Migraine Headaches – Rethinking an Old Malady

Neuroscience_Neurology2.jpgPhysicians must choose among numerous treatment options for pain. Many pain syndromes would benefit from more effective approaches. Migraine headaches are a prime example of a painful condition in need of a better solution. Recent insights provided by research investigating the mechanisms causing migraines are beginning to generate new approaches to an old problem.

In addition to producing throbbing (usually unilateral) head pain, a migraine attack is often accompanied by nausea, vomiting, sensitivity to light, tenderness over the scalp, and at times a strange visual disturbance called an aura that precedes the headache by about thirty minutes.

Understanding the cause of migraine headache and aura symptoms has proven to be a daunting task. Since the brain feels no pain, the discomfort that accompanies a migraine is believed to arise from both the blood vessels in the brain and the coatings of the brain, called the meninges. For many years, the so-called vascular theory of migraine directed pharmaceutical approaches. It was believed that aura symptoms were due to constriction of blood vessels in the back part of the brain, which then produced diminished blood flow, reduced oxygen supply, and subsequently generated the characteristic visual symptoms of flashing, shimmering lights that move across the visual field. The subsequent headache component was felt to be related to dilation of meningeal blood vessels with an associated release of inflammatory chemicals over their surface.

More recently, attention has shifted from a vascular theory to a neural theory of migraine causation. What acts as the ultimate trigger is unknown, but it appears to be located in the cerebral cortex – the convoluted surface of the brain. There may even be multiple cortical regions that contribute. It is postulated that some perturbing event in the surface of the brain is the culprit, which is followed shortly thereafter by a depolarization (or firing) of surrounding brain tissue that creates an expanding ripple like the rings on a pond when a stone breaks the surface. This expanding wave of depolarization is referred to as cortical spreading depression (CSD). Some researchers believe this helps explain the migraine aura, especially when CSD develops in the visual cortex.

Evidence from a rare type of headache called familial hemiplegic migraine, because of the development of one-sided weakness concurrent with the headache, has provided insight into possible triggers for the wave of CSD. Genetic mutations that result in malfunction of specific ion channels in nerve cells have been identified in this headache variant. When these ion channels undergo periods of decreased function, sodium, potassium and other ions build up where they don’t belong, making the nerve cells irritable and more likely to fire uncontrollably. Such unregulated depolarization (firing) is energetically expensive and results in accumulation of the excitatory neurotransmitter glutamate. This initiates a metabolic cycle that further stimulates nearby neurons, thus creating increased energy demands. As available cellular energy supplies fall, glutamate continues to increase and the cycle intensifies.

This process is reminiscent of what occurs when seizures are triggered. It just so happens that CSD can be suppressed by the continuous use of a wide array of anti-seizure medications. These drugs are effective not only for migraines with aura, but also for migraines without aura. This suggests the possibility that CSD may or may not cause visual auras (presumably when it doesn’t involve the visual cortex).

It seems that by alleviating the ionic imbalance that triggers the wave of CSD, these medications suppress migraine development. By decreasing cortical excitability they also suppress the “hyperexcitability-energy depletion cycle” that ensues. In addition to pharmaceuticals, non-prescription approaches that might achieve the same results can be envisioned. A report by a physician whose wife suffered from persistent migraines revealed a serendipitous result. Apparently the woman went on a reduced calorie diet consisting of low-carbohydrate protein shakes to lose weight after two pregnancies. Not only did she lose the desired weight, she also “lost” her migraine headaches. They didn’t return even when she assumed a more conventional diet.

The relationship between her physiologically induced ketotic state and migraine cessation is reminiscent of the use of ketogenic diets for epilepsy. If the current evidence identifying cortical instability as the inciting stimulus for CSD holds, both triggers (seizures and migraines) involve foci of irritable cortex and would be expected to respond similarly to therapeutic intervention. However, rather than suggest that a person change to a ketogenic diet, it might make more sense to recommend a trial of MCT oil (medium chain triglyceride oil) for migraine suppression. MCT oil is rapidly metabolized by the liver into ketone bodies that are delivered to the brain. Just as occurs during ketogenic dieting, ketone bodies would be expected to beneficially affect the glutamate/GABA balance of neurotransmitters while simultaneously improving the neuronal energy charge. These would act to diminish neuronal excitability and suppress CSD. If this occurs, and it seems likely based on the anecdotal report of the doctor’s wife, MCT oil may prove to be a novel alternative to drug induced prophylaxis for migraine prevention.

Larry McCleary, M.D., is the former acting Chief of Pediatric Neurosurgery at Denver Children’s Hospital, the author of The Brain Trust Program: A Scientifically Based Three-Part Plan to Improve Memory, Elevate Mood, Enhance Attention, Alleviate Migraine and Menopausal Symptoms, and Boost Mental Energy, and maintains his own blog at www.drmccleary.com.
  • Sam

    Though I don’t have familial hemiplegic migraine, I suffer from another subtype. I found your article truly beneficial.

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  • Rose

    I was very interested to read the article suggesting trying an MCT oil. Can you tell me how much one would need to take at a time, please? I have suffered from common migraine for the last 45 years so any assistance would be gratefully received. Also, when I went on a ketogenic diet (Cambridge) I didn’t experience any migraines either, although I only did it for a fortnight.

  • Eric Yen

    Could you please advise me how much MCT oil one has to take at a time., and where I can buy it?


  • Raylene Morgan-Smalley

    The Morgan Clinic at 4 McDowell Street Mt Maunganui New Zealand has been successfully treating
    patients suffering Migraines for many years along with many other painful conditions.

    We use a New Zealand developed technique called NEURO-MYOPATHY and it normally requires
    two or three visits to correct the problem over a two to four day period.

    We have now treated over 7000 patients at this clinic a number of whom were former Migraine

  • Helen

    MCT oil? How is it derived, where can I get it, how much should I take, and does my physician need to be apprised?
    Profusely thanking you for any info.

  • Widely available forms of MCT oil include nonhydrogenated coconut or palm oil, both of which can be found at health food stores and ethnic groceries, if not at the local supermarket.

  • Mary Titus

    I have been using pure MCT oil. Although it is derived from coconut and palm oils, it is only about 10% in these forms. The pure MCT oil is 100%. I have been a low carb dieter for 6 years. I am also a former sufferer of migraines. The migraines left once I began low carbing, although I continued to get the auras.
    I would like to note that I have had just one aura since I added MCT oil to my diet. It probably occured because I became a tad lazy with taking my “medicine”. Plus, MCT oil gives me quality energy. Thanks Dr. McCleary for the information.


  • Allison

    I suffered severe headaches as a child, they became migraines in my twenties and continued to increase in frequency, intensity, and duration until I was having a migraine two days out of three in my mid-forties. I was so debilitated that I couldn’t work. That led me to do my own web search instead of relying on doctors. I tried a gluten-free diet and my migraines vanished. If I eat a bit of either gluten a migraine or headache reappears for 2-3 days. I have since found hundreds of similar accounts on the gluten-free and celiac forums.

    I think a reason the ketogenic diet in the form of protein shakes may have worked is that it is gluten-free.

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  • Hilary

    Anything that gets people eating more saturated fat and other good fats, and fewer carbs, is a good thing as far as I’m concerned. Even better if it also helps with migraines and other brain problems, such as Alzheimer’s. But in any discussion of migraines, wouldn’t it make sense to first discuss caffeine? Is it not the case that probably the majority of what passes for migraine is actually severe headache related to caffeine’s interference with adenosine and adenosine receptors? Caffeine, by occupying and bocking adenosine receptors, upregulates both the number of adenosine receptors and the extracellular levels of adenosine. I personally never have splitting headaches anymore since completely eliminating all sources of caffeine. I used to get a horrible headache once or twice a month. I never saw a doctor about it, and never applied the label “migraine”. But it was incapacitating. At around the same time, maybe ten years ago, I also went mostly paleo, low-carb, so that could be why the headaches went away. But I’m pretty sure I’ve observed headaches coming back when I dally with caffeine, and not when I lapse on the carbohydrates and get out of ketosis.

  • Jenny

    This is so interesting I wish I had come across it long ago. I have suffered from debilitating migraines since my first pregnancy 16 yrs ago. After suffering without much relief from a very expensive medication that I would take at the first sign of aura, I finally started prophylactic Inderal about 7 yrs ago with great relief of my migraines but I’m desperately unhappy with the side effects and would love to be able to stop it. It seems I am one of the ‘lucky’ ones who gets the rare familial hemiplegic migraines and after years of success with Inderal I actually suffered the worst migraines of my life a few months ago and honestly thought I was having a stroke! Neither my doctors or I could pinpoint the causes of this episode and I haven’t had any since but I do remain on the Inderal. I’m definitely going to try the MCT oil (if anyone can help with doses and where to find it I’d love to hear from you) and am going to follow a ketogenic diet more consistently in an effort to get off the Inderal. I’ve gained 15kg’s in 7 years, have terrible short term memory and am much slower in myself than I used to be and no matter how much I exercise, it is extremely difficult to stop gaining weight, let alone lose it. To top it all off, I’ve just read that Inderal can effect Insulin levels (which could be leading to my weight gain), the last time I had my BSL done it was on the high end of normal so I’m very keen to get off the Inderal and get my life back.

    • Mary Titus

      I wish I had seen your post so much sooner. Hopefully by now you have found answers to your inquiries. MCT oil is derivied from coconut oil. It is metabolized instantly into ketones. It does not need to follow the typical digestive pathways that other fats need to take. The supplement company called NOW is where I get my oil.It is quite powerful so don’t think that you can just gobble it down. Work gradually up to 3 tablespoons a day. There are other fats that you would want to take such as DHA/DEA and krill oil. Dr. McCleary calls this a cocktail. Magnesium is still very important to take to help your brain to fight migraines. Take a form of magnesim that is easily absorbed. To tell if the form is easily absorbed, askk yourself, “is this helping me to become more regular or is it causing diahrrea”. If it causes diahrrea then you are not absorbing it well. I take an ionic ( liquid ) form of magnesium by Eidon.Magnesium oxide is not absorbed well at all. Dark green leafy vegetables, halibut, natto and sea vegetables are wonderful food sources of magnesium. Magnesium salts baths are another great way to get your magesium. As for supplements, I cannot absorb mag citrate well at all.My diet is ketogenic, meaning my carb intake is very low and my fat intake is as high as I can comfortably tolerate. Fortunately I have always loved fatty foods and have no problem adding butter, coconut oil olive oil etc to my cooking. I have exemplary cholesterol ratios and my triglycerides continue to be low.

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Larry McCleary, MD

Larry McCleary, MD, is the former acting Chief of Pediatric Neurosurgery at Denver Children’s Hospital. He is trained and has practiced as a pediatric neurosurgeon and has completed post-graduate training in theoretical physics. His scientific publications span the fields of metabolic medicine, tumor immunology, biotechnology and neurological disease. He has lectured to audiences around the world. He is the author of Feed Your Brain Lose Your Belly (Greenleaf Book Group, 4/1/11).

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