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Diamine Oxidase (DAO) is Why I’m Doing Better

The Amazing Feat of a Normal Life prompted a lot of questions about why I’m feeling so much better. It’s still the digestive enzyme, diamine oxidase (DAO), that I started in January. (To learn more, read The Post I Never Thought I’d Get to Write and follow the links at the end for more details. If you want to try DAO yourself, you can get it through Amazon. Even though it’s called Histamine Block, it isn’t an antihistamine and doesn’t block histamine.)

I continue to follow a restricted diet, though that’s more about wanting to reintroduce foods slowly and methodically rather than any particular food being a problem. As long as I take DAO, I’m doing great with nearly every food I try (even dairy and wheat). I’ve even tried a few high-histamine foods (with a little extra DAO) and have done fine.

The other dietary change is that I’m eating most foods on a rotating schedule, leaving two or three days between each time I eat a particular food. I began this when I developed an intolerance to coconut after eating it multiple times a day for months without a problem. This has been a very effective way to vary my diet.

It’s a slow process, but I’m getting almost complete nutrition from the foods I eat (I’m still a little low on calcium). I eat mostly vegetables, though I have salmon a couple times a week and am currently testing eggs and milk.

That’s it. I’m past the three-month placebo window and continue to feel better than I ever thought possible. I know DAO is an unconventional migraine treatment. I know the science behind it is weak. I also know it’s working better for me than anything else I’ve ever tried.

Related posts:

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Opioids Under-Prescribed Due to Addiction Fears?

Fear of Addiction Means Chronic Pain Goes Untreated, according to an NPR story that aired last weekend. While there’s definitely some truth to the headline, it obscures the nuances of physicians’ reluctance to prescribe opioids (a.k.a narcotics) for chronic pain in general and headache disorders specifically (particularly migraine).

Opioids were originally prescribed for short-term pain, like from surgery or an injury, or for use in end-of-life care. Chronic pain is a serious medical issue that is both under-treated and has limited treatment options, so it’s understandable that opioid painkillers filled that void, especially because opioids are the only source of relief for many people with chronic pain. Unfortunately, they began to be prescribed for long-term use before there were a lot of studies on their long-term effects. Now that research is catching up, this use is being questioned.

Beyond addiction, other potential problems for using opioids for chronic pain include opioid-induced hyperalgesia, tolerance and the systemic effects of long-term use. Opioid-induced hyperalgesia, when opioid use increases a person’s sensitivity to pain, is one concern. Tolerance — which requires taking increasingly higher doses of the medication for it to still be effective — is another. The repercussions of regular (and often increasingly higher) doses of opioids could have on the body’s systems should also be considered.

Headache disorders have additional issues. Rebound headache (medication overuse headache) is the most widely addressed concern. In addition, the American Migraine Prevalence and Prevention study found that using opioids more than eight times a month can cause episodic migraine to transform into chronic. (Diana Lee recently reported that there may be a difference between short-acting opioids and long-acting ones and that long-acting opioids may be OK for long-term pain management for people with chronic migraine.) Headache specialists also believe opioids impair the efficacy of preventive medications.

On top of all that, opioids aren’t even particularly effective for any type of head pain. In the video I shared last week, headache specialist Mark Green explained why:

“Part of the reason for that is there are fundamental differences in the chemistry of head pain compared to visceral pain. In the receptors subserving head pain, we really don’t have a lot of opioid receptors, so the upside for the use of opioids is rather low. That’s why we use, for example triptans and ergots. Those serotonin receptors are very well represented on those receptors that subserve headache.”

What do I get from all this?

  • Boiling down concerns about opioid use to a fear of patients becoming addicted is an oversimplification.
  • There are a lot of unknowns about opioid use for chronic pain. As more research is published, the less they seem like a good long-term solution.
  • Head pain is different than bodily pain and migraine may different still.
  • Chronic migraine isn’t a chronic pain disorder, nor are chronic cluster headaches. I don’t know where tension-type headache falls on the continuum, but I’m inclined to believe it’s more on the side of other types of headache disorders.
  • Using opioids can significantly alter treatment for an underlying headache disorder.
  • Mostly, I’m left with a lot of questions (and so are researchers and physicians).

I’m not anti-opioid, but want anyone who takes them for headache disorders to know the facts and to be very, very careful. Ideally, your headache specialist would be the prescriber, but fewer and fewer are willing to prescribe opioids (not out of fear of addiction or the DEA, but because of the ramifications for treating the condition you’re using opioids for in the first place). If your headache specialist won’t prescribe them, still be honest with them about how often you use them and at what dose — without that information, your specialist can’t treat your headache disorder properly.

Note: I’ve used words like “potentially” and “can” a lot in this post because not everyone’s the same. It’s important to be aware of the risks, but also to remember that not everyone will have all the same issues.

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Candesartan Trial (and Overlooking the Obvious)

Candesartan (Atacand), a medication for high blood pressure, has recently shown to be quite effective for migraine prevention. After writing about it for Migraine.com (Candesartan: Effective Preventive, Low Weight Gain Risk) and having the week of more severe than usual migraine pain, I finally decided to fill the prescription my headache specialist wrote for me in January.

It’s the reason I’ve been so quiet the last few weeks.

My blood pressure is normally on the low end of the healthy range. That’s great for cardiovascular health, but limits migraine prevention options. While my headache specialist won’t prescribe beta blockers because of this, candesartan works in a different way than beta blockers do, so he didn’t think it would lower my blood pressure too much.

Over two weeks of taking 4 mg candesartan each morning, I was increasingly fatigued and brain fog made writing nearly impossible. It felt a lot like I had a migraine all the time, but the pain wasn’t any worse than usual. When checking my blood pressure finally occurred to me, it was bordering on too low. Not dangerously low, but considerably lower than I was used to. Whether that was the issue or I was feeling typical side effects of the drug, I decided to stop taking candesartan*. A week later, I feel almost back to normal (my new normal, that is).

I’m very careful to monitor my symptoms when I take a new drug or try a different food, but I so often miss changes that seem like they should have been obvious. It’s funny how the mind goes with what it knows rather than making new connections. My symptoms were migraine-like, so I dug around for triggers because that’s what I always do. It took a week of significant, escalating fatigue before I considered that the drug could be the culprit, even though I thought I was vigilant in watching for adverse effects.

Candesartan wasn’t for me, but I do recommend trying it if you’re looking for a new preventive and aren’t at risk for your blood pressure dropping too low. The research is quite strong (as far as migraine preventives go) and the side effect profile is pretty minimal.

*Stopping blood pressure meds abruptly could cause a stroke. If you’re considering discontinuing yours, please talk to your doctor about the safest way to do so.

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Promising Migraine Preventive Drugs Target CGRP

Positive findings from two phase II clinical trials of promising migraine preventive medications were announced today (here’s the full press release). If these drugs make it to market, they’ll be the first developed specifically for migraine prevention.

These drugs are the first to test monoclonal antibodies for migraine prevention and both target the protein calcitonin gene-related peptide (CGRP). If those words are gibberish to you, here’s a brief introduction to CGRP and its role in migraine from James at Headache and Migraine News. (I intend to write an explanation at some point, but don’t currently have the mental ability.)

The first study included 163 people who had five to 14 days of migraine attacks each month. They either received a single IV dose of the drug, called ALD403, or a placebo*. After 24 weeks, those who received the drug had an average of 5.6 fewer migraine days a month (a 66% reduction) than before receiving the dose and 16% were migraine-free after 12 weeks. Those who received the placebo had 4.6 fewer days per month (a 52% decrease) and none were migraine-free. Side effects were the same for both groups.

The second study included 217 people who had migraine from four to 14 days per month. For 12 weeks, participants received biweekly injections of the drug, LY2951742, or a placebo. After 12 weeks, those who received the drug had an average of 4.2 fewer migraine days a month (a 63% decrease), while those who received the placebo had 3 fewer migraine days a month (a 42% reduction). Participants who received the drug were more likely to have side effects than those who received the placebo. These side effects included pain at the injection site, upper respiratory tract infections and abdominal pain. Still, the drug was considered overall to be safe and well-tolerated.

Those are definitely good early results. More, larger studies are needed to confirm the findings.

Even more than the results, I’m struck by the positive, hopeful comments from two researchers involved in the studies, both highly regarded in the field:

“These results may potentially represent a new era in preventive therapy for migraine.” –Peter Goadsby, MD, PhD, UC San Francisco

“We’re cautiously optimistic that a new era of mechanism-based migraine prevention is beginning.” –David Dodick, MD, Mayo Clinic Arizona

While not effusive, these comments echo the optimistic, hopeful attitude I’ve heard countless headache specialists use when talking about CGRP drugs. I, too, am quite hopeful for these drugs.

*The placebo effect is way oversimplified as the power of positive thinking. The process is far more intricate that “you think it will work, so it does.” It’s another topic I’m planning a post on, but I don’t know when I’ll get to it. If you’re curious to learn more, Jerome Groopman’s book The Anatomy of Hope describes it well, and Placebo Effect Stronger Than We Thought? is a good article.

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Opioids (Narcotics) for Migraine & Headache Disorders: Two Specialists Weigh In

Opioids are highly controversial in the world of headache medicine. Beyond the obvious issues of dependence and addiction, there are risks specific to headache disorders. In this short video, two headache specialists address some of the issues, including:

  • Taking opioids more than eight times a month puts a person at risk for rebound headache (also called medication overuse headache or MOH).
  • Opioids can reduce the efficacy of other migraine medications, including abortives and preventives.
  • Migraine is an inflammatory condition. Opioids may increase inflammation, counteracting any migraine relief they might provide.
  • Opioids aren’t particularly effective for head pain to begin with. The receptors of the brain associated with head pain have few opioid receptors, so there’s not much for the opioids to work on.

This is a huge, controversial topic, but the more I learn about it, the more convinced I become that opioids should be of limited use in treating headache disorders. Opioids have a place, but that place is small and specific. They shouldn’t be a front line treatment, which they too frequently are.