Chapter 5
What the Future Holds

Headache research is focused on learning what factors cause or encourage the development of headaches. Since certain dietary, sleep-related, and emotional factors are involved in the workings of blood vessels and the flow of blood to the brain, scientists are focusing their attention on investigating the link between these factors and headaches. If such factors can be identified, scientists can then develop ways to rectify them and thus prevent headaches. At the same time, scientists are working on developing more advanced methods to manage headaches.

A Nutritional Deficiency

Scientists know that the body needs certain nutrients in order for blood vessels to work effectively. These nutrients include magnesium and riboflavin. Since headaches are linked to blood-flow changes in the brain, scientists theorize that a deficiency in either of these nutrients may cause problems in the workings of blood vessels, resulting in headaches. Therefore, a number of studies are being conducted exploring this theory.

Magnesium

One of the most widely studied nutrients is magnesium. Scientists say that magnesium has an antivasospastic action on blood vessels: That is, it keeps the arteries from going into spasms. It also inhibits the constriction and dilation of blood vessels. Magnesium is also thought to be essential in keeping hormones balanced, which helps prevent hormonally triggered headaches. Scientists believe that magnesium regulates muscle tone throughout the body, thus alleviating muscle tension that can lead to headaches. They also think that magnesium may be involved in the regulation and transmission of serotonin. Therefore, they theorize that when people lack an adequate supply of magnesium, they are more likely to develop headaches. In fact, some studies have shown that many headache patients have lower-than-normal levels of magnesium.

A 2002 study at the University of Pecs, Hungary, for example, examined magnesium levels in people with migraines. In this study, during a twenty-four-hour period, three thousand milligrams of magnesium was given to forty subjects, half of whom were migraine sufferers and half of whom were not. Baseline samples of the subjects' blood and urine were taken at the start of the study and after dosing. At the start, both groups had similar levels of magnesium in their bloodstream. The migraine group, however, had less magnesium in their urine. At the end of the study, both groups had significantly higher levels of magnesium in their blood, and the control group also had high levels of magnesium in their urine. The magnesium level in the urine of the migraine group, on the other hand, was still low. This is important because magnesium is water soluble. This means that excess magnesium is not stored in the body. Instead, after the body uses all the magnesium it needs, excess magnesium is eliminated from the body in urine. The researchers concluded that the migraine group retained the magnesium in order to normalize low magnesium levels in their bodies, suggesting a magnesium deficiency in these subjects.

Dr. Alexander Mauskop, a leading expert in the relationship between magnesium and headaches, estimates that as many as 50 percent of all migraine patients and 40 percent of all cluster headache patients may be deficient in magnesium. One study led by Mauskop and conducted at the State University of New York Downstate Medical Center in Brooklyn in 2002 looked at the link between a magnesium deficiency and hormonally triggered headaches. In this study, researchers analyzed magnesium levels in blood samples of sixty-one women with menstrual-associated migraines. Forty-five percent of the subjects had low magnesium levels. "The high incidence of ionized magnesium deficiency we found in our patients during menstrual migraine attacks indicates that magnesium may have a role in the development of the disease in a subgroup of patients,"⁵¹ explains Mauskop.

Based on the results of these and other studies, researchers are exploring whether treatment with magnesium can prevent or lessen both hormonally triggered and nonhormonally triggered headaches. To test whether magnesium can prevent headaches, a 1996 study at the Munich-Harlaching Clinic in Germany divided eighty-one migraine patients into two groups. One group received six hundred milligrams of magnesium everyday for twelve weeks, while the other received a placebo. The frequency of headache attacks in both groups was monitored and compared. Headaches in the group taking magnesium were reduced by 41 percent compared to the placebo group whose headaches decreased by 15 percent. In addition, the duration and intensity of only the magnesium group's headaches decreased.

With such encouraging results, it is not surprising that interest in the role magnesium plays in headaches is growing. If scientists can conclusively prove that people who suffer from chronic headaches are deficient in magnesium, then it may be possible to supplement headache sufferers' diets with large doses of magnesium in order to prevent headaches. However, since large doses of magnesium can cause stomach upset and diarrhea, scientists want to continue studying the link between headaches and magnesium before prescribing the mineral. Nonetheless, many doctors are advising headache patients to add magnesium-rich foods, such as leafy green vegetables, whole grain cereal and breads, seafood, milk, and bananas, to their diets.

Riboflavin

Riboflavin, or vitamin B2, is another nutrient that scientists are investigating. Riboflavin, which is found in whole grains, organ meats, mushrooms, and leafy green vegetables, is required for cells to efficiently use oxygen. Scientists know that before a headache strikes, the brain's supply of oxygen is reduced. Having adequate riboflavin helps people to efficiently utilize even reduced amounts of oxygen. Conversely, without adequate riboflavin, the body has trouble metabolizing oxygen and needs increased rather than decreased oxygen in order to function normally. Therefore, scientists theorize that a combination of reduced oxygen and riboflavin causes headaches. Correspondingly, if headache patients take large doses of riboflavin, their brains will be able to use oxygen more efficiently thus preventing headaches.

To test this theory, in 1998, researchers at the University of Liege in Belgium gave fifty-five migraine patients four hundred milligrams of riboflavin daily for three months, while a control group was given a placebo. The subjects kept a headache diary in which they recorded the number of migraines they had during this time and the severity and duration of each attack. Fifty-nine percent of the patients in the riboflavin group had at least a 50 percent reduction in the number of headaches they experienced, whereas only 15 percent of the placebo group noted any improvement. The researchers observed that the longer the subjects took riboflavin, the more effective it became. This led them to speculate that headache patients may be so deficient in riboflavin that it must build up in their systems before it can work. Therefore, scientists plan to conduct a long-term study to see whether the effectiveness of riboflavin increases with time. If so, treating people prone to headaches with daily doses of riboflavin may prevent headaches.

In the meantime, many headache sufferers and doctors are experimenting with riboflavin supplements. One such headache sufferer explains: "I found it took about a month to kick in, but after that it seemed to work in conjunction with my preventive meds. I notice a big difference without it."⁵²

Too Much Dietary Fat

Another group of scientists thinks that too much dietary fat, rather than a deficiency of certain nutrients, affects the workings of blood vessels and causes headaches. Scientists know that high levels of fat in the bloodstream thicken the blood and slow down blood flow. When the blood is too thick, it becomes difficult for platelets to move easily. As a result, the platelets clump together, which, many experts say, causes a number of other biochemical changes that lead to headaches. In addition, a number of unrelated headache triggers are also linked to a rise in blood fat. Stress and hunger, for instance, cause the body to release stored fat into the bloodstream for energy to help the body cope with danger or hunger. Alcohol and caffeine also appear to raise blood fat levels, as do hormonal changes. Therefore, some scientists hypothesize that high blood fat is the cause of headaches.

Curious about the possible link between high blood fat and headaches, between 1994 and 1996 scientists at Loma Linda University, California, conducted a study to see whether reducing migraine patients' blood-fat levels would prevent headaches. The study was conducted over a twelve-week period. The first month was the control month. During this time, the subjects maintained their normal eating habits and kept detailed headache diaries. At the end of the first month, the subjects' blood fat, in the form of blood cholesterol, was measured. For the next two months, the subjects were instructed to reduce their fat consumption to no more than 30 grams a day and to continue keeping their headache diaries. Since some of the subjects normally ate as much as 120 grams of fat each day, this was a reduction of approximately 75 percent. At the end of the twelve weeks, the subjects' blood was again tested and their headache diaries evaluated.

According to Zuzana Bic, director of the study, "The outcome of the experiment surpassed even the most optimistic expectations. It has demonstrated clearly a very strong connection between high dietary fat intake and migraine headache. Patients who had decreased their fat intake significantly lowered their frequency, intensity, and duration of migraine headaches."⁵³

Indeed, before reducing their fat intake, the subjects averaged nine headaches per month. At the end of the study, this was reduced to an average of two headaches per month, an improvement of 71 percent. In addition, based on a rating scale from zero to five with zero indicating no pain and five indicating extreme pain, the intensity of the subjects' headaches fell from an average of three to below one, a decrease of about 66 percent. Similarly, the duration of the subjects' headaches decreased by 74 percent while blood fat or cholesterol levels decreased from an average of 206 to 178.

Although more studies must be conducted in order to confirm that high blood fat causes headaches and that a diet low in fat can prevent them, it is an interesting theory. Some scientists, including Bic, are encouraging their patients to make lifestyle changes that include reducing dietary fat and increasing fat-burning physical activity as a way to prevent headaches. Bic explains, "One of the most important contributions of the study was the identification of elevated amounts of blood fat as a common denominator of primary headaches.… This opened the way to a radically new treatment of headaches based on specific lifestyle modifications to reduce blood-fat levels."⁵⁴

Most health experts agree that limiting one's fat consumption is a good general health practice. Therefore, following Bic's advice should, at the very least, help headache patients to improve their overall health, which should help them better cope with headaches.

Poor Digestion and Headaches

Other scientists think that poor digestion, which hinders the way the body utilizes nutrients, rather than a deficiency or an over-abundance of certain nutrients causes headaches. These scientists theorize that people with headaches cannot efficiently digest nutrients or effectively eliminate waste. This keeps essential nutrients from reaching the brain as well as causing toxins, which are not eliminated through bowel movements, to build up in the bloodstream and thus cause headaches. These scientists speculate that if these two factors can be corrected, then headaches can be prevented. Therefore, in 2001, a group of naturopathic physicians in Hamden, Connecticut; Schuylkill Haven, Pennsylvania; and Orem, Utah, recruited forty migraine patients to determine the validity of this theory. For ninety days, all the patients were administered specially formulated supplements designed to improve digestion and elimination. The first supplement, known as Combination A, consisted of helpful bacteria known to stimulate digestion and the absorption of nutrients, and peptides that are natural substances commonly used to improve digestion in patients with intestinal and stomach injuries. The second supplement, called Combination B, was made up of twenty-one different ingredients, including a variety of vitamins, minerals, herbs, fibers, and natural chemicals.

After ninety days, in which the subjects took three capsules of Combination A and two capsules of Combination B ten minutes before their two largest meals of the day, 60 percent of the subjects experienced almost total relief from migraine attacks. According to the researchers, "These study results support the theory that migraines may be, at least in part, caused by an underlying deterioration of normal body functioning. In this study by improving assimilation [digestion] and elimination mechanisms, the manifestation of migraines diminished or ceased for the majority of the participants."⁵⁵

Although the results were encouraging, the study did not include a control group. Therefore, a larger study in a medical hospital with a control group is being planned. Still, it cannot hurt migraine patients to consume foods that stimulate the digestion and elimination process, such as fiber-rich food like bran, fruits, and vegetables, as well as yogurt that contains beneficial bacteria. Besides being healthy, based on the result of the study, these foods may help prevent headaches.

Sleep Issues

While some scientists are examining dietary factors, others are investigating the possibility that the sleep disorder sleep apnea may cause headaches. People with sleep apnea stop breathing while they are sleeping for periods of at least ten seconds at a time. Since this reduces the supply of oxygen to the brain, scientists are exploring a possible link to headaches. Because cluster headaches most often begin while a person is sleeping, scientists are focusing their attention on the connection between sleep apnea and cluster headaches.

In 2000, scientists at the Sleep Disorders Center at the University of Michigan in Ann Arbor measured the breathing patterns of twenty-five cluster headache patients while the subjects slept. Of these, 80 percent were found to have obstructed breathing. The more severe the sleep apnea, the more likely the subject would awaken with a cluster headache. Consequently, the scientists concluded that sleep-disordered breathing is likely to occur in cluster headache patients.

Hence, treating sleep apnea may help prevent cluster headaches. In fact, in a case study reported by the Organization for Understanding Cluster Headaches, doctors at the University of Manitoba, Section of Respiratory Diseases, in Winnipeg, Canada, found that treating a cluster headache patient for sleep apnea eliminated the patient's headaches entirely.

In a similar manner, since snoring is caused by a breathing disturbance, scientists hypothesize that snoring, too, may be linked to headaches. A 2003 study at the National Institutes of Health in Bethesda, Maryland, for example, compared the snoring habits of 206 people with chronic headaches to 507 people with occasional headaches. The study found that the chronic headache patients were 2.5 times more likely to be nightly snorers than the control group. Scientists do not know whether snoring causes headaches or vice versa. But they do believe there is a link between the two, and future studies are planned. In the meantime, some doctors are assessing and treating headache patients for snoring in hopes of preventing headaches.

Suppressed Anger

Other headache specialists wonder if emotional issues take a physical toll on blood vessels and cause headaches. Researchers at Saint Louis University in Missouri studied 422 people, 171 of whom suffered from chronic headaches and 251 who did not. Looking for a common emotional link, the researchers found that most of the headache sufferers all dealt with anger by bottling it up inside. The headache-free group, on the other hand, handled anger by letting it out. Scientists know that suppressing anger stresses the body and contributes to other diseases in which blood flow and blood vessels malfunction, such as heart disease, ulcers, and high blood pressure. Suppressing anger, they theorize, causes people to tense their muscles, which in turn tenses blood vessels, in response. Anger also causes the body to respond by releasing a constant supply of stress hormones to cope with the anger. Both are factors that can result in headaches. Commenting on the findings of the study, Dr. Merle Diamond, associate director of the Diamond Headache Clinic in Chicago, explains: "Just like some people get ulcers and grind their teeth, some people get headaches. Anger has to come out somewhere."⁵⁶

Researchers do not know if every headache patient suppresses feelings of anger. If, through other studies, they find this to be the case, then psychiatric treatment that deals with handling anger might become the norm for headache sufferers. For now, Diamond suggests that in an effort to prevent headaches, people develop methods to cope with suppressed anger, such as practicing martial arts.

Botox Treatment

While some scientists are trying to determine what causes headaches, others are developing new forms of treatment. One such treatment is the botulinum toxin, a bacteria commonly known as Botox. Used to alleviate facial wrinkles, when Botox is injected into the face, it temporarily paralyzes facial muscles. Surprisingly, a number of headache patients undergoing Botox wrinkle treatment have reported that the substance also alleviated their headaches. Although scientists do not know why Botox has an effect on headaches, this coincidence prompted a number of studies investigating the feasibility of using Botox as a preventive headache treatment. So far, the results have been promising.

The largest study to date was conducted in 2003 in San Diego, California, by Kaiser Permanente, a nonprofit health maintenance company that sponsors research on different health care issues. In this study, 271 migraine- and tension-headache patients received preventive treatment of two to five Botox injections every three months. As a result, 80 percent of the subjects reported that their headaches were less frequent, less intense, or both, and 60 percent reported getting good to excellent pain relief. Since three-quarters of the subjects had previously tried many different pain remedies without success, these statistics were encouraging. In addition, unlike many of the subjects' experiences with headache medications, 95 percent reported no side effects with Botox. According to the director of the study, neurologist Andrew M. Blumenfeld, "Many of these patients otherwise would be left with narcotics as their best option. Our study also shows Botox causes fewer side effects than many standard medications."⁵⁷

Although the FDA has not yet approved Botox for headache treatment, because of the mounting evidence of its effectiveness, many experts think it will be approved soon. In fact, because it is approved as a treatment for wrinkles, some headache patients are already using it as a dual treatment. A patient who was administered twenty-two Botox injections explains: "I felt a difference almost immediately. My headaches are less severe, and I've cut back on other medications."⁵⁸

Electrode Implants

Even though Botox appears to be effective in treating most migraine and tension headaches, it is not powerful enough to relieve the intense pain of cluster headaches. These stubborn headaches need a stronger form of treatment. Therefore, scientists are exploring a powerful pain treatment that has long been used to alleviate back pain. This treatment involves implanting a tiny electrical device on a nerve, such as the one above the eye for cluster headaches. The device, which the patients turn on or off via a remote control, emits an electrical signal to the nerve and subsequently disrupts pain signals.

Although such a device has been implanted into people's spinal cords to treat back pain, it was first used for headaches in 2003 when doctors at Rush-Presbyterian-St. Luke's Medical Center and Northwestern Memorial Hospital, both in Chicago, implanted a device into six headache patients with excellent results. Theresa, one patient, explains: "The minute he put it in, the pain was gone."⁵⁹

Treatment with electrical implants is still experimental, however. Scientists are investigating whether the device can be implanted in the scalp or forehead to treat severe migraine headaches as well as developing even smaller devices. Indeed, scientists are working hard to perfect this form of treatment, just as they are doing with Botox. It is hoped that in the not-too-distant future, these treatments will provide much-needed relief for chronic headache pain. At the same time, there is optimism in the scientific community that eventually the cause of headaches will be determined. With that discovery, a way to permanently prevent headaches will be found. Therefore, headache patients can look to the future with hope.