Category Archives for "Migraine"

Coenzyme Q10

It’s been awhile since I got a post up here on the blog.  December was a whirlwind with a trip to ASHP Midyear and Disneyland, closing on our house and moving 2 days before vacation with my family. We threw our boxes in, then headed to warm weather for a week in Key Largo.  You can find pictures about our adventures on Instagram. We celebrated Christmas with my family on Christmas Day at my sister’s new home in Lexington, KY,  and later in the week with Dustin’s family in Northeast Ohio.  We celebrated New Years Eve with our local friends and church family in our new home, and visited our college friends on New Years Day in Findlay, Ohio.  We have had our New Years Day gathering tradition for over a decade now!  So far January has been stay home and work on getting our house together and of course fight off viral gunk 🙂 Back in November,  Marina Reid, who is a DO student, rotated with me and we worked on this post together. She will be Dr. Reid in the spring and someday an anesthesiologist!  I love getting to spend a few weeks with medical students sharing my passions for diabetes care and functional medicine. CoQ10 is an amazing compound with lots of potential.  Make sure to read this post to the end!

Dr. Hartzler

 

One of the most widely sold supplements on the market is the compound with the mysterious – sounding name, CoQ101. As it turns out, this is an abbreviation for an enzyme that is found in every cell in the human body2. Logically, an enzyme so widely prevalent was given a name ‘ubiquinone’. CoQ10 describes the chemical structure of ubiquinone molecule, that is actually similar to vitamin K in structure3. ‘Co’ is short for ‘coenzyme’, ‘Q’ is for ‘quinone’ chemical group, and ‘10’ refers to the number of isoprenyl chemical subunits in the molecule4. CoQ10 is an essential molecule that participates in the rate limiting transfer from step II to step III of the electron transport chain in mitochondrial membrane to produce ATP molecules. In basic terms this means that CoQ10 is a vital part of energy production in our cells.

You may remember from high school biology class that the mitochondria are considered the powerhouse of the cell.  Organs such as the heart, liver, and kidneys are packed with mitochondria. Unfortunately, with age5 or certain disease states,6 our bodies get depleted of this essential enzyme and those vital organs suffer the most.

The role of CoQ10 in treatment of ischemia (inadequate blood supply to the heart) and congestive heart failure has been widely supported by the research. Q-SYMBIO was a prospective, randomized, double-blind, placebo controlled multicenter study that showed that patients treated with CoQ10 supplementation had significant reduction in cardiovascular death, all-cause mortality and heart failure hospitalizations7. There are reports that also show the improvement of cardiac function in transplant patients with CoQ10 supplementation8. CoQ10 supplementation can be especially beneficial for pediatric9 and postpartum patients10 with dilated cardiomyopathies (enlarged hearts). The exact mechanism of this cardio-protective function is still to be determined. Suggested mechanisms include stabilization of mitochondrial membranes and prevention of cell death,11 and prevention of damage to the lining of the blood vessels12 which may be contributing to restoring delicate balance in heart failure patients.

Another widely accepted use for CoQ10 supplementation is the prevention of muscle pain associated with a common prescription medication class called “statins” that are used for cholesterol reduction and secondary prevention of heart attacks. Both CoQ10 and cholesterol production share a common pathway, this pathway gets inhibited by statin drugs4, so not only do statin drugs slow cholesterol production, they also deplete CoQ10.

Since CoQ10 is an essential molecule for energy production, it’s depletion may contribute to one of the most common side effects of statin medications, muscle pain, also known as myopathy. Hence, taking CoQ10 supplements while taking statins may prevent the negative side effects.14 In addition, CoQ10 has been shown to lower blood pressure in several controlled studies. One study reduced Systolic Blood Pressure (SBP, the top number) by 17 mmHG!15. 

As a potent anti-oxidant, CoQ10 has been also shown to decrease the frequency and severity of migraines16,17.  This is a really exciting area of exploration, considering how debilitating migraines can be.  There are also several other uses that are being currently investigated: fibromyalgia pain18, depression in patients with bipolar19, skin texture improvement20, and Parkinson’s disease21.

Since CoQ10 is an endogenous molecule produced by our bodies, getting too much is highly unlikely even in high doses.21 Mild side effects reported include nausea, vomiting, and diarrhea12. It has to be administered with caution in patients on warfarin or chemotherapy due to the risk of drug interactions12. Always disclose supplements to your healthcare providers so they can work with you to make the best decisions for your health! 

Based on this review of the literature, the current recommended doses are listed below.

  • 100-300 mg daily for Congestive Heart Failure (CHF)12
  • 100 mg per day for high blood pressure15 statin induced myopathy14 and migraine prevention16,17

Lastly, as always, if you are going to add any supplement to your regimen for you or a patient, make sure it’s from a high-quality source.  Here are a couple of my favorite CoQ10 products. FullScript is an amazing resource with all kinds of reputable supplement manufacturers.

 

References

  1. Bronzato S, Durante A. Dietary Supplements and Cardiovascular Diseases. Int J Prev Med. 2018;9:80. Published 2018 Sep 17. doi:10.4103/ijpvm.IJPVM_179_17
  2. Tran UC, Clarke CF. Endogenous synthesis of coenzyme Q in eukaryotes. Mitochondrion. 2007;7 Suppl(Suppl):S62-71
  3. Hemmi N. Bhagavan & Raj K. Chopra (2006) Coenzyme Q10: Absorption, tissue uptake, metabolism and pharmacokinetics, Free Radical Research, 40:5, 445-453, DOI: 10.1080/10715760600617843
  4. Mikael Turunen, Jerker Olsson, Gustav Dallner, Metabolism and function of coenzyme Q, Biochimica et Biophysica Acta (BBA) – Biomembranes, Volume 1660, Issues 1–2, 2004,Pages 171-199, ISSN 0005-2736, https://doi.org/10.1016/j.bbamem.2003.11.012. (http://www.sciencedirect.com/science/article/pii/S0005273603003717)
  5. Del Pozo-Cruz, Jesús & Rodriguez Bies, Elizabeth & Ballesteros, Manuel & Enamorado, Ignacio & Bui Thanh, Tung & Navas, Placido & Lopez-Lluch, Guillermo. (2014). Physical activity affects plasma coenzyme Q10 levels differently in young and old humans. Biogerontology. 15. 10.1007/s10522-013-9491-y.
  6. Chase M, Cocchi MN, Liu X, Andersen LW, Holmberg MJ, Donnino MW. Coenzyme Q10 in acute influenza. Influenza Other Respi Viruses. 2018;00:1-7 https://doi.org/10.1111/irv.12608
  7. Mortensen SA, Rosenfeldt F, Kumar A, Dolliner P, Filipiak KJ, Pella D, et al. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial. JACC Heart Fail. 2014;2(6):641–9. https://doi.org/10.1016/j.jchf.2014.06.008.
  8. Karl Folkers, Peter Langsjoen, Per H. Langsjoen,Therapy with coenzyme Q10 of patients in heart failure who are eligible or ineligible for a transplant, Biochemical and Biophysical Research Communications, Volume 182, Issue 1, 1992, Pages 247-253,ISSN 0006-291X,https://doi.org/10.1016/S0006-291X(05)80137-8.
  9. Chen, F.-L.; Chang, P.-S.; Lin, Y.-C.; Lin, P.-T. A Pilot Clinical Study of Liquid Ubiquinol Supplementation on Cardiac Function in Pediatric Dilated Cardiomyopathy. Nutrients2018, 10, 1697
  10. https://www.drkarafitzgerald.com/2018/09/04/dr-stephen-sinatra-past-present-future-integrative-cardiology/
  11. Haas RH. The evidence basis for coenzyme Q therapy in oxidative phosphorylation disease. Mitochondrion 2007;7 Suppl:S136–45. https://doi.org/10.1016/j.mito.2007.03.008
  12. Sharma A, Fonarow GC, Butler J, Ezekowitz JA, Felker GM. Coenzyme Q10 and heart failure: a state-of-the-art review. Circ Heart Fail. 2016;9(4):e002639. https://doi.org/10.1161/ CIRCHEARTFAILURE.115.002639.
  13. https://www.lifeextension.com/magazine/2008/2/Alleviating-Congestive-Heart-Failure-With-Coenzyme-Q10/Page-01
  14. Caso G, Kelly P, McNurlan MA, Lawson WE. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol. 2007;99:1409–1412.
  15. Yang Y-K, Wang L-P, Chen L, et al. Coenzyme Q10 treatment of cardiovascular disorders of ageing including heart failure, hypertension and endothelial dysfunction. Clinica Chimica Acta; International Journal Of Clinical Chemistry. 2015;450:83-89. doi:10.1016/j.cca.2015.08.002.
  16. Shoeibi A, Olfati N, Soltani Sabi M, Salehi M, Mali S, Akbari Oryani M. Effectiveness of coenzyme Q10 in prophylactic treatment of migraine headache: an open-label, add-on, controlled trial. Acta Neurologica Belgica. 2017;117(1):103-109. doi:10.1007/s13760-016-0697-z.
  17. Elyas Nattagh-Eshtivani et al. The role of nutrients in the pathogenesis and treatment of migraine headaches: Review, Biomedicine & Pharmacotherapy, Volume 102, 2018, Pages 317-325, ISSN 0753-3322, https://doi.org/10.1016/j.biopha.2018.03.059.
  18. Cordero MD, Santos-García R, Bermejo-Jover D, Sánchez-Domínguez B, Jaramillo-Santos MR, Bullón P. Coenzyme Q10 in salivary cells correlate with blood cells in Fibromyalgia: improvement in clinical and biochemical parameter after oral treatment. Clin. Biochem. 2012 Apr;45(6):509-11 https://doi.org/10.1016/j.clinbiochem.2012.02.001.
  19. Mehrpooya M, Yasrebifar F, Haghighi M, Mohammadi Y, Jahangard L, Elevating the Effect of Coenzyme Q10 Augmentation on Treatment of Bipolar Depression: A double-blind controlled clinical trial. Journal of Clinical Psychopharmacology 2018 Oct;38(5):460-466
  20. Knott,A.;Achterberg,V.;Mielke,H.;Sperling,G.;Dunckelman,K.;Vogelsang,A.;Kruger,A.;Schwengler,H.; Behtash, M.; Kristof, S.; et al. Topical treatment with coenzyme Q10-containing formulas improves skin’s Q10 levels and provides antioxidative effects. Biofactors 2015, 41, 383–390. https://doi.org/10.1002/biof.1239
  21. Mischley L, Lau R, Bennet R, Role of diet and Nutritional Supplements in Parkinson’s Disease Oxidative Medicine and Cellular Longevity, Volume 2017, Article ID 6405278, 9 pages https://doi.org/10.1155/2017/6405278
  22. K.Ferrante, et al, Tolerance of high-dose (3,000 mg/day) coenzyme Q10 in ALS. Neurology Dec 2005, 65 (11) 1834-1836; DOI:10.1212/01.wnl.0000187070.35365.d7.

 

 

1 Natural Approaches to Migraine: Part 1

I had the opportunity to host another pharmacist, Christine Lewis, over the last few weeks at my practice site. Dr. Lewis is actually doing a residency in Arizona but has a huge passion for functional medicine and heard me speak at the ASHP Midyear Clinical Meeting last December and called me up and asked if she could do a rotation at my site. She is also working on an elective in functional medicine for the pharmacy school there. It’s exciting to see more and more pharmacists engage with this type of practice. I was flattered that she wanted to come out to my small practice in Ohio (she didn’t know it was going to snow in April before she signed up!). This month as part of her projects, she put together a two part series for you on migraines. Enjoy and stay tuned for part 2!

Dr. Hartzler

Migraine headaches are a debilitating condition that affects as many as 12% of the US population (1). Migraines are more common among women than men and occur more frequently between the ages of 18-44 (2). Migraine headaches typically are one-sided, pulsating, aggravated by daily routine activity, and can vary in duration from 2-3 hours to days (3f).

The Headache Society guidelines, which are what many providers refer to when treating patients, recommend anti-seizure medications and beta-blockers (blood pressure/heart medication) for migraine prevention and a class of medications called triptans and non-steroidal anti-inflammatory medications (like ibuprofen) for acute symptoms (4). While these agents have been shown to be effective, these agents come with side effects including mood changes, nausea, dizziness, and fatigue (5). Not to mention there are many drug-drug interactions with anti-seizure medications.

Fortunately, a 2012 update to the guidelines include evidence supporting alternative therapies (such as supplements) that are effective at prevention of migraines (6). In my experience many providers are not aware of this update and routinely still only recommend pharmacologic methods for migraine prevention. Some providers may recommend their patients to keep a migraine diary so that potential triggers can be identified. While the migraine diary is good advice, the guidelines treat all patients suffering from migraines similarly. Biologically we are all unique with differences in genetics, environments, exposures, diet, lifestyle, etc. thus having different factors affecting the etiology of migraines.

Functional and natural approaches to  migraine headaches include to identify the root cause. Three people may have migraines, but they could have different underlying root causes. One person could have a food sensitivity or allergy, one could have a magnesium deficiency, and one may have hormone imbalances. For providers it’s important to gather a patient’s history that includes environment, toxin exposure, diet, stress management, and lifestyle as well as requesting appropriate laboratory assessments to determine each patient’s underlying cause of migraine headaches.

Common causes of migraine headaches
Food sensitivities/ intolerances/ or allergies:
Food sensitivities intolerances, and allergies are common and can contribute to disease by causing chronic inflammation. Common food culprits include gluten, eggs, soy, dairy, or peanuts (7). Many patients may not realize that they have a sensitivity to a food group until that group is eliminated and later reintroduced. If you are a follower of this blog, you have read about leaky gut and why the number of people with food sensitivities is increasing.

Nutrient deficiency:
Nutrient deficiency is thought to cause migraines in some patients such as magnesium deficiency or some b-vitamin deficiencies. Magnesium deficiency is prominent. In 2005 over 48% of the population did not consume enough magnesium in their diet (9). Even if you do eat healthy and have lots of fruits and vegetables in your diet you still may be deficient in certain vitamins, minerals, and phytonutrients. This is due to nutrient depleted soil, because decreased crop rotation, the use of pesticides, GMO’s, and the lack of animals fertilizing the soil. Vegetarians and vegans may be more susceptible to nutrient deficiencies for multiple reasons but should be cautious of B-vitamins, magnesium, calcium, and iron.

Stress:
As we get busier and busier in our day to day our bodies are vulnerable to becoming chronically stressed. Those of us that have recently lost a loved one, moved, changed jobs, have other health conditions are more susceptible to adrenal fatigue or dysregulation of the stress response in our system. During the stress response the body produces more cortisol. While we need cortisol to handle stress and engage the fight or flight response, chronically elevated levels of cortisol can cause headaches and have other adverse effects on our health as well (10).

Hormone imbalance:
Stress, sedentary lifestyle, high sugar intake can all affect hormone balance negatively. When hormones become unbalanced it can trigger migraine headaches. Some women only experience headaches in premenstrual times demonstrating that for some, migraines are caused by hormone imbalances. Some studies have found that estrogen is possibly effective at the prevention of migraines (6). Evidence to support only using estrogen therapy alone is not strong and may not be appropriate for everyone. Hormone replacement therapy should be personalized and should be balanced for optimal outcomes. Other women may be deficient in other hormones other than estrogen such as progesterone or testosterone which can also contribute to headaches (11).

Other:
Other causes of migraine headaches for some may be blood glucose dysregulation, electrolyte imbalances, inadequate sleep, infections, high sodium intake, decreased hydration, and vasoactive foods such as chocolate, cheese, citrus, and alcohol (7).

Stay tuned later this week for Part 2 which includes natural treatment approaches and supplements.

References:

  1. About migraine. Migraine Research Foundation.http://migraineresearchfoundation.org/about-migraine/migraine-facts/. Accessed April 5, 2018.
  2. QuickStats:Percentage of Adults Aged ≥18 Years Who Reported Having a Severe Headache or Migraine in the Past 3 Months, by Sex and Age Group — National Health Interview Survey, United States, 2015. MMWR Morb Mortal Wkly Rep 2017; 66:654. DOI: http://dx.doi.org/10.15585/mmwr.mm6624a8
  3. Headache disorders. World Health Organization. http://www.who.int/mediacentre/factsheets/fs277/en/ Updated: April 2016. Accessed April 5, 2018.
  4. Loder E, Burch R, Rizzoli P. The 2012 AHS/AAN guidelines for prevention ofepisodic migraine: a summary and comparison with other recent clinical practice guidelines. Headache. 2012 Jun;52(6):930-45.
  5. He A, Song D, Zhang L, Li C. Unveiling the relative efficacy, safety and tolerability of prophylactic medications for migraine: pairwise and network-meta analysis. The Journal of Headache and Pain. 2017;18(1):26. doi:10.1186/s10194-017-0720-7.
  6. Holland S, Silberstein SD, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1346-1353. doi:10.1212/WNL.0b013e3182535d0c.
  7. Gaby, AR. Migraine. Nutritional Medicine, 2ndEdition. Concord, NH: Fritz Perlberg Publishing; April 2017.
  8. Żukiewicz-Sobczak WA, Wróblewska P, Adamczuk P, Kopczyński P. Causes, symptoms and prevention of food allergy. Advances in Dermatology and Allergology/Postȩpy Dermatologii I Alergologii. 2013;30(2):113-116. doi:10.5114/pdia.2013.34162.
  9. Andrea Rosanoff, Connie M Weaver, Robert K Rude; Suboptimal magnesium status in the United States: are the health consequences underestimated? Nutrition Reviews, Volume 70, Issue 3, 1 March 2012, Pages 153–164, https://doi.org/10.1111/j.1753-4887.2011.00465.x.
  10. Ramachandran R. Neurogenic inflammation and its role in migraine. Semin Immunopathol. 2018 Mar 22.
  11. Li W, Diao X, Chen C, Li C, Zhang Y, Li Y. Changes in hormones of the hypothalamic-pituitary-gonadal axis in migraine patients. J Clin Neurosci. 2018 Apr; 50:165-171.

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