Headaches and CAM [NCCAM Health Information]

Headaches and CAM © Matthew Lester

IntroductionHeadaches are one of the most common forms of pain. For some people a headache may be a minor irritation once or twice a year, while others can suffer disabling pain on an almost daily basis. Researchers are studying treatments for different types of headaches, including a number of complementary and alternative medicine"A group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. Complementary medicine is used together with conventional medicine, and alternative medicine is used in place of conventional medicine." (CAM) therapies. This fact sheet provides basic information on headaches, summarizes research on the effectiveness and safety of selected complementary and alternative practices for headaches, and suggests sources for additional information. If you are considering a complementary and alternative therapy for headaches, this information can help you talk to your health care provider about it.


Key PointsHeadaches can be primary (without an underlying cause) or secondary (resulting from another condition). Secondary headaches may be symptoms of a serious illness.

It is important not to replace conventional medical treatments for headaches with an unproven CAM therapy.
Complementary and alternative therapies for headaches include massage; meditationA conscious mental process using certain techniques—such as focusing attention or maintaining a specific posture—to suspend the stream of thoughts and relax the body and mind., biofeedbackThe use of electronic devices to help people learn to control body functions that are normally unconscious (such as breathing or heart rate). The intent is to promote relaxation and improve health., and other stress-reduction techniques; spinal manipulation; acupuncture; and dietary supplements, such as riboflavin (vitamin B2), magnesium, feverfew, and butterbur.
Tell all your health care providers about any complementary and alternative practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.


About Headaches
Headaches occur when pain-sensitive nerve endings around the scalp, in the blood vessels that surround the skull, in the lining around the brain, and in other areas around the head send impulses to the part of the brain that interprets pain signals from the rest of the body. Some headaches are related to tender spots in head, neck, and shoulder muscles.

More than 45 million Americans have headaches severe enough to require the help of a health care professional. The toll on the economy from migraines alone is immense—direct costs (from prescription drugs, outpatient expenses, and emergency room and inpatient care) are estimated at $11 billion and indirect costs (such as missed work days) may exceed $12 billion annually. Migraine headaches also cause an annual loss of 157 million workdays.


Primary Headaches
Primary headaches are those that are not a symptom of another medical condition. There are three major types of primary headaches.

Tension-type headaches are the most common kind of primary headache, affecting about 38 percent of American adults annually. A tension-type headache usually affects both sides of the head and is of moderate severity. People describe them as feeling like a band is tightening around their head. A tension-type headache may be triggered by stress, anxiety, depression, or too little sleep. Episodic tension-type headaches can last from 30 minutes to several days. Chronic tension-type headaches usually occur more than 15 days each month (not always consecutive) for about 3 months. The pain of a chronic tension-type headache may be more severe than an episodic one.
Migraines affect about 12 percent of the U.S. population and are more common in women than men (although childhood migraines are more common among boys). Symptoms of migraine headaches typically include throbbing or pulsing pain on one side of the head, nausea, vomiting, and sensitivity to light and sound. Migraines are generally of moderate to severe pain. If a migraine occurs more than 15 days each month for about 3 months, it's considered chronic. The two most common types of migraine are
Migraine with aura (visual disturbances or other symptoms such as trouble speaking, numbness, muscle weakness on one side of the body, confusion, or a tingling sensation in the hands or face that appears before the actual headache and usually lasts less than an hour). This affects about a third of people with migraines.
Migraine without aura. This type of headache can often be confused with a tension-type headache.
Many people who have migraines report that their headaches are triggered by certain conditions or substances such as:
Environment (weather changes, exposure to bright light, high altitude, smoke, certain odors, and prolonged loud noise)
Diet (chocolate, garlic, pickled products, processed meats and fish, aged cheese, alcohol—especially wine, or caffeine withdrawal)
Other factors (exertion, too much sleep, fatigue or exhaustion, irregular motion such as amusement rides or boats, stress, or hormonal changes).
Trigeminal autonomic cephalalgias (TACs) are identified by severe pain in or around one eye and other symptoms such as eye redness and tears, drooping eyelid, and runny nose. The most common TAC is called a cluster headache, because these headaches occur in clusters over a period of weeks or months. Attacks last for about 60 to 90 minutes and may occur at the same time each day or night for days or weeks. People who have cluster headaches say the pain is excruciating and describe it like a "hot, burning poker in the eye."
Cluster headaches are much less common than migraines, affecting about 0.3 percent of the general population.

Secondary Headaches
Secondary headaches are the result of another health disorder and may be signals to seek medical care. Some of the more serious causes of secondary headaches include brain tumor, blood vessel problem (e.g., stroke), head injury, inflammation resulting from infection (such as meningitis and encephalitis), or seizure.

These symptoms require prompt medical attention:

Sudden onset of a severe headache
Severe headache accompanied by fever, nausea, vomiting, or a stiff neck that is not related to another illness
Headache accompanied by confusion, double vision, weakness or loss of sensation in part of the body, or loss of consciousness
Headache that worsens or changes in pattern over time
Recurring headache in children
Headache following a head injury
Headache associated with convulsions
Headache associated with shortness of breath
Two or more headaches per week
Persistent headaches in someone who previously has not had headaches (particularly in someone older than 50)
New headaches in someone with a history of cancer or HIV/AIDS.


CAM Therapies for Headaches
Many people take over-the-counter pain relievers or prescription pain medications to relieve their headaches. Those who have frequent and severe migraine headaches may take some form of prescription medication regularly as a preventive measure. Some people may try to reduce their discomfort by adopting lifestyle or dietary changes. In addition, researchers are studying some complementary and alternative therapies for headache relief. These include:

Mind and body interventions such as relaxation training, biofeedback (the use of simple electronic devices to teach people how to consciously regulate bodily functions, like breathing, heart rate, and blood pressure), acupuncture"A family of procedures that originated in traditional Chinese medicine. Acupuncture is the stimulation of specific points on the body by a variety of techniques, including the insertion of thin metal needles though the skin. It is intended to remove blockages in the flow of qi and restore and maintain health.", tai chi"A practice in traditional Chinese medicine that uses a series of slow, gentle movements coordinated with breathing and meditation. The goal is to enhance physical functioning, improve balance and concentration, and reduce stress.", and cognitive-behavioral therapy
Massage
Spinal manipulation
Dietary supplements.


What the Science Says About CAM and Headaches

Mind and Body Approaches
Relaxation training. One review article noted that relaxation training significantly reduced headache activity compared to other forms of therapy. Relaxation techniques are generally considered safe for healthy people. There have been rare reports that certain relaxation techniques might cause or worsen symptoms in people with epilepsy or certain mental illnesses, or with a history of abuse or trauma. People with heart disease should talk to their doctor before doing progressive muscle relaxation.
Biofeedback. The same article reported that adding biofeedback to a combination of an antidepressant and high blood pressure medication was more effective in treating tension-type headaches than medication alone. Results from one study indicated that biofeedback provided no additional benefit over relaxation therapy in reducing headache frequency and severity.

Acupuncture.
In a review of two large trials in people with tension-type headaches, researchers found that adding acupuncture to the use of pain relievers was more effective than using pain relievers alone.
A review that analyzed results from two large and three small trials comparing true acupuncture with sham acupuncture (in which needles were either inserted at incorrect points or did not penetrate the skin) demonstrated a slightly better effect for true acupuncture in treating tension-type headaches.
Results of another review article determined that adding acupuncture to acute treatment or routine care may be beneficial in reducing migraine frequency and intensity.

Acupuncture is considered safe when performed by a qualified and competent practitioner using sterile needles. Few complications have been reported. Serious adverse events related to acupuncture are rare, but include infections and punctured organs.
Tai chi. Results from a small clinical trial suggested that a 15-week program of tai chi was effective in reducing the impact of tension-type headaches when compared to a wait-list control group. Tai chi is a relatively safe practice; however, some health care providers may advise their patients to modify or avoid certain tai chi postures due to acute back pain, knee problems, bone fractures, sprains, and osteoporosis.
Cognitive-Behavioral therapy. It has also been suggested that cognitive-behavioral therapy may offer additional relief when combined with medication used for preventing migraines.

Massage
Only a few studies have rigorously examined the role of massage"Pressing, rubbing, and moving muscles and other soft tissues of the body, primarily by using the hands and fingers. The aim is to increase the flow of blood and oxygen to the massaged area." as a headache treatment.

Results of one small clinical trial suggested that massage with relaxation may be more beneficial than acupuncture for migraines, but both were equally effective for tension-type headaches.
A 2008 pilot study involving 16 participants suggested that massage may be beneficial in reducing the frequency of tension type headaches as well as the intensity and duration of pain.
In another small study, researchers observed that a specific type of massage called craniosacral therapyLight touch and manipulation focused on the skull and spine. The intent is to sense and remove perceived blockages or imbalances in order to promote health., which involves light touch and manipulation"The application of controlled force to a joint, moving it beyond the normal range of motion in an effort to aid in restoring health. Manipulation may be performed as a part of other therapies or whole medical systems, including chiropractic medicine, massage, and naturopathy." of the skull and spine to release restrictions in tissues, was more effective than no treatment in relieving pain from a tension-type headache but suggested that larger studies are needed to determine the efficacy of massage as a headache treatment.

Researchers are also investigating whether massage therapy"Pressing, rubbing, and moving muscles and other soft tissues of the body, primarily by using the hands and fingers. The aim is to increase the flow of blood and oxygen to the massaged area." may help prevent migraines. In a 2006 study, researchers randomly assigned 24 people with migraines to receive six 45-minute massages that focused on the muscles of the back, shoulders, head, and neck while 24 people without migraines acted as a control group. Although there was no change in the average intensity of migraines experienced, the researchers observed a significant reduction in migraine frequency among those who received massages.


Spinal Manipulation
Literature reviews suggest that spinal manipulation (a technique often practiced by chiropractors) may offer some benefit for tension-type headaches and that it also may prevent migraines as well as the medication amitriptyline. Except for high-speed neck manipulation, which is associated with the very rare but serious risk of arterial tearing or stroke, spinal manipulation is not likely to be harmful. Side effects from spinal manipulation can include temporary headaches, tiredness, or discomfort in the parts of the body that were treated.


Dietary Supplements
Researchers are studying dietary supplements to see whether they may prevent, relieve, or reduce the number of headaches people experience.

Some research suggests that the supplements riboflavin and coenzyme Q10 may be helpful headache treatments. Studies using magnesium to prevent migraines were inconclusive. Riboflavin and coenzyme Q10 are generally well tolerated, but magnesium supplements may cause diarrhea.
The herbs feverfew (Tanacetum parthenium) and butterbur (Petasites hybridus) have been used historically for headache relief. Study results have indicated that feverfew and butterbur may help reduce migraine frequency. In clinical trials, use of feverfew was associated with mild side effects such as open sores in the mouth and upset stomach. Butterbur is generally well tolerated but may cause mild gastrointestinal upset. Some butterbur products contain potentially harmful chemicals called pyrrolizidine alkaloids (PAs). If seeking a butterbur product, look for one labeled or certified as PA-free.
Riboflavin supplements, feverfew, and butterbur are not recommended for pregnant women.

NCCAM Research
NCCAM-supported research on headaches includes the following:
Craniosacral therapy for preventing migraine headaches and to determine if this form of treatment will partner well with conventional care
Spinal manipulation for relieving headaches and neck pain and to determine the number of treatments that are needed to sustain its benefits
To see if acupuncture is more effective than a sham procedure or usual care in reducing the frequency and severity of chronic daily headaches
Assessing the efficacy of therapeutic massage in relieving tension-type headaches.
If You Are Considering CAM for Headaches
Do not replace proven conventional medical treatments for headaches with CAM treatments that are unproven.
Speak with your health care providers if you are pregnant or nursing and thinking of using a dietary supplement"A product that contains vitamins, minerals, herbs or other botanicals, amino acids, enzymes, and/or other ingredients intended to supplement the diet. The U.S. Food and Drug Administration has special labeling requirements for dietary supplements and treats them as foods, not drugs.".
Be aware that some dietary supplements may interact with conventional medical treatments.
If you are considering a practitioner-provided complementary and alternative therapy such as biofeedback or acupuncture, ask a trusted source (such as your doctor or nearby hospital) to recommend a practitioner.
Find out about the training and experience of any CAM practitioner you are considering. To learn more, see the NCCAM fact sheet Selecting a Complementary and Alternative Medicine Practitioner.
Tell all your health care providers about any complementary and alternative products and practices you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care. For tips about talking with your health care providers about CAM, see NCCAM's Time to Talk campaign.

Selected References
Bronfort G, Haas M, Evans R, et al. Effectiveness of manual therapies: the UK evidence report. Chiropractic & Osteopathy. 2010;18(3).
Bronfort G, Nilsson N, Haas M, et al. Non-invasive physical treatments for chronic/recurrent headache. Cochrane Database of Systematic Reviews. 2004;(3):CD001878 [edited 2009]. Accessed at http://www.thecochranelibrary.com/ on October 5, 2011.
Evans RW, Taylor FR. "Natural" or alternative medications for migraine prevention. Headache. 2006;46(6):1012–1018.
Friedman DI, De ver Dye T. Migraine and the environment. Headache. 2009;49(6):941–952.
Halker R, Vargas B, Dodick DW. Cluster headache: diagnosis and treatment. Seminars in Neurology. 2010;30(2):175–185.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews. 2009;(1):CD001218. Accessed at http://www.thecochranelibrary.com/ on September 8, 2011.
Linde K, Allais G, Brinkhaus B, et al. Acupuncture for tension-type headache. Cochrane Database of Systematic Reviews. 2009;(1):CD007587. Accessed at http://www.thecochranelibrary.com/ on September 8, 2011.
Lipton RB, Dodick DW, Silberstein SD, et al. Single-pulse transcranial magnetic stimulation for acute treatment of migraine with aura: a randomized, double-blind, parallel-group, sham-controlled trial. Lancet Neurology. 2010;9(4):373–380.
Mullally WJ, Hall K, Goldstein R. Efficacy of biofeedback in the treatment of migraine and tension type headaches. Pain Physician. 2009;12(6):1005–1011.
National Institute of Neurological Disorders and Stroke. Headache: Hope Through Research. Accessed at www.ninds.nih.gov/disorders/headache/detail_headache.htm on September 8, 2011.
Robbins MS, Lipton RB. The epidemiology of primary headache disorders. Seminars in Neurology. 2010;30(2):107–119.
Sun-Edelstein C, Mauskop A. Foods and supplements in the management of migraine headaches. Clinical Journal of Pain. 2009;25(5):446–452.
Tsao JC. Effectiveness of massage therapy for chronic, non-malignant pain: a review. Evidence Based Complementary and Alternative Medicine. 2007;4(2)165–179.
Wahbeh H, Elsas SM, Oken BS. Mind-body interventions: applications in neurology. Neurology. 2008;70(24):2321–2328.


For More Information
NCCAM Clearinghouse
The NCCAM Clearinghouse provides information on CAM and NCCAM, including publications and
searches of Federal databases of scientific and medical literature. The Clearinghouse does not provide medical advice, treatment recommendations, or referrals to practitioners.
Toll-free in the U.S.: 1-888-644-6226
TTY (for deaf and hard-of-hearing callers): 1-866-464-3615
Web site: nccam.nih.gov
E-mail: info@nccam.nih.gov
National Institute of Neurological Disorders and Stroke
The National Institute of Neurological Disorders and Stroke (NINDS), a component of the National Institutes of Health (NIH), conducts and supports research on brain and nervous system disorders.
Web site: http://www.ninds.nih.gov/
Toll free in the U.S.: 1-800-352-9424

PubMed®
A service of the National Library of Medicine (NLM), PubMed® contains publication information and (in most cases) brief summaries of articles from scientific and medical journals.
Web site: www.ncbi.nlm.nih.gov/sites/entrez

National Library of Medicine's MedlinePlus
To provide resources that help answer health questions, MedlinePlus brings together authoritative information from NIH as well as other Government agencies and health-related organizations.
Web site: www.nlm.nih.gov/medlineplus

Acknowledgments
NCCAM thanks the following people for their technical expertise and review of this publication: Albert Moraska, Ph.D., University of Colorado; Stephen Silberstein, M.D., Jefferson Medical College of Thomas Jefferson University; and John Glowa, Ph.D., NCCAM.

This publication is not copyrighted and is in the public domain. Duplication is encouraged.
NCCAM has provided this material for your information. It is not intended to substitute for the medical expertise and advice of your primary health care provider. We encourage you to discuss any decisions about treatment or care with your health care provider. The mention of any product, service, or therapy is not an endorsement by NCCAM.
NCCAM Publication No. D462

Headaches and CAM [NCCAM Health Information]