Richard G. Petty, MD

Fibromyalgia is Real! A Battle That Should Not Have To Be Fought Again

Fibromyalgia is a chronic, widespread pain in muscles and soft tissues accompanied by fatigue, it is a fairly common condition, affecting 3% to 6% of the general population, and is most commonly diagnosed in people between the ages of 20 and 50, though onset can occur in childhood. The disease is not life-threatening, though the degree of symptoms may vary greatly from day to day with periods of flares (severe worsening of symptoms) or remission. The syndrome is generally perceived as non-progressive, yet that issue is still a matter of debate.

The cardinal symptoms of fibromyalgia are chronic, widespread pain and tenderness to light touch together with moderate to severe fatigue. Those affected may also experience heightened sensitivity of the skin ("allodynia"), tingling of the skin that is often needle-like, a deep ache in the muscle and , less often, the tendons, prolonged muscle spasms, weakness in the limbs, and nerve pain. Chronic sleep disturbances are also characteristic of fibromyalgia, and some studies suggest that these sleep disturbances are the result of a sleep disorder called alpha-delta sleep , a condition in which deep sleep (associated with delta EEG waves) is frequently interrupted by bursts of brain activity similar to wakefulness (i.e. alpha waves). Deeper stages of sleep (stages 3 & 4) are often dramatically reduced, and that is the likely cause of the cognitive problems that so often accompany fibromyalgia.

There is not any structural damage in an organ, though it may sometimes start after trauma, such as a motor vehicle accident.

It is that last fact, that there is s often no obvious physical pathology, that has lead so many people to claim that fibromyalgia is “nothing more than” pain associated with depression. I have has some interesting “discussions” with health care professionals convinced that people wit fibromyalgia do not have a “real” illness, and that they need psychotherapy or antidepressants. Yet pain is pain, and the false dichotomy: “Is the pain my mind or in my body?” helps nobody.

Twenty-five years ago, Muhammad B. Yunus and his collaborators published the first controlled study of the clinical characteristics of fibromyalgia syndrome. That seminal article, published in Seminars in Arthritis and Rheumatism, led directly to formal recognition of this disease by the medical community. Last month, again in Seminars in Arthritis and Rheumatism, Muhammed makes another enormous contribution to the field of chronic pain and fatigue by meticulously synthesizing and interpreting the extensive body of scientific literature on fibromyalgia and his own insights into the concept of central sensitivity syndromes (CSS) that include irritable bowel syndrome, migraine and restless legs syndrome.

In fact there are at least 13 separate conditions that are related to central sensitization (CS), where the central nervous system becomes extremely sensitized with respect to certain parts of the body, so that even mild pressure or touch would cause much pain. This hypersensitivity may also be associated with other symptoms such as poor sleep and fatigue.

Muhammed took a rather more biological approach to fibromyalgia in the past, now emphasizes a biopsychosocial perspective:

“In my view, this is tremendously important because it is the only way to synthesize the disparate contributions of such variables as genes and adverse childhood experiences, life stress and distress, posttraumatic stress disorder, mood disorders, self-efficacy for pain control, catastrophizing, coping style, and social support into the evolving picture of central nervous system dysfunction vis-à-vis chronic pain and fatigue. Science and medicine now have rational scaffolding for understanding and treating chronic pain syndromes previously considered to be 'functional' or 'unexplained.' Neuroscience research will continue to reveal the mechanisms of CS, but only if informed through a biopsychosocial perspective and with the interdisciplinary collaboration of basic scientists, psychologists, sociologists, epidemiologists, and clinicians."

One of the reasons that I so like this new version of his model is because it fits so well with the concept of  “Salience Disruption Syndrome.” A fancy name for a common problem that I talk about in Healing, Meaning and Purpose.

So very many people are super-sensitive to the environment and also have trouble in filtering out and deciding what is important. As a result pain, attentional problems, impulse control disorders, addictions and several other things tend to cluster together.

Happily we now have an array of novel techniques for dealing with these problems, and I plan to put out more books and papers on ways in which we can help.

Biofeedback for Tension Headaches

Tension headaches are common and can cause a great deal of pain and distress. They can also be hellish hard to treat.

Medicines do not always help, so I have since the 1970s been interested in anything else that could help. In 1982 my boss gave me the money to set up a biofeedback laboratory at Charing Cross Hospital in London, and it turned out that this form of treatment helped around a third of people with tension headaches. Most experts have assumed that biofeedback helps by reducing muscle tension, though I have never been so sure: not everyone with tension headache has increased muscle tone, and many simply reported that they felt less stressed and more in control of their lives.

So it was very interesting to see some new research (NR10) presented yesterday at the 2007 Annual Meeting of the American Psychiatric Association in San Diego, California.

Researchers from Ingok Ja-Ae Hospital in Chungbuk Eumseong, South Korea looked at the efficacy of biofeedback assisted autogenic training for chronic tension headaches.

They examined 35 people aged 20-40 with chronic tension headaches. 17 had treatment as usual, and 18 received 8 sessions of biofeedback. The researchers used some standard measures of headache. Both groups improved, but the people who had biofeedback showed a greater improvement using a simple visual analog scale.

But this is what was interesting: people who had biofeedback had a significant improvement in their levels of anxiety and depression. The reductions of anxiety correlated with the improvements in headache, while biofeedback had no impact on the electrical activity of the muscles in the head and neck. This is an important finding, since it suggests that biofeedback may be helpful with other problems in which anxiety is an issue. There are few problems that are only physical or only psychological: there will almost always be a psychological component in anyone who suffers from chronic pain.

I recently discussed the use of a particular form of biofeedback that seems to help many people with attention-deficit/hyperactivity disorder (ADHD). The treatment seems to help attention itself, but it would also be very helpful if it reduces anxiety, since excessive worrying is a common issue in ADHD.

I shall keep you updated on the use of biofeedback as more research is published.

The most important conclusion from all this work is that it confirms that the mind has extraordinary powers over the body.

And that is incredibly encouraging for all of us.

Mindfulness and Eating Disorders

There is a very interesting report about a study that is going on at Griffith University in Brisbane, Australia.

They are using a psychological technique called "mindfulness" that is firmly rooted in Buddhist philosophy, in which a person becomes intentionally aware of his or her thoughts and actions in the present moment, non-judgmentally. Mindfulness is applied to both bodily actions and the mind's own thoughts and feelings.

The idea is  to help them understand and deal with the emotions that trigger their binges. Unlike many other therapies used in the treatment of eating disorders, there is less focus on food and controlling eating and more on providing freedom from negative thoughts and emotions.

Psychologists Michelle Hanisch and Angela Morgan said that women who binged were often high-achievers and perfectionists and  when they perceived that they didn't measure up to self-imposed standards or were not in control of situations, they indulged in secretive eating binges.

It is well known that many women with eating disorders develop elaborate methods of hiding the evidence of their binges. Some feel so guilty afterwards they also induce vomiting, overuse laxatives or exercise excessively to counteract the effects of the binge.

The researchers say, "Binge eating is largely a distraction - a temporary escape from events and emotions that nevertheless can cause long-term physical problems including electrolyte imbalances. Instead, women need to learn how to react in a different way... Women who have been through the program report less dissatisfaction with their bodies, increased self-esteem and improved personal relationships," and "They learn that thoughts and emotions don't have any power over us as they are just passing phenomena and aren't permanent."

Mindfulness involves techniques and exercises that are very similar to meditation. They could help people live more in the moment, and develop a healthy acceptance of self and become aware of potentially destructive habitual responses.

There is quite a large literature on the use of mindfulness in a variety of clinical situations including substance abuse, oncology, chronic stress, reducing symptoms after organ transplantation, chronic headache and perhaps anxiety.

It will be interesting to see the final results of this study: I shall keep you informed about this and other studies on mindfulness, meditation and acceptance and committment therapy (ACT).

“Peace can be reached through meditation on the knowledge which dreams can give. Peace can also be reached through concentration upon that which is dearest to the heart.”
--Patanjali (Indian Philosopher said to be the Compiler of the Yoga Sutras, Dates Unknown)

"Meditation is not to escape from society, but to come 
back to ourselves and see what is going on. Once there is 
seeing, there must be acting. With mindfulness, we know 
what to do and what not to do to help.”
Thich Nhat Hanh (Vietnamese Buddhist Monk, 1926-)

“Generosity is another quality which, like patience, letting go, non-judging, and trust, provides a solid foundation for mindfulness practice. You might experiment with using the cultivation of generosity as a vehicle for deep self-observation and inquiry as well as an exercise in giving. A good place to start is with yourself. See if you can give yourself gifts that may be true blessings, such as self-acceptance, or some time each day with no purpose. Practice feeling deserving enough to accept these gifts without obligation -- to simply receive from yourself, and from the universe.”
--Jon Kabat Zinn (American Mindfulness Meditation Teacher and Associate Professor of Medicine at the University of Massachusetts Medical School, 1944-)

Food Additives and Behavior

Few things generate as much heat and as little light as the debate about a possible association between food additives and cognition, mood and behavior.

There are a number of ways in which food may influence all three, including:

1. Malnutrition
2. Composition of the diet
3. Nutrient quality of the diet
4. Eating habits
5. Pharmacological effects of foods
6. Food allergy
7. Food sensitivity
8. Contamination of food with heavy metals, hormones and pesticides
9. Fatty acid deficiency
10. Food additives

It is often surprising to learn that many people do not realize that in children – particularly if malnourished – omitting breakfast can have a marked effect on cognitive functioning. But it is the last of those that I want to look at today.

Until the 1950s if food manufacturers wanted to add color to a food it was done primarily with natural plant and vegetable based compounds: pale red colors could be achieved from beets; green from chlorophyll-containing vegetables; yellows and orange could be achieved from extracts from a number of other plants and spices.  But then things began rapidly to change as we outlined in Healing, Meaning and Purpose.   

The notion that food additives could be a cause of hyperactivity is at least 30 years old. I think that Ben Feingold was the first to introduce the idea and with it his notoriously difficult diet.

Over the years there have been some positive clinical trials of the diet and some negative. But I think that every clinician working with behavior problems has seen some startling improvements in some children and adolescents when they go on an elimination diet.

In 1985 a controversial study published in the Lancet claimed to show that 79% of hyperactive children had symptomatic improvement when food chemicals were removed from their diet. Then when the food chemicals were re-introduced the symptoms returned. No other study has ever produced figures anything like that high.

It is also important that in young children, though additives may cause a problem in some, there does not seem to be a link between allergies and food sensitivities, and parents often pick up behavior changes that simple clinical screening tools do not. So mom and dad may really know best.

Several years ago we tried to look at the impact of food additive not on behavior, but on headache. When the additives were administered double blind, we were unable to replicate most people’s symptoms, even when they were sure that a certain food caused a problem.

However, unsupervised restriction diets are not without their dangers. And we also need to make sure that practitioners know what they are doing: I once saw a young woman who had seen by an “alternative allergist,” who had left her on a diet consisting of spring water, rice and lettuce. And nothing else.

Another problem is that many of us do not know what additives are lurking in the food that we eat. There was a recent study in the United Kingdom indicated that on average, Britons consume 20 different food additives every day, with some eating up to 50. Yet most people were unaware of this figure, with nearly half of the 1,006 people surveyed thinking they ate only 10 additives each day.
The research also found that many people did not understand which foods are most likely to contain additives. I have not yet seen the raw data from this study, but I shall have more to say about it once it becomes available.

A number of large independent studies are currently underway (for example, here) which should help us to better identify who is susceptible to additives, how to test for sensitivity to additives and who might benefit from their withdrawal.

The trouble with a lot of the discussion about food additives, behavior, mood and cognition is that it usually begins from a false premise: that there is a single cause for a behavior.

When I am teaching it continues to astonish me that most health care professionals still expect there to be one “cause” for a problem. Yet as I have mentioned before, this is rarely clinical reality.

A food additive may be associated with problems, but only in a minority of children, and only if they are genetically predisposed and if the right set of environmental circumstances are in place.

If you suspect a problem, first, learn to look at labels. And see if simple exclusion helps. An allergist is the next stop, but also ask whether an additive could be causing a biochemical rather than an allergic problem. If it is a biochemical effect, it may not show up on routine allergy tests, but there are other ways of testing.

Temporomandibular Joint Dysfunction and Posttraumatic Stress Disorder

Over the last few years I’ve had the privilege of visiting Croatia several times. I was one of the first Western academics to go back there to teach after the war, and I’ve made many good friends. It is a beautiful country with lovely people and it is a terrible shame what happened there.

One of the big problems that remain is the incredible number of people suffering from posttraumatic stress disorder (PTSD). There continues to be some debate about whether PTSD can only occur in response to one major traumatic event in which a person feels that their life is in danger, or whether it can also occur as a result of repeated less serious traumata. We have discussed the relationships between PTSD, resilience and neurological dysfunction, and of the association between PTSD and laterality.

There has also been at least one report of an association between PTSD and atypical facial pain.

A new paper from colleagues in Croatia has clarified this association by showing that people with PTSD are at increased risk of temporomandibular muscle and joint disorder, or TMJD, which used to be known simply as temporomandibular joint (TMJ) dysfunction. This is intuitively obvious, but it is an important finding. The main complaint was of headache, and it is important not to dismiss these headaches as migraine, tension headaches or as some kind of somatization.

There is currently an $8 million project underway to establish valid and reliable TMJD diagnostic criteria. It is to be hoped that the results of the study will advance the field of TMJD research and aid clinicians in their practices. At a meeting of the American Association of Dental Research in Orlando, Florida in March, Richard Ohrbach  from the University of Buffalo presented data from the study indicating that 82% of People whose recurrent headaches have been diagnosed as tension-related actually had TMJD.

In April of this year, we had the first meeting of the National Institutes of Health Pain Consortium. There’s a good report in Clinical Psychiatry News about ongoing studies from the University of Washington in Seattle. Niloofar Afari presented data that confirms the findings in the Croatian study. And provides yet more useful information.

The investigators used state records to identify twins and surveyed more than 1,700 female twins by mail and by telephone. The results so far indicate that the association between PTSD and TMJD is real and that there may be a genetic predisposition to the association.

It is important not to miss this possible association. Misdiagnosis can cause a lot of needless suffering.

Multiple Sclerosis and Vitamin D

I have commented before that the increasing rates of multiple sclerosis as we move away from the equator has lead to speculation that it might have something to do with lack of sunlight and therefore reduced production of vitamin D in the skin.

A lack of vitamin D may also explain the increased rates of both type 1 and type 2 diabetes, as well as cluster headache at higher latitudes.

Vitamin D is not a single vitamin, but is instead a group of fat-soluble prohormones as well as the metabolites and analogues of these substances. There are two major forms of vitamin D: D₂ (or ergocalciferol) and D₃ or cholecalciferol. Vitamin D₃ is produced in skin exposed to sunlight, specifically ultraviolet B radiation. Very few foods are naturally rich in vitamin D, and most vitamin D intake is in the form of fortified products including milk and cereal grains.

It used to be that we all made plenty of Vitamin D simply by being outside in the sun, but our time outside has been steadily falling since the beginning of the Industrial Revolution, and there are the increasing concerns about exposure to sunlight and some skin cancers.

Vitamin D is involved in many critically important chemcial reactions in the body, and Vitamin D receptors are found in cells in most organs in the body, including the brain, heart, skin, gonads, prostate, and breast. Apart from its effects on regulating calcium and phosphorus, Vitamin D is involved in maintaining the integrity of cell membranes and in modulating the immune system. There is some evidence that a modest increase in Vitamin D intake may reduce the risk of colon, breast and ovarian cancers.

There is a risk of overdosing with Vitamin D. The U.S. Dietary Reference Intake Tolerable Upper Intake Level (UL) of vitamin D for childern and adults is 50 micrograms/day (2000 IU/day). In adults, a daily intake of 2500 μg/day (100,000 IU) can, over a period of weeks and months, produce toxicity  and, if taken for years, as little as 50 to 75 μg/day (2000 to 3000 IU) can produce toxicity.

In this week's issue of the Journal of the American Medical Association, there is an important report that endorses everything that we have been saying. Researchers from several prominent institutions in the United States have examined the hypothesis that higher levels of 25-hydroxyvitamin D are associated with a lower risk of multiple sclerosis.

The study confirmed the hypothesis: the risk of multiple sclerosis (MS) fell as blood levels of the vitamin rose.

The researchers uncovered 257 cases of MS among more than seven million military personnel who had given blood samples to the US Department of Defense.

Amongst white personnel, there was a 41% decrease in MS risk for every 50 nanomoles per litre increase in 25-hydroxyvitamin D, the key form of the vitamin found in the blood.

Those whose vitamin level was in the top 20% had a 62% lower risk of MS than those whose level was in the bottom 20%.

The researchers found no such association among black and hispanic personnel, but this could be a reflection of the smaller size of these sample groups.

This new research ties in with other work that has shown that Vitamin D supplements can prevent or favourably affect the course of a disease similar to MS in mice, as well as evidence that if you live in the Northern Hemisphere, being born in May is associated with a lower risk of MS than if you were born in the winter. If you are born in May, your mother will probably have been exposed to more sunlight - and therefore have produced more Vitamin D - during the later part of pregnancy when the final development of the nervous system takes place. Or alternatively you may have had a heathy dose of sunlight in the weeks immediately after your birth.

It is most likely that the Vitamin D helps by modulating the immune system and suppressing autoimmune reactions caused by specialised T helper 1 cells attacking myelin, the insulating material that sheathes most nerves. It is these attacks that are thought by most experts to play a key role in the development of MS.

If confirmed, the finding suggests that many cases of MS could be prevented or its severity reduced by increasing our levels of Vitamin D.

The data also confirm a point that we have made before: we should not be aiming to "boost" our immune systems, but to "modulate" them.

If you see an advertisement for some potion that is supposed to boost your immune system to help you ward off colds, the flu or something more serious, be suspicious: if the seller does not know the  difference between boosting and modulating, it would be best to move on.

Cluster Headache: A New Approach

By a strange "coincidence", just a couple of days after posting about cluster headaches, the BBC is carrying an article about a woman with cluster headache who was successfully treated by a neurosurgeon who implanted a nerve stimulator attached to the greater occipital nerve at the back of the skull.

It has been known for some time that there is a type of atypical cluster headache that can be treated by blocking these nerves. Some experts feel that since cluster headache is usually driven by the hypothalamus, headaches that can be stopped by nerve blockade or nerve stimulation are not cluster headaches at all.

That is something for us to sort out at scientific conferences.

But for now, there is at least one person - who was featured in the BBC's article - who has been cured after everything else failed.

But here's the strange thing: none of the neurologists or neurosurgeons has a clue how the treatment works.

Yet anyone versed in Traditional Chinese Medicine would tell you immediately the nerve runs directly above a key acupuncture point - Fengchi, or Gallbladder 20 - that is often used in treating severe headaches. Because disturbances in the subtle systems of the liver and gallbladder are common in many types of headache.

In other words, knowledge of the subtle anatomy of the body can explain how the nerve stimulator is working, but the best of current Western neurological science cannot.

A beautiful example of how the combined approaches of Integrated Medicine can help and inform everyone involved.

And it is the patient who gets all the benefits.

Cluster Headache

There are dozens of types of headache, but one of the most serious and debilitating is called "cluster headache."

It is a very severe headaches of a piercing quality that most often occurs near one eye or temple. The pain typically lasts for fifteen minutes to three hours. The headaches are usually unilateral and occasionally change sides.

It is difficult to overstate the severity of the pain. I once mentioned that I could always tell if there was someone in the clinic experiencing a cluster headache because everyone could hear him banging his head against the wall to try and get some relief. They may also be described as "suicide headaches:" a reference to the excruciating pain and resulting desperation that has culminated in actual suicide.

There are some odd symptoms that may accompany the headache, such as:

• Stuffy or runny nose in the nostril on the affected side of the face
• Red, flushed face again on the side of the headache
• Swelling around the eye on the affected side of the face
• Reduced pupil size
• Drooping eyelid

As the name implies, cluster headache usually comes in clusters that last for a week or two or as long as two months. In about 10-15% of people they are chronic. The periodicity of the clusters is remarkable and has lead many of us to speculate an involvement of the brain's "biological clock" or circadian rhythm. In an observational study we found that clusters were more likely to begin in the month of birth of the sufferer, though we never knew how much to read into this.

Cluster headache is far more common in tall men: most are over six feet tall. When we first described cluster headache in women in the early 1980s it was a rarity, though more women have been getting cluster headache in recent years: we have no idea why. Some years ago we also described that they were more common in men who smoked heavily and drove more than 15,000 miles each year. It was impossible to say whether the smoking was cause or effect. Cluster headache is, along with diabetes and multiple sclerosis, an illness that becomes more common in peple who live far from the equator.

We and others also found that nitrates could trigger episodes in some people: that first came to light when we saw three men who used them during sex.

Cluster headaches are most likely to be due to an abnormality in the hypothalamus, which could explain why cluster headaches frequently strike around the same time each day, and during a particular season, since one of the functions the hypothalamus performs is regulation of the biological clock and the metabolic abnormalities that have been reported in some patients.

During the onset of a cluster headache, the most rapid abortive treatment is the inhalation of pure oxygen (12-15 litres per minute in a non-rebreathing apparatus). When used at the onset of headache this can abort the attack in as little as 5 minutes. Once an attack is at its peak, using oxygen therapy appears to have little effect. Alternative first-line treatment is subcutaneous administration of triptansumatriptan and zolmitriptan. Because of the rapid onset of an attack, the triptan drugs are usually taken by subcutaneous injection rather than by mouth. While available as a nasal spray, it had been thought that the spray would not be effective to sufferers of cluster headache due to the swelling of the nasal passages during an attack. However new research from London has shown that 5-mg and 10-mg doses of zolmitriptan intranasal spray are effective within 30 minutes and well tolerated in the treatment of acute cluster headache.

Lidocaine (or any topical anesthetic) sprayed into the nasal cavity may relieve or stop the pain, normally in just a few minutes, but long term use is not suggested due to the side effects and possible damage to the nose and sinuses.

Previously vaso-constrictors such as ergot compounds were also used though less so now becuase of their side effects and new options being available. Oddly enough some sufferers report a similar relief by taking strong cups of coffee immediately at the onset of an attack.

Many different types of prophylaxis have been tried, with lithium, the calcium channel blocker verapamil at a dose of at least 240mg daily, and the anticonvulsant topiramate.

Now a new report in the journal Neurology suggests that 22 out of 26 people with cluster headache who used psilocybin reported that the drg aborted their attacks. 25 of 48 psilocybin users and 7 of 8 LSD users reported cluster period termination; 18 of 19 psilocybin users and 4 of 5 LSD users reported remission period extension. The authors conclude that research on the effects of psilocybin and LSD on cluster headache may be warranted.

From what we do understand about the pathogenesis of cluster headache it is not difficult to see how psilocybin and LSD may help. But it did worry me that this report might lead to people self-medicating with hallucinogens without any kind of support or guidance.

That being said, this recent report shows once again the importance of listening to what people have to say: they often have the answers inside of them. And those answers may lead to a new range of treatments.

 

Breathing

“Without mastering breathing, nothing can be mastered.”
--George Gurdjieff (Armenian-born Adept, Teacher and Writer, c.1873-1949)

I strongly recommend breathing. It’s actually one of my favorite pastimes….

Of course breathing is all-important, but it is just as important to ensure that you are breathing in good quality air. Scattered throughout the world are weather fronts accompanied by hot dry winds of ill repute:

• The Santa Ana Winds of Southern California,
• The Mistral of France
• The Khamsin of North Africa
• The Foehn of Switzerland
• The Sharav in Israel
• The Chinook of Canada
• The Sirocco in parts of the Mediterranean
• The Xlokk of Malta
• The Zonda in Argentina
• The Halny of the Carpathian Mountains

These are just some of these winds, that have been known for centuries to precipitate a variety of symptoms in the exposed population, including depression, irritability, insomnia and headaches. The explanation of these effects is an increase in the number of positive ions in the atmosphere, which alter the amount of serotonin in some parts of the brain. I was consulted about an epidemic of headaches amongst people working in an electrically insulated room. It soon became clear that the setup had allowed an enormous concentration of positive ions, and once they installed a negative ionizer virtually all the headaches stopped. We believe that many of the beneficial effects of high altitudes or of being near waterfalls of fountains spring from the way in which they generate large numbers of negative ions.

Poor oxygenation of the lungs has been known for many years to be associated with disease. Pulmonary tuberculosis classically affects the upper lobes of the lung, where there is the poorest oxygenation, and it has been known for a century that people suffering from a blockage of the mitral valve of the heart, which leads to high blood pressure in the lungs, do not get tuberculosis in that part of the lungs.

Conscious control of the breath enables us to modulate the activity of the autonomic nervous system. Specific types of breathing can induce specific psychological and physical effects.

We usually breathe through one nostril at a time. Either the right or left nostril is dominant for anywhere from 45 minutes to two hours. You then switch sides. This is known as the nasal cycle, and is one of the faster circadian rhythms. The popular yogic practice of single nostril breathing is thought to feedback directly into the hypothalamus of the brain. You can learn to use this to your advantage. If you are right handed, if you direct your focus onto opening the right nostril, you may well find an increase in salivation, which is an aid to good digestion. A useful trick that we have used for many years is at bedtime to start by lying on your left side, which has the effect of opening the right nostril, and after ten minutes roll onto your right side for sleep. Again you reverse this if you are left hand dominant. It seems that this simple trick lowers your core temperature, which is one of the main determinants of sleep. There is some research that opening the right nostril increases body temperature, while opening the left has a calming effect. These techniques are often very helpful. Apart from these physical effects, using the breath is one of the quickest ways to learn to sense the subtle forces of the body.

You may already have some breathing practice that you like, and by all means continue using it. If you need a new one, the simplest that I have ever been taught, and that I have used with countless students and patients is this:
Count your breaths. Breathe deeply using your abdominal muscles, so that you are drawing more air into your lungs. Stop immediately if you feel faint or dizzy. As thoughts come up, keep concentrating on the incoming and outgoing breath. Gradually slow the breath, by extending the pause between the inhalation and exhalation.

I always make myself unpopular when I insist that people check with a healthcare provider before stating any exercise plan, including breathing. But I'm going to say it anyway. It just makes good sense!

“Controlled deep breathing helps the body to transform the air we breathe into energy. The stream of energized air produced by properly executed and controlled deep breathing produces a current of inner energy which radiates throughout the entire body and can be channeled to the body areas that need it the most, on demand. It can be used to fuel a specific physical effort, such as tennis or jogging. Or you can use this current of inner energy to relieve muscular tension throughout the body, revitalize a tired mind, or soothe localized aches and pains.”
--Nancy Zi (American-born Chinese Opera Singer, Voice Teacher and Qigong Expert)

Handedness and Immunity

In 1982, one of my mentors, the late Norman Geschwind, and two colleagues – Al Galaburda and Peter Behan - proposed an extraordinary hypothesis. It was that the levels of testosterone to which a baby is exposed before birth influence the development of both the cerebral and immune systems. According to this theory, high levels of testosterone result in greater incidences of left-handedness, deviations from the standard distribution of cerebral functions and increased autoimmune dysfunction. If the theory is right, then male brains should mature later than female brains, and the left hemisphere should mature later than the right.

It is certainly true that if a boy gets a head injury or infection involving the brain, he is less likely to recover than would a girl, and boys are far more likely to have some types of neurodevelopmental problems like dyslexia.

For a while it seemed as if there was also a strong association between left-handedness and certain types of allergy, and also with inflammatory bowel disease. This association with immunity also seemed to be present in mice: those who had left paw preference had more reactive immune systems, and they were thought to be more likely to produce auto-antibodies, suggesting that the central nervous system was involved in the genesis of some autoimmune diseases. Over the years the data has become less clear-cut, but the idea of an association between anomalous cerebral asymmetry and autoimmune disease never completely went away.

Recent data has again found an association between inflammatory bowel disease and laterality. And left-handers really do have more autoimmune disease.

The Geschwind-Galaburda hypothesis proposes that there should be a four-way association among neurodevelopmental disorders, special talents, non-right handedness, and immune disorders. In a huge study of 11,578 children, less than 1% had all four.

So where does this leave us?

The original theory was half right:

1. There is indeed a link between testosterone and early brain development
2. People who are left-handed or have a strong tendency toward left-handedness do seem to be at slightly increased risk of several autoimmune conditions
3. People who are left-handed or have a strong tendency toward left-handedness may have a slightly increased risk of high blood pressure, asthma and migraine
4. People who are left-handed or have mixed handedness are more likely to excel in certain disciplines: creative arts, music, computer programming and mathematics. What we don’t know is whether people with these special skills are more likely to have autoimmune diseases
5. Amongst very successful tennis players,  there are far more left-handers than would be predicted by chance. This supports the idea that support the notion that left-handed people have neurological advantages in performing certain tasks, such as visuospatial visuomotor cognitive tasks.

I was reminded of the way in which Nature seems to like to balance things out a bit: with some notable and famous exceptions, many successful athletes have not done so well academically and many academics would be unlikely to survive on the plains of Africa. Only some of these differences can be explained in terms of early direction and encouragement in school or while growing up: it seems that most of us cannot hope to become the kind of superman that Nietzsche used to dream about.

Perhaps it’s a way of stopping us from getting too full of ourselves.

Psychiatric Illnesses and Fibromyalgia

There’s an interesting and important article in last month’s issue of the Journal of Clinical Psychiatry, by a group of investigators from the University of Cincinnati.

They have shed important new light on fibromyalgia. We’ve recently learned how it is linked to disturbances of the serotonin transporter, as well as anti-inflammatory proteins, and that is may respond best to the kind of comprehensive multi-leveled approaches that we use in Integrated Medicine.

The new research compared people with fibromyalgia with people with rheumatoid arthritis, and it found that fibromyalgia, but not rheumatoid, may be associated with a range of psychiatric illnesses:

1. Major depressive disorder
2. Bipolar disorder
3. Comorbid anxiety disorders including panic disorder, social phobia, posttraumatic stress disorder and obsessive-compulsive disorder
4. Eating disorders and
5. Substance abuse

What was particularly important in this study was that the psychiatric problems usually preceded the onset of fibromyalgia. So it wasn’t that people were developing psychological problems because they were in chronic pain.

It’s beginning to look as if fibromyalgia is part of a larger group of disorders that all share common etiologies or causes. Family studies have indicated that fibromyalgia and mood disorders share some of the same - perhaps genetic - determinants.

The study also confirms what we have said before: fibromyalgia is not only associated with some psychiatric problems, but also with other medical disorders, several of which may also co-exist with the same psychiatric problems. They include:

1. Chronic fatigue syndrome
2. Irritable bowel syndrome
3. Interstitial cystitis
4. Multiple chemical sensitivities and
5. Migraine

Not only does this research highlight the need to check people with fibromyalgia to see if they might also be struggling with a psychiatric problem, but it is helping us home in on some of the mechanisms linking these apparently separate problems.

This particular study was done mainly in white women, and the investigators knew who had fibromyalgia, so there’s more work to be done.

But if you or a loved one is struggling with fibromyalgia, it is good news to know that we are making rapid progress in unraveling this horrible illness.

Migraine and Bipolar Disorder

Back when the world was new, I cut my teeth in migraine research, and migraine and other headaches were the topic of my first book. So I’ve always kept an eye out for new developments.

There’s an interesting case report from India, about a nineteen year old who developed mild mania as part of the aura or warning of his attacks. This sort of case is interesting for what it might be able to teach us about each illness. It is also good for us to know that bipolar disorder is highly co-morbid: it is associated with many other illnesses apart from migraine:
1.    Anxiety disorders
2.    Substance abuse disorders
3.    Attention deficit disorders
4.    Personality disorders
5.    Impulse control disorders
6.    Eating disorders
7.    Insulin resistance
8.    Obesity
9.    Diabetes mellitus
10.  Cardiovascular diseases
11.  Pain disorders

This is why diligent clinicians are always on the lookout for bipolar disorder: if it is missed and remains untreated, it can cause havoc: suicide attempts, damaged relationships, substance abuse and general misery.

Migraine is one of the vascular headaches that is occasionally associated with an array of other vascular problems, like Raynaud’s phenomenon, ischemic heart disease and stroke. But the aura is something else altogether. For many years it was thought that the migrainous aura was a result of a reduction in blood flow to regions of the cerebral cortex. Almost 25 years ago that was shown to be inaccurate. It is due to a release of witches’ brew of excitatory and inhibitory amino acids in the cortex. It is highly likely that the release of excitatory amino acids is the explanation for the manic symptoms.

Migrainous mania is evidently rare, but apart from visual disturbances, I’ve seen all sorts of strange auras: sudden food cravings; intense sweating; extreme irritability and many other things besides.

The treatment of migraine still revolves around avoidance or modulation of triggers, pain relief and prophylaxis. The big change in recent years has been the increasing amount of experience and small amount of evidence indicating the value of non-pharmacological approaches like spinal manipulation, temporomandibular joint adjustment, acupuncture, the tapping therapies and homeopathy.

To an integrated practitioner, the key is to understand the problem as more than just headache: we can guide a person to see the problem in its broader context, as a challenge designed to find a path toward inner wellness. We also see it as a process that has meaning and purpose and is a Divinely inspired invitation to grow spiritually and as an individual.

That may sound a lot for a headache, but it is the best possible way to triumph over the problem!

“The cure of the part should not be attempted without treatment of the whole.”
--Plato (Athenian Philosopher, 428-348 B.C.E.)

Technorati tags: Migraine Bipolar disorder Insulin resistance Attention deficit disorder AnxietyIntegrated medicine

Acupuncture for Migraine

It was frustration at being unable to help so many people with migraine, that first lead me to begin my training in acupuncture. At the time I was working as a young research fellow in the main migraine clinic in London and I quickly discovered that acupuncture could be a wonderful treatment for many people suffering from this illness. I did my advanced training in acupuncture in China and even there – working with some of the best practitioners in the world - I confirmed my observation that acupuncture is no panacea. But it is a very helpful addition to our therapeutic toolbox.

There is a most interesting article in this week’s Lancet Neurology, that was also picked up by the BBC. The study came from Germany, and involved 960 patients who were randomly assigned to normal migraine medication treatment, traditional acupuncture, and sham – or fake – acupuncture. People in all three groups got better, and there was nothing to choose between the treatments in terms of efficacy.

So what does that mean? That acupuncture was in this trial as good as medications. But it adds to the growing literature that indicates that the precise placement of needles is not always as important as we used to think. But we also need to know exactly where the “sham” needling was done. During my years with the Research Council for Complementary Medicine and Prince Charles’ Foundation for Integrated Medicine, I saw a great many studies and proposals for studies in which the “sham” needles had actually been placed in highly active acupunctures points.

When I was training in China, most of my fellow students had trained in classical acupuncture in Europe, and some were outraged when they heard Chinese professors of acupuncture say that only some acupuncture points were always in the same place, and that it was not necessary to follow all the classical teachings. Some of the Europeans felt that the Chinese were destroying an ancient legacy. The Chinese simply responded by saying that the practice of acupuncture was being evolved on the basis of clinical observations and empirical research. It looks as if they were correct!

Technorati tag: acupuncture, migraine

Migraine and Hormones

Migraine (can be a frightfully difficult problem to treat. It is such an interesting puzzle, that the first book that I ever wrote was on migraine and other types of headache. Migraine is a great deal more than just a severe headache. It is can also be associated with neurological symptoms, and people often become exquisitely sensitive to light and sound. Additionally, at the beginning of the attack, the stomach stops working properly, which can make the absorption of medicines very difficult. Then comes the vomiting and sometimes diarrhea.

Although migraine is usually described as a “vascular” headache, there are strong reasons for thinking that it is more than that. People who suffer from the classic type of migraine often have spreading visual problems or partial visual loss, which goes on for between ten and sixty minutes. These visual problems are likely the result of a spreading wave of neurological depression spreading over the visual cortex at the back of the brain. The sensitivity to light and sound suggests that something is going wrong in the neurological systems that normally filter sensations, and the gastrointestinal problems indicate that something is going wrong in some of the control centers of the brain. There are some real oddities about migraine: it is exceptionally uncommon in people with diabetes; appears to be slightly more common in people who are left handed and is one of the only illnesses that tends to gets better as we get older.

There are a number of well-known triggers to migraine attacks. Though the scientific literature on triggers is not conclusive, here are some of the more common ones, that if avoided, have helped a great many people:

• Stress (either during stress, or when the pressure comes off)
• Cheese
• Chocolate
• Coffee
• Citrus fruit
• Red wine
• Changes in the weather (especially when there are a lot of positive ions in the atmosphere)
• Mono-sodium glutamate (MSG)

One of the best-known features of migraine is that it is considerably more common in women and that there is often a relationship between headaches and phases of the menstrual cycle, in particular during the pre-menstrual days. There have been many small studies that have indicated that oral contraceptives might increase the risk of suffering from migraine. A new study from Trondheim in Norway, has confirmed a link between oral contraceptive and migraine. The Nord-Trøndelag Health Study was done between 1995 and 1997. It included 14,353 pre-menopausal women, of whom 13,944 (97%) responded to questions regarding their use of contraceptives. There was a significant association between migrainous and non-migrainous headaches and the women’s reported use of estrogen-containing oral contraceptives. An important finding was that there was no relationship between the number of headaches and the amount of estrogen in the contraceptive pill.

There is one more thing to factor into the equation. Over the last two decades, there have been many reports of an association between certain types of migraine and cerebrovascular accidents (“strokes”). In the largest analysis of the data, that was published in the British Medical Journal, there was indeed a higher rate of strokes in women who had migraine and who were taking oral contraceptives. These studies included some of the older ones done in the days when the doses of hormones were higher than they are today, but when making decisions, it is important to be aware of this rare association.

An editorial in the British Medical Journal made these recommendations, with which I agree:

1. In an otherwise healthy young person, there is little cause for concern because the absolute risk of stroke is very low.

2. People with migraine who are on oral contraceptives have another reason for not smoking

3. Use low dose estrogen or progesterone only contraceptives in young women with migraine.

4. Although there isn’t much good evidence, many neurologists suggest stopping oral contraceptive pills if the migraine becomes more frequent or changes in character.

5. The risk of stroke gradually increases over age, particularly in smokers, so a slightly older smoking woman with migraine, should probably not be taking an oral contraceptive, unless it is the only option for her.

Technorati tags: migraines,hormones, headache, womens health