain axis. Also, food allergies or sensitivities may lead to inflammation and worsening of both conditions—which is why diets that eliminate offending foods may lead to improvement in migraines and IBS.

Does scalp or neck tension contribute to migraine pain?

Dr. Rajneesh: We colloquially call scalp tension headaches “ponytail headaches,” and they can contribute to migraine. Traction on the scalp makes headache more likely through what we call allodynia, or pain from something that isn’t normally painful. The remedy is to remove the traction—by removing the ponytail elastic or hair clip, taking off the cap you’re wearing, or changing the part in your hair—for a few hours. Neck tension can lead to cervicogenic headache, in which neck and head tension cause head pain.

Dr. Derwenskus: Often, tension headaches and migraines overlap, and it can be difficult to know the difference. It’s not uncommon that someone will have neck stiffness or spasms with their migraine. You can treat these symptoms with heat, massage, stretching, physical therapy, and sometimes, muscle relaxers.

When should I be concerned about changes in my migraine pain or patterns?

Dr. Rajneesh: If it’s the worst headache of your life in terms of intensity, if you’ve lost vision for an hour or two, if you perceive a bad smell or taste for no apparent reason, or if you vomit more than once, your symptoms may be due to pressure on the brain or indicate something else. If you have any of these symptoms, go to urgent care or the emergency room.

Dr. Derwenskus: Discuss any new or changed headache symptoms with your healthcare provider.

Can migraine cause damage to your brain?

Dr. Derwenskus: People with migraine can have white-matter lesions—white spots on MRI—that are often referred to as nonspecific changes. We don’t know the clinical significance of these spots, but at this point, we don’t think there’s long-term risk for neurological issues, such as cognitive changes, related to these lesions.

Dr. Rajneesh: There’s no long-term data that migraine causes lasting damage in brain function. But if you have lots of white spots in your brain, this may affect how aggressively we want to treat your headaches.

How do sleep disorders such as insomnia impact migraine—and vice versa?

Dr. Rajneesh: The brain needs a certain amount of time to recharge. When you don’t get enough sleep, a ballet of things can happen—hormones and other substances get depleted or are not released in the brain. That leads to a lower threshold for migraine—and more headaches. And headaches can lead to more insomnia. In addition, with obstructive sleep apnea, the airway collapses during sleep. When that happens, the brain doesn’t get enough oxygen, which can lead to more migraine attacks.

Dr. Derwenskus: Any change in sleep patterns—sleeping more or less—can trigger migraines. Insomnia is the most common sleep problem in people with migraine, and it can be impacted by anxiety, depression, medications, and caffeine. Also, when you have a migraine, you may have more trouble falling asleep—or wake up from the pain. Other sleep disorders, such as sleep apnea, are associated with headaches upon awakening.

What other health conditions can exacerbate migraine?

Dr. Derwenskus: Anxiety, depression, chronic pain, obesity, asthma, snoring, and obstructive sleep apnea—all of these can.

Dr. Rajneesh: Being overweight or obese creates a constant state of inflammation in the body, which lowers your migraine threshold. The same is true of diabetes and hypertension. Also, chronic pain syndromes, such as back, hip, or knee pain, amplify other types of pain and lower your migraine threshold.

Our Experts:

  • Kiran Rajneesh, MD: Director of the Neurological Pain Division, Ohio State University Wexner Medical Center, Columbus, OH

  • Joy Derwenskus, DO: Associate Professor of Neurology, Vanderbilt University School of Medicine, Nashville, TN

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