The Keeler Migraine Method
A Groundbreaking, Individualized Treatment Program from theRenownedHeadache Clinic
A revolutionary and scientifically backed prevention and rescue treatment plan for migraine attacks.
More than 30 million people suffer from debilitating headaches. Yet our understanding of the science behind migraines is still in its in-fancy. At the Keeler Center for the Study of Headache, Dr. Robert Cowan and his team of specialists conduct some of the most cutting-edge research in the field. Their treatment program, which combines the latest alternative and conventional therapy strategies, has helped thousands of sufferers manage their symptoms effectively and regain control of their lives.
As Dr. Cowan explains, each patient presents unique sets of triggers and pain patterns and requires a customized treatment approach. The Keeler method helps migraine sufferers identify their own headache triggers and then create an individualized formula for dramatically decreasing the frequency and severity of these attacks. It also illustrates how to design a foolproof, reliable “rescue” plan when necessary, and offers surprising information, such as:
· Why elimination diets and “foods to avoid” lists may not work
· Why frequently prescribed medications can actually make a headache worse
· Why many headache treatments stop working over Time
With a step-by-step program and expert advice throughout, The Keeler Migraine Method will be the most comprehensive guide to migraine management in the bookstore.
The Keeler Method for Migraine Management
She sat across the desk from me, her arms and legs crossed, wearing an expression I could describe only as hostile. For more than thirty of her forty- four years, she had dealt with a long line of doctors for her headaches, and I was just the latest. So far, all I had done was introduce myself, and already I was in trouble. It didn’t help that she looked a lot like my fourth- grade teacher. For a second, I thought about having her change into a gown in case she was packing a weapon. “Do you have a headache today?” I asked her, instead. “I can turn down the lights if you like.”
She glared a moment longer, sizing me up. “I have a headache every day. But yes, that would be very nice.” Her expression softened a bit. “I hate the fluorescents.”
“Me too,” I commented as I flicked the switch, “especially when I have a migraine.”
She uncrossed her arms.
“You get headaches?”
Her resistance melted away as I explained to her, apparently for the first time, why fluorescent lights bother migraine sufferers, even when we don’t have a headache. I told her that certain shades of sunglasses work better than others for light sensitivity, and mentioned that some recent research in Japan suggests that specific preventives are better for people with severe light sensitivity. She and I were developing what we doctors call a therapeutic relationship, meaning we were finding a common ground where we could work together on her headaches.
At least for the moment, she suspended the defenses that she’d developed during a lifetime of trying to convince doctors, coworkers, and even family members that her headaches are real, serious, and important. Over the next several months, we reworked some aspects of her lifestyle, changed her medication strategy, and gently educated her employer and her family. While she had suffered daily headaches and missed an average of four workdays per month, we reduced that to one weekly headache that she treated early and effectively with a different rescue medication.
Her case is pretty typical of the results we see at the Keeler Center, but every treatment plan we create is unique, custom fitted to each individual patient. That, in a nutshell, is why the Keeler plan is so successful. When I tell patients that I, too, get headaches, it is not a ploy to gain their trust or sympathy (though this is often a beneficial consequence). I mention it as a simple reality. The fact is, I get migraines. Some days I may have to cancel their appointments because I have a headache.
Migraines are just part of my world, and I have had some really bad ones. I know how they feel, how they can ruin too many days and can dominate your life. Like most migraine sufferers, I have tried on occasion to work through a migraine and ended up making a mess of things. During migraines, I have made bad decisions, missed major family events, gotten into fights with my wife, been short with my kids, and even thrown up in my host’s bathroom once or twice. Twenty- five years ago, I even considered dropping out of medical school because of my headaches. I practice what I preach and, now, I doubt that I miss more than one or two days a year because of a headache. Today, for the most part, I know what causes my headaches, how to avoid them, and how to treat them when avoidance doesn’t work. With the help of my patients, my research, and the many scientists and clinicians with whom I work, I have gotten a lot better at managing my own migraines, and most of these incidents are just painful memories. Now my headaches are a footnote rather than the focus of my life. And while the plan you develop with the Keeler Method will likely be different from mine, it should do the same for you as it has for me.
A Migraine Cure?
I would love to have titled this book The Migraine Cure, but the reality is, we’re not there yet. Both patients and practitioners tend to look for and latch on to the notion of a cure, that one thing that will make it all go away. That is why there is such a proliferation of books, articles, and websites claiming to offer “the cure”:
“Heal Your Headaches with Magnesium!”
“Magnets Cure Migraines!”
“Eat Away Your Headaches!”
“Pilates for Headache Health!”
The list is endless. Any one of these approaches may be perfect for a given patient, but in twenty- five years of caring for headache patients (fifty years, counting caring for myself), I have studied— and tried— dozens upon dozens of miracle cures. But I still get headaches and, unfortunately, so will you. The reality is, there is still no cure. A cure would not stay a secret for long. If we had a one- size- fits- all solution to headaches, it wouldn’t be buried in a back- page ad in the National Enquirer, you wouldn’t need to search the Internet for it, and you wouldn’t hear it from your aunt in Omaha. Thirty million of us suffer from migraines, so a cure would be on the front page of The New York Times, Matt Lauer would be talking about it on the Today show, and the Internet would be lit up with references to major medical journals.
Brains are complicated, and so are the conditions that affect them. If every headache sufferer had the same triggers, responded the same way to every medication, and had readily predictable headaches, migraine management would be easy. It isn’t. Still, I have yet to meet the headache sufferer who, with the help of the Keeler plan, does not experience a significant improvement in quality of life, usually through a reduction in the number, severity, and duration of headaches. That’s why I wrote this book— because all headache patients are unique, and so are their headaches. This book will help you identify your unique migraine characteristics and teach you how to use this information to better manage your headaches.
Procrustes, the son of Poseidon, invited weary travelers to rest at his inn, and then broke their bones so that they would fit into a bed too small for them. Many doctors have a very “Procrustean” approach to headache treatment. They generate lists of foods that give some people headaches, asserting that avoiding those foods will prevent all headaches. They simply prescribe one drug after another, hoping one will work, and they try the same therapies in the same order, on patient after patient. Sometimes these measures work, sometimes not, because, aside from the pain, my headaches are probably not exactly like yours. What works for me might not work for you, and vice versa.
Until very recently (about the last fifteen years), headache was the “poor relation” in neurology. Until the last ten years or so, we had no fellowship programs (special postresidency training) in headache and, even today, there are only a few programs. Indeed, through seven years of training in medical school and residency, headaches were covered in a few hours, with the emphasis on secondary headaches (those headaches that are a symptom of something else, like brain tumors or ruptured blood vessels). Even today, federal funding for headache research is less than $15 million per year. Headache sufferers and their treating physicians know the frustration in treating a condition about which they know little and for which there is minimal support, either from the medical community or from society at large. When the treating physician is also a headache sufferer, this frustration is multiplied.
If migraine were like an infection, we could draw some blood, put it in a petri dish, see which infectious agent caused the problem, and pick the right drug to knock it out. But migraine is not an infection. Migraine is a disorder of sensory processing. People with migraine often feel pain after stimuli that typically do not bother nonmigraineurs. Migraine sufferers have symptoms in common, starting with the pain (although some forms of migraine do not have pain as a component). What triggers the pain, however, varies from individual to individual. This is the focus of clinical research. We endeavor to identify the unique features in migraineurs that will lend insight to the common underlying causes of head pain. For example, recent research suggests that people who experience their headaches as “exploding” may have a different response to certain treatments from the response of those whose headaches are described as imploding. While this has yet to be verified, it is an exciting clinical observation that can teach us a great deal about the nature of head pain and its treatment.
Since all headache sufferers have their own unique triggers, they each need their own unique management plan to address those triggers as well as the pain and other symptoms that result. This means that one of the biggest problems for migraine sufferers today is with our health care system. While the medical community is extraordinarily good at dealing with acute and life- threatening conditions (like major trauma, cancer, and pneumonia), it is not set up to treat chronic, episodic, progressive diseases— like asthma, depression, diabetes, obesity, heart disease, and migraine.
When a physician’s schedule only allots seven minutes to take a headache sufferer’s history, examine the patient, and design a treatment plan, it is impossible to provide ample customization to prevent and treat that patient’s migraines. But without that level of customization, the plan is doomed from the outset. Instead, patients and their doctors perform endless experiments with drug after drug, or get referrals to psychiatrists, neurologists, or pain specialists. The fortunate ones may find their way to headache specialists, yet often even these superspecialists are overworked and overwhelmed. In the end, patients often feel that they have not been heard, their questions have not been answered, and they have no plan. Still, they have a new prescription and a follow- up visit in three months, when, one hopes, they will get some relief.
We shouldn’t blame the doctors, the emergency room staff, or anyone else who is honestly trying to help. Most of them weren’t trained for this and, almost always, these practitioners are doing the best they can. Even so, the greatest challenge in implementing your treatment plan can often be to enlist effective support from your doctor, your insurance company, your benefits counselor, and everyone else involved in your health care.
The Keeler Center for the Study of Migraine
When I was the chief of the Headache and Facial Pain Section at the University of Southern California (USC), I learned a great deal about how to improve care for headache sufferers. I also began to understand what would be required to care for headache sufferers effectively. I came to envision the perfect headache clinic, a facility that offered both traditional and alternative treatment modalities. It would have a close affiliation with a cutting- edge research institution committed to applying state- of- the- art scientific investigation to the problems of headache pathophysiology and treatment. This clinic would be free of economic constraints, so any headache sufferer who needed help could get access, regardless of their ability to pay for it. And I wanted it all housed in a friendly environment with skilled nurse practitioners, physical therapists, psychologists, biofeedback technicians, yoga instructors, nutritionists, and patient educators— all working with patients to improve their lives, given the reality that, at least for the present, headaches are a part of life. My years trying to care for and understand headaches in a traditional medical environment convinced me that such a model was the only option. At the time, it was all a fantasy, unless I won the lottery. Since I didn’t play the lottery, this seemed unlikely.
With the dawn of a new millennium, the fates conspired to make my fantasy a reality. First, I met Michael Harrington, M.D., Ch.B., FRCP, formerly of the National Institutes of Health (NIH) and the California Institute of Technology (Caltech), and presently director of the molecular neurology program at the prestigious Huntington Medical Research Institutes (HMRI) in Pasadena, California. Dr. Harrington came to present grand rounds at USC, and offered the most innovative approach to the study of a variety of neurological disorders that I had ever encountered. Unfortunately, migraine was not on his radar. But after his lecture, we talked. And talked and talked. Before long, we wrote a proposal for NIH funding. We received the funding and began to research migraines.
The next bit of good fortune came from the family of the late Fred Keeler, a very successful businessman and philanthropist in Ojai, California. When Mr. Keeler passed away, his family wanted to honor his memory by continuing his good works in the community. The family generously funded the Keeler Migraine Center in Ojai. Essentially, they gave me carte blanche— and the resources— to create a state- of- the- art clinical facility as well as the advice and expertise of a remarkable assembly of people to guide the fiscal, administrative, and creative efforts that would guarantee the clinic’s success.
Located just inland from Santa Barbara, California, the Keeler Migraine Center treats patients suffering from some of the most difficult and severe headaches in the world. One of the most renowned clinics in the country, the center is a refuge for headache sufferers. It is quiet, the colors are soothing, the pace is calm. As medical director, I work with a team of specialists, the best minds with the most powerful treatment options and newest resources, to practice at the cutting edge of migraine management. Closely affiliated with Dr. Harrington and HMRI’s molecular neurology program, we focus our efforts on helping patients overcome their migraines. At the Keeler Center, we study new and innovative approaches, and integrate the latest science with treatments dating back thousands of years and crossing many cultures, so we can offer every scientifically proven tool— including traditional and alternative modalities— to treat chronic headaches.
Comprising physicians, scientists, and many others, the Keeler team integrates the latest research discoveries and cutting- edge science into our treatment plans. Not only do we have our own laboratories investigating the biology and chemistry of migraines, but we also actively incorporate discoveries from other researchers into our treatment strategies.
Making the Study of Headache a Priority
Today, we know a great deal about why we get headaches, how to prevent them, and how to take care of them when they break through our defenses. We know that migraine is a genetic disease with a clear (if incompletely understood) biological basis. We know that migraine is a chronic condition, which does not mean that patients always have a headache, but that they are always susceptible to getting one, just as an asthmatic is always susceptible to an asthma attack. We also have a much better understanding of what triggers, worsens, and alleviates headaches. We even have medicines that are not simply generic painkillers, but that work specifically for migraines.
There is still a lot we don’t know. We don’t know if migraines start in the cortex (the “thinking” part of the brain) or if they start in the brain stem, where “unconscious” processing takes place. We don’t know if people who have an aura or warning before their migraines have a different condition from those of us whose headaches come on without warning. We don’t know why chocolate triggers headaches in one patient but not in the next. Nor do we know if having migraines places you at increased risk for other medical conditions, particularly neurological ones. Migraine is a very complicated puzzle. But it is one that is coming together quickly.
Since the 1940s, the scientific underpinnings of migraine had not changed much, until the introduction of the triptans. With the introduction of sumatriptan in 1993 and the ensuing infusion of money from drug companies, an explosion in research funding and clinical fellowships in studying headache followed, and as a result, our understanding of and ability to care for migraine changed dramatically.
Today, we have an awareness of the basic pathophysiology of migraines that simply did not exist as recently as 2007. Drugs now in development could revolutionize our current rescue and prevention strategies. We are learning about the microenvironment of the brain and its interactions with the outside world and the rest of the body. Even our understanding of migraine pain has become much more sophisticated. We now know that headache pain proceeds in several distinct phases, each of which can (and should) be addressed differently. Pain begins peripherally in the nerves that mediate sensation in the head, and then proceeds into the central nervous system where, if left unchecked, it eventually becomes a vicious cycle of inflammation. We have a better understanding of how to recognize where in this pain cycle a patient is at any given moment, and how best to treat the pain.
Despite the recent explosion of information, the science of migraine is still in its infancy. The Keeler Center works closely with the HMRI molecular neurology lab to understand the basic science of migraine by examining the spinal fluid of headache sufferers. Through a combination of private and federal funding (from the National Institutes of Health), our laboratory, under the direction of my colleague Dr. Harrington, uses chromatography and other sophisticated technologies to study the spinal fluid of hundreds of volunteers. Eventually, this research will yield information about diet, medication, and genetics that will dramatically improve the lives of those suffering from debilitating migraines.
Our approach to research is a little like that of a private detective who goes through a subject’s garbage looking for clues. In our case, the subject is migraines, and the garbage is the spinal fluid, which carries the products of brain metabolism (its garbage, so to speak) off to the veins and eventually to the kidneys for excretion in the urine. Since spinal fluid can be obtained only through an invasive spinal tap, we hope eventually to access this information from more obtainable fluids such as blood, urine, saliva, and even tears. We are interested in understanding the basic biology of headache; developing an easy test to determine if a given headache is a migraine (for which certain medications will be effective); learning the effect of dietary alterations, such as changing the ratio of omega- 3 fatty acids to omega- 6 fatty acids; and developing novel drugs that work at specific sites in the brain to prevent or stop a migraine. We already have promising data in each of these areas.
Our laboratory research has already helped our patients at the Keeler Center in many ways. Many of our treatment protocols, dietary recommendations, and lifestyle modifications are based on research from our laboratories and the research of the laboratories of our colleagues across the country and around the world.
For example, recent work has shown that migraine has two stages and that triptans are effective primarily in the first stage but considerably less so in the second. A phenomenon called cutaneous allodynia helps us identify when the first stage is ending and the second stage beginning. Basically, cutaneous allodynia refers to that time in a headache when the skin and skin appendages, such as hair and teeth, become very sensitive, even painful to the touch. For most migraineurs, this occurs between ' thirty minutes and two hours into a headache and can last for hours, often beyond the end of the pain phase of the headache. In terms of treatment, this is very helpful information because it
which is expensive medication.
Another example of recent scientific progress influencing migraine treatment comes from our own laboratory, where we identified a particular prostaglandin found in high concentration in the spinal fluid of migraineurs compared to nonmigraineurs. This prostaglandin is associated with sleep. This lends insight into the healing magic of sleep for migraineurs, and also gives us a tool for managing migraines through the medical manipulation of the prostaglandin pathway. We are also studying dietary manipulations.
By closely following the scientific literature and meeting with the scientists and clinicians in the group on a regular basis, we continually upgrade and modify our treatment strategies as our understanding of headaches continues to evolve.
The Keeler Method for Migraine Management
Most of us have ideas about how to take care of our headaches. Most patients try to avoid situations they think might cause a headache, and sometimes go to the emergency room when things get really bad. For the most part, these are partial solutions or desperate measures. They do not constitute a plan. But thirty million Americans suffer from headaches. They can’t all come to Ojai— nor do they need to.
This book outlines my general principles as well as specific steps you can take to develop your own unique treatment plan, your own strategy to guide you away from a life dominated by headaches. This is the Keeler Migraine Method, the culmination of more than twenty years of caring for people with headaches, myself and thousands of others. The Keeler Migraine Method is different. The Keeler Method offers each patient a customized, personalized, workable plan for managing their headaches. This approach works much better than trial- and- error medications, chiropractic adjustments, purges, purgatives, electroshock, or any other treatment out there. We combine many tiny adjustments and interventions that, when taken together, dramatically reduce the number of headaches you get as well as the severity of the pain and other symptoms when headaches do occur. The Keeler Method provides a philosophy of migraine management to help patients understand their headaches and use that understanding to create an antimigraine environment.
Most headache sufferers can control their headaches with some education, a few simple self- assessment tests, and the help of a good and willing physician. This book will help you understand the source of your headaches, show you how to isolate your specific triggers, and give you pointers on how to communicate effectively with your doctor. Here, you will learn the most current strategies for treating migraines, from the newest scientific discoveries to tried- and- true clinical medicine and alternative therapies, too. This book describes every aspect of the treatment plans we use to successfully treat our patients at the Keeler Center. Every migraineur (a person whose headache meets the criteria for being migraine) presents unique sets of triggers and pain patterns. That’s why the Keeler program does not include lists of forbidden foods, rigid diets, or blanket edicts about things you must avoid. The reality is that triggers differ from person to person, and anything can be a trigger. Triggers can be:
In Chapter 3, I explain much more about the vast array of triggers that can cause migraines. However, some generalizations do seem to apply to many migraine sufferers. From these observations, we have developed a philosophy that guides our treatment strategies:
When we understand the individual migraine sufferer’s unique triggers, we can influence disruptions to the lifestyle patterns associated with each trigger and gain control of the headaches.
Migraineurs do not do well with chaos. Put another way, migraines thrive on change. All individuals have a unique set of responses to disruptions to their environment, and migraines can be one of these responses. So each migraineur has specific lifestyle elements to which that person is especially sensitive, and changes in these areas of life are more likely to trigger that individual’s migraines. The key, then, to effective migraine management is for individual migraineurs to understand their personal sensitivities and to create strategies to minimize disruption of those patterns. Whether we are talking about sleep schedules or meal timing or an exercise routine, we encourage patterned behavior whenever possible and, when a change is unavoidable (such as plane travel, a big party, or tax season), we try to anticipate that disruption and take extra headache precautions. This philosophy is at the heart of the Keeler Migraine Method and this book.
It’s not a magic formula. But when you understand the importance of careful observation, keeping a routine, and clever planning (facilitated by the self- assessment tools in this book), you can understand your headaches and create your own formula for controlling them. For example, Jeri is a twenty- year- old college junior who has had headaches since her early teens. For the most part, they were Tylenol headaches, meaning she could knock them out with a couple of Tylenol. Over the last couple of years, her headaches became more of a problem and were now affecting her academic and social life. We had her keep a headache diary for one month. When she came back to the clinic, she said that her headaches were no longer a problem. Just from her own observation, she realized that her headaches were linked to her erratic sleep pattern, caffeine consumption, and inconsistent exercise. With a little organization and awareness, she was back on track.
While we have yet to cure our first migraine, my patients will tell you that their headaches have never been better, that they are less frequent, less severe, and of shorter duration. More important, their lives have never been better. They miss fewer workdays. They attend more family events. They can exercise, go out to dinner, and maybe even have a drink or two. They have regained control of their lives. While they still get migraines, headaches are no longer the focus of their lives. They are a footnote. So while some patients (such as those who suffer from chronic daily headaches) should see a headache specialist, and every headache sufferer should be under the care of a physician, every migraine sufferer can significantly improve their life by following the Keeler Migraine Method.
Constructing Your Keeler Migraine Method Treatment Plan
Every migraine patient is unique, and so is every treatment plan, but all of our treatment strategies have three parts: lifestyle modification, prevention, and rescue. Many new patients tell me that “nothing works,” or “only one thing works.” But nearly always, these migraineurs have not experienced such a comprehensive treatment program.The Antimigraine Lifestyle
Generally, migraineurs need a healthy rhythm in their lives. But creating a healthy rhythm is the last thing we want to think about after a headache. People do not want to think about their headaches when they are without headaches. We are far more interested in getting on with our lives and making up for the time we have lost to headaches. We frantically take advantage of these good days, rushing about, making up for lost time, and avoiding anything that might break the delicate, pain- free balance. And when we do have a headache, we just want to lie down, never mind developing a migraine prevention strategy. Between these two states, that pretty much covers all the time there is, and doesn’t leave any opportunity for planning. As a result, we live in a constant cycle of headache, catch- up, tiptoe, trigger.
It is clear that migraineurs do better when their lives are more patterned, but often the nature of the headache sufferer’s life resists patterning. This is the challenge. How do we break the cycle and create a fresh behavior pattern?
The Keeler Method starts with our most basic patterns: sleeping, eating, and physical activity. For most migraineurs, keeping regular hours, eating regular meals, and exercising regularly can work wonders with their headaches. So we want to work toward living an antimigraine lifestyle. This alone can often solve a multitude of problems— migrainerelated and otherwise.
While the antimigraine lifestyle thrives on patterns, it does not need to be boring. Too many migraineurs avoid special events, parties, travel, and other pleasures for fear of getting a headache. But with creative anticipation and strategic planning, you can effectively manage most situations and stop letting headaches decide how and where you spend your time.
Lifestyle modification is the process of analyzing your behaviors, activities, relationships— everything— in order to identify those components that may contribute to your headaches. Once we identify them, we can figure out how to modify lifestyle such that the quality remains but the headaches diminish. This is a decision- making process. It involves:
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