​Complementary and Integrative Treatments for Migraine:

An Expert Interview

​Tori Rodriguez, MA, LPC

An estimated 59 million people in the United States spend a collective $30.2 billion dollars on complementary and integrative medicine annually.An estimated 59 million people in the United States spend a collective $30.2 billion dollars on complementary and integrative medicine annually.1Approximately half of the 14% of Americans who have severe headache and migraine report having tried interventions such as meditation, yoga, and deep breathing exercises.2,3
Despite this high prevalence, many patients do not disclose to their healthcare providers that they use such interventions, and many clinicians are unfamiliar with these approaches and the mechanisms underlying their effectiveness. A review published in February 2019 in Current Pain and Headache Reports noted that nearly 85% of providers did not feel adequately informed to advise patients on complementary medicine interventions.4
With the aim of increasing providers’ comfort level in discussing such approaches with patients, researchers from Wake Forest Baptist Health in Winston-Salem, North Carolina, examined studies published between 2015 and 2018 in which complementary and integrative medicine interventions used for migraine treatment, either as monotherapy or in combination with other modalities, were examined.4Selected findings by intervention type are highlighted below.
Mind/body therapies. In a 2015 study of 37 patients with chronic migraine or tension-type headache, an 8-week mindfulness-based stress reduction (MBSR) program, when combined with pharmacotherapy vs medication alone, was associated with improved pain intensity and quality of life (assessed with a headache log and short-form 36 questionnaire, respectively).5
In a 2018 study in a similar patient group, MBSR was associated with improvements in disability (P<.0001), mindfulness (P <.001), distress (P <.0001), and the emotional dimension of pain (P <.0001), as evaluated with the Migraine Disability Assessment; the Freiburg Mindfulness Inventory; the Depression, Anxiety, and Stress Scale; and the McGill Short Form Questionnaire, respectively.4
Another study examined the effects of a mindfulness intervention compared with medication after a 5-day outpatient day program for medication overuse in chronic migraine.4 The results indicate similar reductions between groups in headache frequency (by 6-8 days per month), medication use, and Migraine Disability Assessment scores.
Yoga practice has been associated with improvements in migraine, including in one study in which 3 weekly sessions of yoga for 12 weeks led to greater reductions in headache severity, frequency, and impact when combined with medication, compared with mediation alone.6 In another study, patients who practiced yoga daily after completion of an Ayurvedic treatment program experienced greater reductions in headache intensity and quality of life compared with those who took nonsteroidal anti-inflammatory drugs for symptom relief.4
Other recent findings indicate that tai chi practice was associated with fewer migraine days (−3.6 migraine days, P <.001) compared with migraine days in a wait-list control group, and this correlated with a significant decrease in systolic blood pressure (P <.05).4
Supplements. In a 2012 guideline update from the American Headache Society and the American Academy of Neurology, it was determined that the efficacy of butterbur for migraine prevention is supported by level A evidence. “However, concerns over hepatotoxicity with butterbur resulted in these entire guidelines being retired, and new ones are now pending,” the review authors wrote.4 Feverfew, magnesium, and riboflavin were classified as having level B evidence, and coenzyme Q10 was found to have level C evidence for migraine prophylaxis.
A small number of studies suggest that several combinations of these and other compounds, including vitamin B6 and folic acid, may improve the number of migraine days, certain symptoms, and quality of life, although results are mixed.4 In other research, melatonin was found to improve migraine4 in adult and pediatric patients, and results from a randomized controlled trial indicated that ginger extract combined with intravenous ketoprofen decreased headache intensity and pain in patients presenting to the emergency department with migraine compared with in individuals who received ketoprofen plus placebo.7
Manual therapies. This category “encompasses a multitude of interventions to enhance mobilization, reduce pathologic restrictions, and provide neuromodulation via a physical treatment,” according to the review.4 Osteopathic manipulation treatment and high-velocity chiropractic manipulation have been linked with fewer migraine days. Additional studies have produced initial promising results for massage therapy and reflexology in individuals with migraine.
Exercise. A range of studies have shown beneficial effects of regular aerobic exercise on migraine, including a 2018 randomized controlled trial, in which such practices were associated with reductions in migraine frequency, duration, intensity, and disability compared with control treatments.8
Acupuncture. There is accumulating evidence that acupuncture improves migraine outcomes. For example, patients who were treated with acupuncture reported reduced headache intensity, which correlated with increased N-acetylaspartate/creatine in the bilateral thalamus on magnetic resonance spectroscopy.9 “This research showed that the biochemical effect of acupuncture may target brain regions important for pain perception (thalamus) and the effect had clinical significance on pain outcomes,” noted the review authors.4
Researchers are investigating several of these modalities in ongoing studies. “As both patients and providers become more educated on both the research-based evidence and on the most common modalities patients practice, an open dialogue can be created to ensure that patients are informed on the safest and most effective treatment options while concurrently playing an active role” in deciding which of these therapies to use.4
For additional insights regarding this topic, Clinical Pain Advisor interviewed review co-author Rebecca Erwin Wells, MD, MPH, associate professor in the department of neurology at Wake Forest and UCNS Certified Headache Specialist; and Mia Tova Minen, MD, MPH, chief of headache research and assistant professor in the departments of neurology and population health at NYU Langone Medical Center.  
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Clinical Pain Advisor: What are some of the complementary and alternative medicine interventions for migraine that are best supported by research?
Dr Minen: Please note that the preferred term is now “complementary and integrative health” so that the modalities can still be paired with more “traditional” medicine. This is why the National Center for Complementary and Alternative Medicine was renamed the National Center for Complementary and Integrative Health.
The approaches with the most evidence are biofeedback and progressive muscle relaxation therapy — these are level A evidence-based migraine preventive treatments. Cognitive behavioral therapy is also level A evidence-based behavioral therapy. There is evidence for acupuncture, although it is not level A evidence. Mindfulness modalities include MBSR and mindfulness-based cognitive therapy. Research is conducted to explore how these treatments might be helpful in migraine.
Daily intake of vitamin B2 400 mg, magnesium 400 mg, and coenzyme Q10 is supported by the oldest and best evidence for its efficacy in migraine. I use the two former ones. Melatonin 3 mg has been shown to have a side effect profile similar to that of placebo and had efficacy rates similar to placebo in one study.
Clinical Pain Advisor: What are the overall treatment implications of these findings for clinicians, and how would you advise those who want to learn more about these strategies to incorporate them into their practice?
Dr Minen: Learn ways in which patients can integrate and access the evidence-based treatments. Find providers who are knowledgeable with these modalities. There are audio files with progressive muscle relaxation, for example. We recently developed a research app based on progressive muscle relaxation.10
Dr Wells: Although integrative treatment options are often considered safe and “all-natural,” it is important for patients and providers to recognize that risks do exist with these treatments. For example, butterbur preparations need to be free of pyrrolizidine alkaloids to ensure safety, given the associated risk for liver toxicity, and high-velocity cervical maneuvers in chiropractic manipulation have a risk for vertebral or carotid artery dissection.  
It is also important for providers to ask their patients about use of integrative treatment options, and for patients to discuss their use with their providers. Many of these treatments may be integrated into conventional treatment approaches as complementary vs alternative to traditional pharmacologic approaches.   
Clinical Pain Advisor: What are remaining needs in this area in terms of research?
Dr Minen: We are still trying to learn more about these modalities, about the optimal duration and frequency of these behavioral techniques. We need to find ways to make the evidence-based treatments accessible to patients because we know that they are safe and effective with long-term enduring benefits.
Dr Wells: Much of the research in this area has methodologic challenges that limit interpretation, so more studies and funding for integrative treatment options for migraine are critical to better understand the benefits, mechanisms of actions, risks, and which patients are most likely to respond to which modalities.
References
1. National Center for Complementary and Integrative Health. Americans Spend $30 Billion a Year Out-of-Pocket on Complementary Health Approaches. June 22, 2016. Accessed on March 18, 2019.
2. Burch RC, Loder S, Loder E, Smitherman TA. The prevalence and burden of migraine and severe headache in the United States: updated statistics from government health surveillance studies. Headache.2015;55(1):21-34.
3. Wells RE, Bertisch SM, Buettner C, Phillips RS, McCarthy EP. Complementary and alternative medicine use among adults with migraines/severe headaches. Headache. 2011;51(7):1087-1097.
4. Wells RE, Beuthin J, Granetzke L. Complementary and integrative medicine for episodic migraine: an update of evidence from the last 3 years. Curr Pain Headache Rep. 2019;23(2):10.
5. Bakhshani NM, Amirani A, Amirifard H, Shahrakipoor M. The effectiveness of mindfulness-based stress reduction on perceived pain intensity and quality of life in patients with chronic headache. Glob J Health Sci. 2016;8(4):142-151.
6. Boroujeni MZ, Marandi SM, Esfarjani F, Sattar M, Shaygannejad V, Javanmard SH. Yoga intervention on blood NO in female migraineurs. Adv Biomed Res. 2015;4:259.
7. Bhering Martins L, dos Santos Rodrigues AM, Fernandes Rodrigues D, dos Santos LC, Lúcio Teixeira A, Matos Ferreira AV. Double-blind placebo-controlled randomized clinical trial of ginger (Zingiber officinale Rosc.) addition in migraine acute treatment. Cephalalgia. 2019;39(1):68-76.
8. Krøll LS, Sjödahl Hammarlund C, Gard G, Jensen RH, Bendtsen L. Has aerobic exercise effect on pain perception in persons with migraine and coexisting tension-type headache and neck pain? A randomized, controlled, clinical trial. Eur J Pain. 2018;22(8):1399-1408.
9. Gu T, Lin L, Jiang Y, et al. Acupuncture therapy in treating migraine: results of a magnetic resonance spectroscopy imaging study. J Pain Res. 2018;11:889-900.
10. Minen MT, Jalloh A, Ortega E, Powers SW, Sevick MA, Lipton RB. User design and experience preferences in a novel smartphone application for migraine management: a think aloud study of the RELAXaHEAD application. Pain Med. 2019;20(2):369-377.
This article originally appeared on Clinical Pain Advisor

​Do massages really work?

by Bev Betkowski, University of Alberta

Credit: CC0 Public Domain

They feel great but do massages really work?

​
The answer isn't black and white, says a massage therapist at the University of Alberta.
"The problem is it can be subjective and difficult to measure," said Deborah McIntyre, a member of the massage therapy team based at the Glen Sather Sports Medicine Clinic. Massage has a mix of benefits for both mind and body, depending on the varying needs of the client, she said.
"It's specific to what the situation and problem is. It could be massage for a musculoskeletal condition, pain relief, relaxation therapy; the question is, have we fulfilled the client's request for a treatment to address their concerns?"
The key to that, McIntyre added, lies in connecting with four of the body's major physiological systems during massage therapy and "trying to manipulate the soft tissue to obtain the favourable results the client desires."
The first is the neuromuscular system, which includes all the muscles in the body and the nerves serving them. In this capacity, massage can treat muscles that are either in spasm (too short and tight) or flaccid (too stretched and weak), McIntyre said.
The second part of the body to benefit from a good massage treatment is connective tissue like ligaments, tendons, cartilage and scar tissue.
"A massage can increase range of motion in a joint or smooth and realign disorganized scar tissue," explained McIntyre.
The circulatory system also benefits from massage by increasing blood flow to the tissues, which aids in delivering oxygen and getting rid of metabolic waste to promote healing. Used with caution, massage can also help lymphatic drainage for mastectomy patients and stimulate better breathing for people with limited lung capacity or other respiratory conditions. It also improves circulation of cerebral spinal fluid, which could hold potential for treating concussions, McIntyre believes.
Massage also helps the autonomic nervous system, which regulates sympathetic responses in the body like heart rate and arousal.
"A massage helps people come down from heightened stress and anxiety," explained McIntyre.
She added the benefits of massage also linger after the appointment is done.
"The physiological experience definitely has a lasting effect. Massages can't solve everything, but they can be very successful when used appropriately."
More research into measuring the effects of massage on the body's four physiologic systems will further help pinpoint its benefits, she added.
Some studies have shown it also holds potential for people with dementia and Parkinson's disease, she noted, because soft massage can decrease aggressiveness and anxiety.
"We can gain some insight by working with other disciplines in medicine and science such as physiotherapy, sports medicine and chemistry. They have the ability to measure the different molecular structures within blood and tissues, and then we can see if we're making a difference as massage therapists," she said.
Relaxation versus deep tissue massages
Whether for pure pleasure or to treat pain, there are massage techniques for both. But deep tissue massages should only be given as part of a plan to treat a specific injury, McIntyre said.
"(When) you're dealing with a problem, there should never be a deep tissue massage without an assessment first. Otherwise the body may not need it and you may damage the tissue. No one wants to feel like they've been hit by a truck after a treatment."
The massage therapist should assess the patient, get their consent and then develop a plan that could also recommend hydrotherapy and other treatments.
"A skilled massage therapist will have many tools to get favourable results without causing further damage."
Relaxation massages are good for treating minor aches and reducing anxiety, McIntyre said.
"It's a softer touch, and you're trying to provide a feeling of well-being as the patient starts to relax."
However, she added, massage treatment may not be appropriate for people with certain conditions that could require first aid or medical attention due to strokes, diabetic comas, systemic infections, high fevers, or uncontrolled high blood pressure and bleeding.
"A trained therapist will be able to accommodate many other medical conditions and medications and is expected to know when and how to consult with doctors and other health-care professionals," McIntyre noted.
What to expect from a massage therapist

• A pre-massage assessment for a client's injury or condition. A proper case history should be taken, including past and current medical history and a list of prescription medication.
• Development of a treatment plan with the client's informed consent. A massage therapist should have a good referral base to other medical professionals.
• A variety of massage techniques to provide relief.
• For a relaxation massage, clients should be asked about any medications they're taking and any other contraindications.

Technology Times

Pakistan's Only Newspaper on Science and Technology

Benefits of Massage you were not aware of

​ !Muhammad Raza 


Massage Therapy is considered a routine for Athletes as it improves athletic performance and stimulates speedy recovery. Here are the following benefits will discuss about massage we were not aware of.
1. Enhances Fitness PerformanceIt does so by reducing muscle stiffness and swelling, in fact, injuries can be avoided all together with regular sessions. Fitness Enthusiasts depend on these treatments for peak performance.
2. Combats Insomnia while MassageSufficient sleep is essential for one’s health and wellness and can help avoid various diseases. Massages is known to improve sleep in children and the elderly. ‘Insufficient sleep is associated with a number of chronic diseases and conditions.
Such as diabetes, cardiovascular disease, obesity, and depression which threaten our nation’s health. Notably, insufficient sleep is associated with the onset of these diseases and also poses important implications for their management and outcome.’(cdc.gov)
3. Relieves MigrainesThere are certain acupressure points related to migraine and other symptoms which if rubbed or put pressure on can provide instant relief.

.4. Immunity Booster

Massage is a great promoter of immune wealth. Some forms of massages increase the lymphocyte count in the body which is a white blood cell defending the body from disease

5. Relieves Postural StressThose who spend most of their time on a desk working are likely to have postural stress because of sitting in one position for multiple hours. Massage Therapy counteracts those effects by releasing the pressure on the lower spine.
6. Improves BalanceMassage Therapy can improve balance in the older persons preventing them from falling, it being a primary cause of death, and increases mobility.

​HEALTH

Can We Touch?Physical contact remains vital to health, even as we do less of it. The rules of engagement aren’t necessarily changing—they’re just starting to be heard.

JAMES HAMBLIN

RICHARD BAKER / GETTY

​Tiffany Field has spent decades trying to get people to touch one another more.
Her efforts started with premature babies, when she found that basic human touch led them to quickly gain weight. An initial small study, published in the journal Pediatrics in 1986, showed that just 10 days of “body stroking and passive movements of the limbs” for less than an hour led babies to grow 47 percent faster. They averaged fewer days in the hospital and accrued $3,000 less in medical bills. The effect has been replicated multiple times.
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Field, a developmental psychologist by training, went on to found the Touch Research Institute at the University of Miami’s Miller School of Medicine. She was a pioneer in highlighting the effects of “touch deprivation” among kids, famously those in orphanages. She explained to me that the effects are pervasive, influencing so many bodily systems that kids are diagnosed with “failure to thrive,” resulting in permanent physical and cognitive impairment, smaller stature, and social withdrawal later in life—which often includes aversion to physical contact.
Physical touch doesn’t make adults larger, but its effects are still coming to light. Field has published similar findings about the benefits of touch in full-term infants, and then children and pregnant women, adults with chronic pain, and people in retirement homes. Studies that involved as little as 15 daily minutes found that touch alone, even devoid of the other supportive qualities it usually signifies, seems to have myriad benefits.
The hug, specifically, has been repeatedly linked to good health. In a more recent study that made headlines about hugs helping the immune system, researchers led by the psychologist Sheldon Cohen at Carnegie Mellon University isolated 400 people in a hotel and exposed them to a cold virus. People who had supportive social interactions had fewer and less severe symptoms. Physical touch (specifically hugging) seemed to account for about a third of that effect. (The researchers conclude: “These data suggest that hugging may act as an effective means of conveying support.”) Cohen and his colleagues continued to show other health benefits of physical contact, such as a 2018 reveal in the journal PLOS titled “Receiving a Hug Is Associated With the Attenuation of Negative Mood That Occurs on Days With Interpersonal Conflict.”Read: Should teachers be allowed to touch students?
Part of the reason this research didn’t happen sooner is that it was seen as extremely obvious. Yet even as evidence of the importance of physical touch has piled up, the world has been moving in the opposite direction. “You don’t see people touching each other anymore, in large part because they’re all on their phones and iPads and computers,” Field said. “It’s very disturbing to see parents doing less touching of kids, if they’re just sitting there on screens.”
The dissonance of people benefiting from touch but doing less of it is only made more confusing by statements like Joe Biden’s. In a video posted to his Twitter account last week, a response to widespread concerns about excessive hugging and incidents of hair sniffing and the like during his time as vice president, the likely 2020 presidential candidate said he had no intention of making anyone uncomfortable. He then pivoted to claim that people are less open to being touched: “Social norms have begun to change. They’ve shifted, and the boundaries of protecting personal space have been reset, and I get it, I get it. I hear what they’re saying. I understand it.”
The explanation raises the question: Are boundaries changing? (And does Biden get it?)
The research is clear on that fact that people both need and react well to physical touch—in controlled environments. There is no evidence that people like to be touched any less than in previous generations, only that negatively received touch is more openly vocalized. What’s new is that people who didn’t appreciate being touched in previous decades, or who were always made uncomfortable by it, especially from people in positions of power, are empowered to process the fact that it’s not something they need to put up with. They have platforms for speaking up, channels for recourse, and supportive listeners to cushion the blowback.
“There is a lot of research on how touch is hierarchical, and males can touch females but not vice versa,” Field said, noting that caretakers in nursing homes tend to touch female residents much more than males, and the latter are at higher risk of touch deprivation. “I think some of that is reflected in what’s going on, where people are seeing the hierarchical aspect of the touch and not the supportive aspect.”