January 14, 2018 at 1:03 pm #1072Monica DurigonParticipant
Chronic migraines and headaches; fatigue; bloating; constipation; tingling and numbness (arms and legs) after short periods of rest.
GI: present concerns
Feeling full after a small amount of food
Severe constipation (movements every 4-5 days)
She used to suffer from stomach pain but that has reduced since she followed a low FODMAP diet and continued a diet gluten and dairy free and low in refined and simple sugars (she is still having fruit, mainly domestic, dates and a little honey or maple syrup).
She identified that she cannot tolerate the following foods:
Coconut, avocado, gluten grains, pea protein
She can tolerate the following in small amounts:
Lentils and chickpeas and cauliflower
She is on the above restrictions since June except for when she was on holiday when she “ate everything” and had stomach pain, felt bloated, heavy, lethargic and had a puffy face.
The problems with her GI started in 2015 after a holiday in Italy. After a dinner in a restaurant, many guests felt sick so much so that they couldn’t fly back home.
She had severe diarrhoea, vomit, temperature – it took her 3 weeks to recover – no antibiotic taken, no stool test, no blood test.
In May 2017, before she came to see me, she had already carried out the following tests:
Coeliac screen negative with DQ8 positive, DQ2 negative
Extensive IgE screening for food and aeroallergens which came back negative
After our first appointment, I recommended a GI effect comprehensive stool test but she couldn’t afford it. I recommended that she saw a private gastroenterologist (through her private insurance to assess her gut for any infections.
I also recommended a SIBO test which she managed to do through allergist.
Hydrogen Lactulose Breath test was negative
The Stool test MC&S negative, no evidence of Giardia, Cryptosporidium or E.coli; fecal calprotectin less than 15.
At the beginning of September when she came to see me for her first appointment, my client had just has stopped taking Amitriptyline which was prescribed to her by her neurologist in May 2015 – for the treatment of her migraines – she felt that it was making her feel “vacant” and worsen her memory and she became chronically constipated.
By the time she saw her gastroenterologist (November 2017) the constipation has worsen ( “ can Amitriptyline have long term side effect of constipation?) with movements every 4/5 days
The following examination were carried out:
Abdominal x-ray to assess for faecal loading:
There was formed faecal residue throughout the large bowel. No evidence of
obstruction. The small bowel gas pattern is normal.
An IUCD was noted in the pelvis. No other abnormality.
The gastroenterologist has subsequently recommended the following:
Dulcoease one tablet Mondays to Fridays, with Dulcolax on Fridays and Saturdays
Followed by 1month supply of Prucalopride 2mg once daily.
My client has just started on the Dulcoease- worked well
Prucalopride was not tolerated. Resulted in a severe migraine that did not respond to any strong prescription migraine medication and lasted for three days and the client decided to stop taking it.
Re: feeling exhausted, difficult to get going the am, history of thyroid disease in the family ( sister has thyroid cancer and suffering from Hashimoto’s)
Various blood test were conducted through a private endocrinologist, since last year to assess her thyroid health
Latest results (November 2017 ) as follow:
HbA1c 29 normal
Thyroid function test:
FT4 11.5 9.00 -22.00
FT3 3.48 2.63-5.70
TSH 2.63 0.35-4.94
CRP 0.6 0.0 -10
TPOab 4 0-35
TGab 11 0-40
From autoantibodies screening the only marker which was positive was the
The endocrinologist told her that in February he will retest for the Anti-adrenals abs.
I have recommended an assessment of adrenal function with a Comprehensive adrenal salivary test by Genova.
Since her migraines seemed to be related to her menstrual cycle (she has migraines before and after her period), (I’m not sure of this anymore) the endocrinologist also assessed the following marker:
FSH – LH- estradiol and progesterone all within the luteal normal reference range
Testosterone 0.90 0.45-2.50
SHBG 67 22-126
Free androgens Index 1.3 0.4-8.0
DHEA Sulphate 4.6 1.9 -9.4
She came off the OCP in 2015 and had a copper coil inserted in October 2015. Her period is regular with heavy bleeding mid way through for 3 days and lasts 6 days in total. Feeling very angry around period.
Migraines/headaches started 8 years ago in 2009 when she moved to Barcelona. It was a very stressful period/ on her own/no friends/ all new/ no language/felt alone and stressed.
It started with something that felt like sinus congestion but she had it checked and her sinuses were clear.
Headaches started to come frequently 2 x week then progressed to daily headaches which sometimes becomes migraines.
She is still suffering from daily headache.
She still suffers daily from a mild facial pain on the right side of her face – the pain is always there; she also has very often a clumping pain at the back of her neck. She used to see an osteopath for some manipulation but it didn’t work and it made the pain worst. She also tried a physio therapist and acupuncture (4 months) but these didn’t help either .
She has mild scoliosis (upper part of the back)- no back pain – only pain in the shoulder and back of neck areas –
The only relief from this pain was when she was taking the high dosage of amitriptyline
She has been seen by a neurologist for the last 18 months
When she has a migraine, she needs to rest but sometime being busy also helps if it is mild – but usually she needs to lay in bed – not sleep though as this can make it worst.
If having too much sleep (>8 hours) this can cause a migraine, or a headache, foggy brain, and puffy face – she noticed this since start taking the amitriptyline (2 years ago) – she stopped the amitriptyline since this September
She almost has a warning before the headache develops, almost like an out of body experience – the body goes tired/exhausted and the connection between the body and the brain is slower – she feels heavy and it is difficult to speak – her throat become painful…a strange feeling -achy to speak
In October 2015 three wisdom teeth were removed – she suffers from TMJ pain and she has been given a mouth-guard but she doesn’t want to wear it as it makes the pain worst. Her father also suffers from migraines, headaches and trigeminal neuralgia.
Exercise resolves the headaches and migraines – run and spinning – makes it temporary better but three hours later the pain will come back –
She has noticed that since our first appointment her migraines have decreased in intensity and frequency but the headaches are still daily and they can last all day.. .she is not medicating for them.
Have been advised by endocrinologist, neurologist and GP to start on low dose of propranolol. Would prefer to avoid if possible.
Other markers checked in November 2017 :
FBC all within reference rages
Haematology all within reference ranges
Vitamin D3 77
GGT low at 6 (9-36)
Iron 24.4 (8.00 – 25.00)
Ferritin low @ 16 (5-204)
B12 577 (187-204)
Red folic acid 236 (180-750)
Ferritin was found previously very law and I recommended some iron supplements for 8 weeks, a non- constipating formula ( 1 x day providing 20mg elemental iron per day ) but this results still show low ferritin with normal circulating iron
After the first consultations at the beginning of September, we discussed importance of maintaining balanced blood sugar levels and to manage migraines pain and frequency I recommended: PHASE I
Eliminate:Foods that contains vasoactive amines Chocolate, Alcohol, especially beer wine (especially red wine), Citrus fruit, Shellfish – she also dairy free
Introduce: Daily fresh ginger (anti-inflammatory properties and reduce platelet aggregation (one of the possible mechanism triggering a migraine)
Increase:Oily fish consumption to at least 3 x week -The Omegas3 in fish have anti-inflammatory properties and contribute to decrease platelets aggregation
Decrease: Animal fats (meat) as it contains arachidonic fat, which is pro-inflammatory.
Ideally buy meat from grass fed bovine and organic chicken (avoid corn fed chicken)
Continue to avoid: Dairy, sugar, gluten containing grains and products, and the legumes that you she has identified as a problem.
I have improved the qualities of snacks and meal adding more protein which wasn’t high enough
Added some post work-out smoothies for better recovery/energy
Supplements recommended: EPA and DHA , Vitamin B6 –P5P Vitamin B complex with L- Theanine, chromium and folic acid, B12- Migran x- Mg chelate – aloe vera – thriphala
The client was so exhausted that 2 weeks ago she stopped all supplements because she forgot to take them, however she thinks that since she has stopped them she feels less tired.
She is only taking the fish oil , the aloe vera and the Triphala now.
She contacted me at the beginning of November to tell me that she noticed that her tingling sensation and her numbness was increased and was more frequent happening also during the day, I did recommend that she stopped taking the B6, although she was only on 20mg daily; she still feel that sensation but less so …I wonder though if this is due more to poor circulations as when she was exercising more regularly this was minimum. This has increased again- everyday and every night.
Her migraines have decreased in frequency and intensity since following the dietary advice but she still suffers from daily headaches.
Her tiredness and fatigue has improved slightly since stopping the supplements and she is now starting to exercise again (yoga, body pump, swimming and spinning)
Constipation is at its worst since stopping the magnesium but she is starting to take the medications recommended by her gastroenterologist. Apologies for the length of this case but I believe that the details were important to build a comprehensive picture of this complex case. Your advice most appreciated. Thank you!
Posted By Monica Durigon 14/1/2018
March 6, 2019 at 1:07 pm #1073Christine BaileyModerator
Many thanks for your detailed case history of your client. You have mentioned a number of ongoing concerns – constipation, headaches ongoing although the migraines have decreased slightly, tiredness although this has recently improved as well. She also appears to have ongoing tingling sensations.
With regards to the constipation I appreciate that the medication from the consultant will help but it is not, however, a long term solution for this client. There can be many underlying factors involved with constipation and many of these you have investigated such as thyroid function, hormone health as well as food sensitivities. Restoring a healthy gut microbiome can be helpful for normal peristalsis particularly Bifidobacterium spp so the addition of the prebiotic and probiotic may be something to consider.
Dimidi et al. The effect of probiotics on functional constipation in adults: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr 2014, doi: 10.3945/ajcn.114.089151 https://tinyurl.com/oe8w92d
In many cases poor bile flow can be linked to constipation so I would consider looking a supporting bile flow with a supplement. Ongoing constipation can also influence the detoxification of toxins including endotoxins which can of course result in foggy head or headaches so ensuring daily bowel movements would be beneficial for this client. You mention that a stool test was conducted but I am not clear whether this is a comprehensive stool test – ie do you suspect there is still an ongoing gut infection in view of her health history? In addition, while she has identified a number of foods she appears sensitive too there may be other reactions and in this case array 10 Cyrex may be useful. Of course, there are other reactions such as salicylates, amines, histamine that may also be relevant. In some cases these are linked to gut dysbiosis and / or insufficient digestive function.
You mentioned she is complaining of tingling sensations – if this is linked just to the hands and arms this could actually be linked to other conditions such as carpal tunnel. Have you considered whether she is struggling with a viral infection for example which may be contributing to the ongoing tiredness and tingling sensations? It may be helpful to run a comprehensive viral screen to confirm.
Yes, vitamin B6 can be helpful but normally only where there is a deficiency, and at 20 mg it is not likely to be causing neurological symptoms. You could therefore consider a vitamin and mineral screen by Biolab to check levels of all B vitamins and other nutrients.
Fuhr JE, Farrow A, Nelson HS, Jr. Vitamin B6 levels in patients with carpal tunnel syndrome. Archives of surgery (Chicago, Ill. : 1960). Nov 1989;124(11):1329-1330. https://tinyurl.com/ybeofdec
If the tingling sensations is linked to nerve inflammation then Alpha-lipoic acid (ALA), an anti-inflammatory agent and powerful free radical scavenger, may be helpful. Other supplements to consider would be turmeric formulas and omega 3 fats.
Mijnhout GS, Kollen BJ, Alkhalaf A, Kleefstra N, Bilo HJ. Alpha lipoic Acid for symptomatic peripheral neuropathy in patients with diabetes: a meta-analysis of randomized controlled trials. International journal of endocrinology. 2012:456279. https://tinyurl.com/yb5ct7dq
With regards to her headaches it appears that her medication is helpful. The triptan drugs (e.g., sumatriptan, rizatriptan, eletriptan, and almotriptan) act on several specific mechanisms of a migraine headache, such as promoting vasoconstriction and blocking pain pathways in the brainstem. Triptans mediate these effects by activating certain serotonin receptors in cranial blood vessels
Ironically, taking too much migraine prevention medication for too long can lead to “medication overuse headache”. Medication overuse headache can become a chronic, self-perpetuating condition called “chronic daily headache”, in which patients experience daily headaches caused by medication overuse, but continue to use medication to relive the headaches. To prevent medication overuse headache, migraine patients should (on average) limit use of NSAIDs to 15 or fewer days a month and limit triptan or over-the-counter combination analgesic use to 9 or fewer days a month – do you suspect this may be a factor in view of her history? Perhaps attention to detoxification may be helpful
Young WB. Medication Overuse Headache. Curr Treat Options Neurol. 2001 Mar;3(2):181-188. https://tinyurl.com/yahdp37s
She has clearly noticed improvements with dietary changes. Avoidance of food allergies and/ or sensitivities may reduce or eliminate migraine symptoms and in addition there are other triggers to consider.
Monosodium glutamate (MSG) is a commonly used flavour-enhancer found in some soups and Chinese food.
Nitrites are preservatives found in processed meats such as hot dogs.
Tyramines are natural compounds found in wines and aged foods (e.g., cheeses).
Phenylethylamine is a stimulant compound found in chocolate, garlic, nuts, raw onions, and seeds.
Many of these nutritional migraine triggers have vasoactive properties (causes constriction or dilation of blood vessels) which is why they may contribute to migraine attacks.
Other potential dietary triggers include cow’s milk, wheat, eggs, alcohol, artificial sweeteners, citrus fruits, pickled products, and vinegar
Fukui PT, GonçalvesTR, Strabelli CG, et al. Trigger factors in migraine patients. Arq Neuropsiquiatr. 2008;66(3A):494-9. https://tinyurl.com/yay9frlk
While you have already suggested various interventions nutritionally there are a couple of others you could consider.
Butterbur – Butterbur extracts possess analgesic, anti-inflammatory, anti-spasmodic, and vasodilatatory properties, which may explain their efficacy for migraine prevention
Pothmann R, Danesch U. Migraine prevention in children and adolescents: results of an open study with a special butterbur root extract. Headache. 2005;45(3):196-203. https://tinyurl.com/yb45n7a3
CoQ10 (at doses of 100-300 mg daily) has been shown to be beneficial for preventing and reducing the frequency of migraine attacks among adults. These actions are attributed to CoQ10’s potential to interfere with inflammatory mechanisms and mitochondrial dysfunction, both of which have been implicated in the migraine process
Slater SK, Nelson TD, Kabbouche MA, et al. A randomized, double-blinded, placebo-controlled, crossover, add-on study of CoEnzymeQ10 in the prevention of pediatric and adolescent migraine. Cephalalgia. 2011;31(8):897-905. https://tinyurl.com/yaomqw2j
Riboflavin (i.e., Vitamin B2) contributes to cell growth, enzyme function, and energy production. One study involving 23 participants showed that supplementation with 400 mg riboflavin daily reduced headache frequency by an impressive 50% at three months, with improvement persisting through six months
Boehnke C, Reuter U, Flach U, Schuh-Hofer S, Einhaupl KM, Arnold G. High-dose riboflavin treatment is efficacious in migraine prophylaxis: an open study in a tertiary care centre. Eur J Neurol. 2004;11(7):475-477. https://tinyurl.com/gpj7d7x
Magnesium levels are often low in people with migraines / headaches. Furthermore, magnesium deficiency can trigger cortical spreading depression (CSD), platelet aggregation, vasoconstriction, and substance P release; all of which are have been implicated in migraine pathology. A dosage of 600 mg of magnesium daily has been shown to be effective for the prevention of migraine attacks
Koseoglu E, Talaslioglu A, Gonul AS, Kula M. The effects of magnesium prophylaxis in migraine without aura. Magnes Res. 2008;21(2):101-108. https://tinyurl.com/y9hgew87
So, there may be some additional tests that could be helpful in identifying underlying triggers as well as dietary modifications. I would also suggest a 2-4 week detox dietary approach avoiding common trigger foods and supporting detox pathways with supplement support
The following supplements are suggested for you to consider in light of your relevant expertise and intimate understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Bowel movements and detox support
Lipid-X (BRC)(magnesium oxide) – take 2-4 daily
Securil (prebiotic) (ARG) – take caps after dinner (evening meal) – https://tinyurl.com/zwsz6mb
BifidoBiotics with L. sporogenes (ARG) – take 2 daily
Beta Plus (BRC) – take 1-2 with each meal (bile support) – https://tinyurl.com/hskrbum
Pro Greens (ARG) – take 1 scoop daily – https://tinyurl.com/gtqgbyo
Acetyl-Glutathione (ARG) – take 1 daily – https://tinyurl.com/gvh7csc
ALA Release (ARG) – 1-2 tabs with breakfast & dinner – http://tinyurl.com/hp72kvl
Enhanced Antiox Formula (ARG) – take 1 twice daily
For Migraines (specific formulas providing CoQ10, Riboflavin, Butterbur, Feverfew, Magnesium)
MigranX (BRC) – 1-2 caps twice daily (or even higher dose) – http://tinyurl.com/y8c5vggf
Low dose, but active form B vits
Bio-3B-G (BRC) – take 2 at each meal
I hope this helps with your client
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