Migraine-free without pills
Relaxation
The best migraine attack is the one that never happens. And if it does occur, it should at least be less severe than usual. That's the topic of this chapter: How can the frequency and severity of attacks be reduced? In many cases, both are achievable – entirely without medication.
But this doesn't come for free. It requires effort from both the patient and the doctor. Both must work together, consistently and continuously. The usual doctor-patient relationship—prescriber of medication and consumer of that medication—must be fundamentally changed for this process. It must become a partnership in which the doctor provides the patient with optimal information, and the patient, in turn, makes all the necessary information about their condition available to the doctor. For the patient, this primarily means meticulously documenting every attack in a headache diary during the course of treatment.
Separate cause and trigger
To understand the development of migraine attacks, the patient must learn to distinguish between the cause of the migraine – a particular predisposition of the brain – and the triggers of a headache attack. Your doctor might explain it something like this:
“To help you understand why you in particular suffer from migraines, I want to give you an example of a similar process in another illness. If two people lie on the beach in the sun, the development of sunburn is not solely dependent on the sun. People with fair skin will develop sunburn very quickly. People with very dark skin, on the other hand, won't get sunburned at all. This clearly shows that the ability to react with sunburn is rooted in the innately low concentration of dark skin pigments as the actual cause. The sunlight itself only serves as a trigger and, if the cause of “low concentration of dark skin pigments” is present, can lead to the illness. Crucial to its development is therefore a specific innate predisposition. The scientific data on the development of migraines indicate that the cause of migraines is a particular sensitivity to sudden changes in the nervous system. This condition seems to be necessary for people to react with migraine attacks. This particular sensitivity cannot yet be “magically” eliminated by any therapy, just as one cannot change one's skin color. Just as one can However, just as you can avoid the sun to prevent sunburn, you can also avoid migraine triggers. Sudden changes in the nervous system can occur in many different ways and be caused by a variety of mechanisms. We need to identify these mechanisms and then develop a strategy to manage your migraines.
Strategies for better coping with migraines
A causal treatment for migraines would mean normalizing the specific migraine predisposition. However, to this day, we don't know exactly how this specific predisposition arises. And even if we were to understand the mechanisms of this predisposition precisely, influencing them would require directly intervening in the brain's functioning. Whether this will ever be possible is impossible to answer today. Nor can we say whether this is something humanity should desire: the brain is not interchangeable, and that's a good thing.
However, even if the predisposition to migraines is not inherently changeable, this does not mean that nothing can be done about the condition. The statement "migraines are incurable" is fundamentally correct, since we cannot "eliminate" the brain's specific predisposition to reacting to them. However, it is also misleading, as it seems to imply that nothing can be done. This is not true: there are indeed effective methods to prevent the predisposition to migraines from manifesting, or to effectively stop an attack if one does occur. Basically, three strategies are available:
- Prevention through avoidance of trigger factors
- Prevention through reduction of seizure susceptibility
- the treatment of the acute effects of the migraine attack
Avoid triggers
A trigger checklist can help you remember potential triggers and give you an idea of what could be causing your headache. If you spontaneously say, "These are my triggers," you should still check this against your headache diary. Please always record in it which potential triggers preceded the attack.
Below you will find the most important trigger factors:
- stress
- Fear
- Care for
- sadness
- depression
- emotion
- shock
- excitation
- Overexertion
- Physical exhaustion
- Mental exhaustion
- Sudden changes
- Changes in behavior over the weekend
- going to bed late
- Start or end of vacation
- Travel
- Skipping meals
- Change in weather
- Climate change
- Foehn wind
- Bright light
- Eye strain
- Hot bath or shower
- Noise
- Intense odors
- Spices
- alcohol
- Medications
- diet
- menstruation
- Blood pressure changes
- Carrying heavy weights
Once you're clear about which triggers seem to be responsible in your case, you can start eliminating them. Of course, we're only talking about factors that you can control. However, please be sure to discuss this approach with your doctor. They need to be kept informed at all times. As you know, it only works if you both work together. It's important that even after you think you've identified your triggers, you continue to carefully keep your headache diary. Only with its help can you recognize new developments in the course of your migraines and incorporate them into your strategy.
The most important thing: A structured daily routine
One of the most important factors triggering migraine attacks is sudden changes in the normal daily routine. Therefore, the most important and simplest measure is to maintain a regular daily routine as much as possible.
Become your own lawmaker, set rules for your daily routine! And demand that others also adhere to these rules in their interactions with you. Here's what you should do specifically:
- Create a weekly schedule. Make sure to include fixed times for meals, work, and leisure. Post the schedule and declare it law.
- Make sure you eat regular, carbohydrate-rich meals and drink enough fluids throughout the day. Start your day with a healthy, carbohydrate-rich breakfast and be sure not to skip any meals. A small, carbohydrate-rich meal (e.g., muesli, whole-wheat bread, whole-grain porridge) shortly before bedtime can help prevent nighttime and morning attacks. These are often caused by the drop in blood sugar during the night.
- Leave room in your timetable for spontaneous decisions. The plan shouldn't bind you to a rigid schedule. Rather, the aim is to exchange an uncontrolled time pattern for a clear structure.
- You should set aside at least 15 minutes each day for relaxation training. The best time for this is when something positive and pleasant is planned afterward, such as a tea break or your daily walk with your dog.
- Plan a reward day. If you've stuck to your plan, you have every reason to treat yourself to something nice. This could be a concert, a trip, or something else you enjoy.
- Don't give up immediately if things don't go as planned at first. Normally, nothing works perfectly right away. You can optimize your timetable as you gain experience.
Bring movement into your life
The bad news first: Excessive physical activity can trigger an attack in some migraine sufferers. The good news: A thorough warm-up before training usually helps to prevent an attack.
There are isolated reports of physically active people who can stop an oncoming migraine attack by jogging or another endurance sport. However, this is the exception. Normally, exercise worsens the pain and should therefore be avoided during an attack.
In general, moderate endurance training is an important component of a comprehensive migraine prevention strategy. Besides its well-known benefits, such as improving cardiovascular health, respiratory function, and fat metabolism, exercise reliably reduces stress hormones and trains the body and mind to maintain a healthy balance between tension and relaxation. Physical activity thus has a balancing effect on the autonomic nervous system, which, when imbalanced, plays a key role in triggering and increasing the severity of migraine attacks.
Pay attention to your heart rate
Anyone who decides to take up exercise after being a couch potato should consult their doctor and, if possible, have their optimal training heart rate determined. Endurance exercise only makes sense if it's performed at the right intensity for each individual. Too much isn't good, nor is too little. It's best to discuss this with a sports medicine specialist who can conduct the necessary tests.
- Please don't overdo it: Almost all beginners tend to overexert themselves. Following the motto "more is better," they push themselves into a heart rate zone that is not only useless but actually harmful. Therefore, be sure to stick to the heart rate guidelines given to you by your doctor. A little tip: When jogging, run at a pace that allows you to easily hold a conversation. And don't let others pull you along. Stick to your own pace.
How often and for how long?
To achieve the desired effects, you should schedule three or four half-hour sessions per week. Again, it's important to include these times in your weekly schedule and stick to them as much as possible. Studies have shown that training in the late afternoon leads to better adaptation responses than training in the morning. If it fits with your work schedule, a start time between 4:00 and 6:00 PM would be ideal.
Choosing the right sport
Four sports are ideal: walking, jogging, cycling, and swimming. Which one you choose is essentially a matter of personal preference. However, not entirely. Cycling and swimming, and to a lesser extent walking, are also suitable for people with joint problems and/or excess weight. For these overweight individuals, jogging can lead to serious issues. Walking is particularly recommended for older people who have never exercised before or haven't for a long time. Cycling is ideal for almost everyone, especially since it can be practiced outdoors in the summer and indoors on an exercise bike in the winter. Swimming is, of course, particularly gentle on the joints due to the buoyancy of the water
The fast track to relaxation: Progressive muscle relaxation
If you ask around, you'll most likely hear about autogenic training (AT) when you ask about relaxation methods. Certainly, those who truly master it have an excellent tool at their disposal to influence their autonomic nervous system in a variety of ways. However, the method isn't for everyone. Furthermore, it takes months or even years to achieve truly significant results. Progressive muscle relaxation according to Jacobson, on the other hand, can be learned by anyone, and good results can be achieved almost immediately. That's why I highly recommend this method. You can then deepen your understanding through additional literature, courses at adult education centers, or suitable CDs. A CD makes learning the training very easy and effective. You can find detailed information on audio recordings for relaxation exercises .
Biofeedback – a help for some
In biofeedback therapy (feedback)
The goal of biofeedback therapy is therefore to enable direct, conscious control of bodily functions that are normally controlled involuntarily. Biofeedback can thus help to make existing dysfunctions visible and to consciously manage them. However, biofeedback typically only provides feedback on a single bodily function. In essence, a very specific segment of the bodily function is mapped and made known to the patient. This is a significant difference between biofeedback and other relaxation techniques—such as progressive muscle relaxation according to Jacobson—which attempt to influence the entire body.
Various biofeedback methods are used to treat migraines. These include autogenic feedback, blood volume pulse biofeedback, and, in experimental studies, transcranial Doppler biofeedback. EMG biofeedback (electromyography = measurement of muscle tension) is also frequently used in migraine treatment to promote general relaxation.
Blood volume pulse biofeedback
Blood volume pulse biofeedback is also based on the theory that migraines are caused by dilation of the superficial temporal artery. In this therapy, the blood volume pulse curve is fed back to the patient via a sensor on the temple. The patient then learns to actively constrict the superficial temporal artery. For this reason, this training is also called vasoconstriction training.
In practice, however, this method is not very widespread. This is partly because the necessary technology is not readily available everywhere. Furthermore, it requires trained therapists. And finally, its use during an acute attack—which is the only relevant factor—is often ineffective. It has also been shown that patients cannot be motivated to use this method long-term. In addition, current studies indicate that the involvement of the superficial temporal artery plays a minor role in the development of migraines.
However, with this method as well, it is likely that the primary factors responsible for therapeutic success are the focus on bodily processes and the perception of potential self-control. The isolated implementation of blood volume pulse biofeedback therapy is not recommended. It is only effective when integrated into other therapeutic approaches.
Disadvantages of biofeedback
Biofeedback therapy has several disadvantages compared to other therapeutic methods: It typically ties the patient to a therapist and a machine in terms of time and location. This entails organizational problems and means at least a temporary loss of independence. Furthermore, this form of therapy is very expensive compared to other methods. Since no significantly better therapeutic results are achieved than with self-administered relaxation techniques, these methods appear uneconomical and cumbersome in everyday practice.
Biofeedback methods are particularly important for patients whose attacks respond inadequately to other relaxation techniques and who frequently require medication due to the high frequency of attacks. In these cases, biofeedback can help prevent medication from making migraines chronic. It is especially crucial for patients who have lost the ability to perceive bodily signals and cannot differentiate between tension and relaxation. This is often the case for severely affected patients with frequent, severe, and prolonged attacks. Furthermore, as mentioned above, the scientific evaluation of such methods is essential, as they can provide insights into the underlying disease processes.
Less stress, more self-confidence
Stress management training aims to enable patients to recognize internal and external conditions that trigger stress and to modify these conditions through targeted behavioral measures. Participants learn techniques that allow them to cope with stressful situations independently.
The first step in stress management training is always an analysis. Together with the therapist, the patient creates a list of stress-inducing situations and ranks them according to importance and frequency. The patient is then asked to mentally visualize the various stressful situations and perhaps even prepare coping strategies.
Following the stress analysis, the patient should learn to view stress triggers as prompts that can be met with targeted coping mechanisms. To achieve this, the individual should use self-monitoring methods, such as stress diaries, to better perceive stressful situations in everyday life and later process them based on their records.
The patient then learns defensive behaviors. This can take place in both individual and group therapy. In group therapy, role-playing is a good way to practice the necessary behaviors in stressful social situations with others. After the behavioral patterns have been learned and practiced in the group, they can be practiced in daily life through homework.
Self-confidence training
The assertiveness training aims to empower patients to stand up for their personal rights and express their own thoughts, feelings, and attitudes. Increased self-confidence and social skills can lead to a more peaceful and serene life, thereby making a significant contribution to migraine prevention.
During assertiveness training, patients are given tasks related to social skills. These exercises are practiced either through role-playing in a group with a therapist or trainer, or as "live" homework. The exercises aim to develop a more confident and socially competent repertoire of behaviors.
Since social situations are particularly stressful, the following skills are important:
- The ability to say no.
- The ability to ask someone for a favor or to express a wish.
- The ability to express positive and negative feelings appropriately to the situation.
- The ability to initiate, maintain, and, if desired, end general conversations.
Everyday life situations
Due to the immense importance of social competence, a number of different training programs have been developed to teach appropriate behavior to those affected. While they all essentially aim for the same learning objectives, their structures differ. The programs should always be led by trained psychologists, as considerable experience and practice are necessary to achieve maximum effectiveness. Below, I would like to present the content of some of these training programs:
- Reduce the announced visit of a relative from the desired period of three weeks to a weekend.
- Urgently request a housemate not to slam the front door shut as usual in the evening, but to close the house and apartment door quietly.
- Ask your boss for a day off work for a special situation.
- To induce the homeowner to repair a water pipe.
- Exchanging a faulty item of clothing.
- To wish to speak to the superior officer of an undesirable civil servant.
- Ask a fellow passenger on the train to stop smoking in the non-smoking compartment.
- Ask for a salary increase.
- Standing up to unfair criticism from a superior.
- Ask your spouse to also take on their duties in the household and in raising the children.
- Take advantage of a pre-reserved seat on the train or in the restaurant.
- Having various shoes shown to you in a store, trying them on, and then leaving the store without buying anything.
- Being able to recognize and interpret facial expressions and gestures of people (surprise, sadness, contempt, happiness, interest).
- Being able to perceive one's own fear avoidance behavior and reduce it through thought.
- To recognize and differentiate social behavior and emotional states, and to be able to develop appropriate behavioral responses.
As the examples show, the programs aren't about theoretical concepts, but about very practical situations that every man and woman can encounter on a daily basis. The focus is always on becoming aware of incompetent social behavior, fear, avoidance, and withdrawal, in order to achieve a stress-free response in these situations through self-control and effective coping mechanisms.
Simple tips for improving social skills
- Use “I” instead of “one” or “we”.
- Use direct phrases and requests instead of indirect suggestions.
- Formulate your demands and wishes clearly and unambiguously (e.g., “I demand of you…”, “I would like…”).
- Establish direct eye contact.
- Convey unexpected physical closeness through your body language.
- Emphasize your words with appropriate gestures.
- Use a facial expression that matches your statement.
- The volume and modulation of your voice should match what you are saying.
Concordance therapy
A similar technique to social skills training is the so-called concordance therapy, which was specifically developed for migraine therapy. Concordance therapy aims to achieve the following learning objectives in patients:
- Learning to perceive the body in stressful situations.
- The active control of bodily processes.
- To be able to recognize the connection between thoughts and bodily processes.
- The ability to change thoughts.
- Learning behavioral strategies to influence bodily processes.
- Learning to align thoughts, bodily processes, and behavior.
The primary goal of concordance therapy is to establish harmony (concordia [Latin]: unity) between thoughts, feelings, and behavior. This makes it possible to realize desires and goals without expending significant energy, instead of expending a great deal of psychological energy to do the opposite. For example, if someone wants to ask their boss for a raise, it's actually a matter of fifteen minutes (regardless of whether it's successful or not). However, someone who goes to work every day for three months without the firm intention of speaking with their boss is investing a tremendous amount of energy in their avoidance behavior.
Concordance therapy, like stress management training, initially attempts to develop a systematic analysis of body perception processes in stressful situations. To achieve this, patients must be placed in various stressful situations, which are unexpectedly created by the therapists. This allows patients to learn to actively perceive these stressful situations and their bodily responses.
Following this, exercises are performed to learn how to control the perceived bodily processes. Additionally, relaxation training – usually progressive muscle relaxation according to Jacobson – is integrated into the concordance therapy. Further exercises aim to identify and raise awareness of the connections between the perceived bodily processes and the situations they occur. In subsequent practice sessions, patients learn appropriate coping strategies for managing stressful situations.
Effectiveness of psychological methods
Several well-controlled studies have been conducted on the effectiveness of psychological therapies. As is to be expected given the wide range of symptoms, some patients respond very well to psychological therapy, while others do not experience any positive effects. However, an analysis of numerous studies showed that, on average, 43 percent of patients undergoing relaxation or biofeedback therapy for their migraine experienced a positive effect, compared to only about 14 percent in a corresponding placebo control group.
This naturally leads to the conclusion that drug prophylaxis has limited scope: Why accept long-term drug therapy with potential side effects when simple non-drug therapies have almost the same or even better effects? Drug prophylaxis is indeed only advisable if the patient has already attempted non-drug migraine prevention – primarily progressive muscle relaxation according to Jacobson – with insufficient success, and of course, they must have practiced it adequately. No patient should expect that long-term therapeutic effects in migraine therapy will be achieved simply by taking medication without their active participation.
Experience has shown that the therapeutic success of stress management training programs and assertiveness training methods is less predictable, as these are complex procedures. Furthermore, they are less specifically aimed at improving migraines and more at general anxiety reduction and an overall increase in quality of life. However, well-controlled studies have been conducted that demonstrate that concordance therapy, stress management training, and assertiveness training are indeed capable of positively influencing certain aspects of migraines. These studies have found effects comparable to those of prophylactic medication. However, cognitive therapies are very time-consuming. This suggests that a simple relaxation technique, such as progressive muscle relaxation according to Jacobson, which patients can perform themselves, is the primary option.
Good long-term results
Interestingly, very positive long-term effects can be achieved with psychological therapy. Studies have shown that 50 to 66 percent of patients who responded well to psychological therapy at the outset were able to maintain these positive effects for a period of one to five years. Similarly good long-term results cannot be achieved with medication-based prophylaxis.
This is another reason why non-drug prophylaxis should be tried before resorting to medication. If the effects diminish, refresher sessions can always be conducted. With progressive muscle relaxation according to Jacobson, in particular, patients can use the CD to familiarize themselves with the relaxation training at any time, even years later, without having to see a therapist again.
Psychological therapy methods are of particular relevance in childhood and adolescence, as medication is especially unfavorable for this group. Therefore, appropriate therapy options should be utilized more frequently for these young patients in the future.