Efficacy of Ayurvedic Medication on Anxiety-induced Migraine: A Case Study

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CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 282 Efficacy of Ayurvedic Medication on Anxiety-induced Migraine: A Case Study Preeti Bhatt 1 , D.B. Vaghela 2 1 Post Graduate Scholar Final Year, Dept. of Shalakya Tantra, Institute of Teaching and Research in Ayurveda, Jamnagar, Gujarat, India. 2 Head & Professor, Dept. of Shalakya Tantra, Institute of Teaching and Research in Ayurveda, Jamnagar, Gujarat, India. I NTRODUCTION As per the criteria of the third edition of the International Classification of Headache Disorders (ICHD-3), Chronic Migraine (CM) is a neurological Address for correspondence: Dr. Preeti Bhatt Post Graduate Scholar Final Year, Dept. of Shalakya Tantra, Institute of Teaching and Research in Ayurveda, Jamnagar, Gujarat, India. E-mail: prtbhatta@gmail.com Submission Date: 11/08/2024 Accepted Date: 26/09/2024 Access this article online Quick Response Code Website: www.jaims.in DOI: 10.21760/jaims.9.9.45 disease characterized by more than 15 headache days per month with at least 8 days of Migraine for more than a period of 3 months. CM is one of the most common causes of disability and affects 1 – 2% of the population worldwide. The vast majority of patients require preventive therapies to sustain a reasonable quality of life. In Ayurveda, Migraine is closely related to the Ardhavabhedaka and characterized by some or all the signs and symptom: severe pain in one half of the forehead, severe pain in the neck resembling that caused by a sharp weapon or sting, episodes of headache every 10 days or fortnight, disease progression giving rise to eye damage or ear damage, dizziness, and the headache is self-limiting, etc. Ayurvedic medications have been used successfully to prevent Migraine attacks in patients who have not A B S T R A C T Anxiety-induced Migraine is a complex and debilitating condition where physiological and psychological stress trigger severe headache episodes. Throbbing pain which is typical of Migraine headache presented with distressing symptoms of anxiety, significantly impacts the quality of life for sufferers. The relationship between stress and Migraine is bidirectional; not only can anxiety provoke Migraine, but the chronic pain and disruption caused by Migraine can also heighten anxiety levels, creating a vicious cycle. In Ayurveda, Ardhavabhedaka is mentioned with the characterization of headache in half of the head (hemicrania) which is the main feature of Migraine. A 29-year-old man with complaints of headache visited Shalakya Tantra OPD of the Institute of Teaching and Research in Ayurveda, Jamnagar for his Anxietyinduced Migraine. He was treated with Laghu Sutashekhara Rasa , Brihata Dashmoola Taila Nasya , Tablet Anzee (combination of Tagar , Ashwagandha , Brahmi , and Sankhapusphi ) and Rasayana Yoga . There was a significant improvement in all three parameters of duration, severity, and frequency of headache and the most important was a reduction in frequency of headaches. The combination of medications shows improvement in the signs and symptoms of Migraine with Anxiety. This study recommends the importance of clinical protocol and evaluation with the clinical study for evaluating efficacy and safety. Key words: Anxiety-induced Migraine, Laghu Sutashekhara Rasa, Brihata Dashmoola Taila, Tablet Anzee, Rasayana Yoga.

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Preeti Bhatt et al. Efficacy of Ayurvedic Medication on Anxiety-induced Migraine ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 283 responded well to standard treatment for several years. As per the Ayurvedic classics, different treatment modules are available. The response is typically measured by the improvement in the monthly headache days. However, to identify therapy benefits accurately it may be advantageous to include other parameters, e.g., headache duration and intensity. Here in this paper, we present a case of Anxietyinduced Migraine. C ASE R EPORT A 29-year-old man with complaints of headache visited Shalakya Tantra OPD of the Institute of Teaching and Research in Ayurveda, Jamnagar for his Anxietyinduced Migraine. The patient has been experiencing episodic headache since 2019 with increasing frequency over time. The headache is more severe in the frontal-temporal region and is a throbbing type of pain. Before the headache episode, he has sweating, restlessness, and pulse. During the headache phase, it is associated with symptoms such as dizziness, nausea, vomiting, and lightheadedness. Onset is acute, episodic, and reoccurs every week, continuous, lasting for 10-12 hrs. /day. Notably, there was no history of visual and ear problems, which helps in narrowing down potential diagnoses. The headaches are triggered specifically by stress episodes, occasionally by sunlight, travel, loud noise, and lack of sleep. Relief is found through relaxation, medicine, sleep, and some breathing exercises. He had less frequent headaches initially but now he has a frequency of 1-2 attacks in a fortnight. He never had an aura. During the attacks, he presented with both photophobia and phonophobia, with nausea usually commencing afterward. He doesn't have any family history of such types of disorders. Regular use of any medications is not present currently; occasional use of painkillers is present during severe episodes of headache. Treatment History Standard therapies failed to provide remarkable relief on his Migraine attacks. He has got a long treatment history along with various investigations which is as follows: Figure 1: Past Treatment History Table 1: Detailed Posology of Past Treatment History 10 th November 2019 Tab. Lithic SR ½ TDS (thrice daily) : It was instructed to take half a tablet three times daily (TDS). The specific medication is a mood stabilizer, potentially related to anxiety or migraines. Proptric F ½ TDS : Similarly, the patient was prescribed half a tablet of Proptric F to be taken three times daily. Proptric F is a beta-blocker and is a combination of Propranolol and Flunarizine; are often used in the management of anxiety and Migraine due to their ability to reduce the frequency and severity of these conditions. 18 July 2023 Patient was provided with Amitone (10 mg tab); Napra D (500 mg tab); and Melzap MD (0.25 mg tab). Amitone contains the active ingredient Amitriptyline. It belongs to the class of tricyclic antidepressants. Napra D is a combination of Naproxen (500 mg) and Domperidone (10 mg). It blocks chemical messengers causing pain, inflammation, fever, and nausea/vomiting associated with Migraine. Melzap MD contains Clonazepam (0.25 mg) which decreases abnormal nerve cell activity. T Sibelium 10 HS (at night) : Sibelium, is a brand name for Flunarizine with a dosage of 10 mg, taken at bedtime (HS). It is used primarily for migraine prophylaxis. T Inderal LA 20 : It is a long-acting form of Propranolol with a dosage of 20 mg, taken twice daily (BD). It works

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Preeti Bhatt et al. Efficacy of Ayurvedic Medication on Anxiety-induced Migraine ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 284 by reducing the excitability of the brain and stabilizing blood vessels. On 10 th September 2019, the patient underwent MRI and EEG tests to rule out causes of headache and associated symptoms. EEG has normal reporting. MRI scan reveals no significant intracranial abnormality (Fig.2). Figure 2: MRI Report Personal History His bowel habit was normal; however occasional constipated stool and gaseous distention is present. Appetite is mild and bladder habit is normal. He has disturbed sleep during anxiety episodes. He shared a history of hectic work life that causes stress and tension. Assessment A detailed history and prior investigations ruled out the disease as Migraine. The Visual Analog Scale was used to evaluate the intensity of the pain. Even though the patient did not report pain during the initial assessment, the average intensity of pain experienced in the last month was rated 8 out of 10 on the pain scale. The same scale was used during the following months to monitor the progress. He had 3 to 4 monthly headache days (MHD) on average during 36 last months before his present visit. The average duration (AD) was 12-14 hrs. and the average severity (AS) was 8 from 10 according to the visual analog scale (VAS) per occasion before the treatment. His blood pressure was 120/69 mmHg and his pulse rate was 51 bpm. Neurological examination was unremarkable. The Migraine Disability Assessment Score (MIDAS) [10] was 22 (Severe Disability, MIDAS Grade IV.) Record of headache and all other associated complaints were assessed with the help of a specialized proforma. In each follow up his symptoms were recorded and treatment evaluation was made. Figure 2: History and Interventions of Present Treatment Treatment Informed consent was taken prior the treatment. The patient was given with a comprehensive prescription. The patient was advised of a list of do’s and don’ts that act as triggers in his Migraine. Proper counseling was done in each of his hospital visits. The treatment protocol was continued for 2 months. At present, the patient is receiving Tablet Anzee and Rasayana Yoga treatment with excellent tolerability. All other drugs

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Preeti Bhatt et al. Efficacy of Ayurvedic Medication on Anxiety-induced Migraine ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 285 were discontinued while Tab. Anzee was suggested to continue. Table 2: Details of Prescribed Interventions Medicine Dosage Mode of administration Remarks Tab Anzee (combination of Tagar, Ashwagandha, Brahmi, and Shankhpushpi ) 2 tab, OD (once daily), HS (at night) Oral With water Brihata Dashmoola Taila 8-8 drops in each nostril Nasya 5 sittings with three days of gap between each sittings, was done in the Kriyakalpa unit of ITRA at the morning time. Laghu Sutashekhara Rasa 500 mg, TDS (thrice daily), PC (post cibum) Oral With water Rasayana Yoga ( Combination of Rasayana Churna 3 gms, Shatavari Churna 2 gms and Ashwagandha Churna 1 gm) 1 tsf (tea spoons full, OD, HS Oral With milk Follow-Up and Outcomes After 15 days, the patient reported improved sleep quality, decreased pain intensity from 8 to 6, and reduced medication usage. The proforma was very helpful in documenting the progress made during the treatment period. There were no complaints of headache, nausea, vomiting, vertigo, and the visual auditory complaints in the following 15 days. He had improved quality of sleep and overthinking has also reduced. Most of these symptoms were absent in the follow-up of 30 days. After one and a half months (6 weeks), an intermediary assessment was performed. The frequency, duration, and severity of headaches has been significantly reduced. Patient’s quality of life has been improved and he no longer has any symptoms of anxiety. The VAS score decreased to 3 (the average of the last 2 migraine attacks). The patient did not report any headaches after 45 days. The MIDAS score was 10 (Mild disability, MIDAS grade II). The patient reported an increase in quality of life and improved work performance. Currently, he attends weekly sessions to maintain the achieved results. The chief complaints were compared in the regular visiting days and followups to evaluate the progress of the symptoms. Table 3: Assessment on Regular Hospital Visits Symptoms Scoring Measurement (As per severity) BT 15 days 30 days 45 days 60 days Headache 1-5 4 3 2 0 0 Nausea 1-5 3 2 1 2 1 Vomiting 1-5 1 0 0 0 0 Vertigo 1-5 2 0 1 0 0 Aura-visual/ auditory 1-5 0 0 0 0 0 VAS 1-10 8 6 5 3 0 DISCUSSION Due to the unclear pathogenesis and lack of targeted treatment options for Migraine, it is challenging to provide an exact prognosis for outcomes in most cases. In the case of this young patient, he experienced a prolonged period of severe pain that significantly impacted his quality of life, increasing stress levels (which itself acted as a trigger for his Migraine attacks), anxiety, and feelings of hopelessness. Understanding the various contributing factors and their impact on headaches is crucial to effectively address and alleviate the pain. Patients with Migraine are very susceptible to anxiety disorders, as evidenced by the different studies. The

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Preeti Bhatt et al. Efficacy of Ayurvedic Medication on Anxiety-induced Migraine ISSN: 2456-3110 CASE REPORT September 2024 Journal of Ayurveda and Integrated Medical Sciences | September 2024 | Vol. 9 | Issue 9 286 relationship between anxiety disorders and Migraine headaches appears to be bidirectional as recurrent headaches in Migraine lead to anxiety and vice-versa. Both these disorders share several standard features making it difficult to diagnose the development of one disorder in the presence of the other. These disorders significantly affect the quality of life in such patients. The treatment focused on managing the anxiety, quality of life, duration and severity of his overall pain, and his frequent episodes. Laghu Sutashekhara Rasa pacifies vitiated Tridosha and opens micro channels, improving sudden vasoconstriction and vasodilation. It improves metabolism and causes better absorption of drugs. Nasya with Brihata Dashmoola Taila causes a decrease in inflammatory mediators, increases microcirculation, gives nourishment to the tissues, regularizes blood circulation, and relieves pain. Drugs present in Brihata Dashmoola Taila along with the Nasya procedure normalizes cranial circulation and break down the pathogenesis of Migraine. Tablet Anzee having drugs that act on the central nervous system helps to reduce anxiety and improve the sleep pattern of the patient. Rasayana Yoga nourishes all the tissues, causes better blood circulation normalizes the functioning of the organs, reduces stress levels, and minimizes headache attacks. CONCLUSION The results obtained from the assessment conducted after the mentioned treatment protocol demonstrates the benefits of Ayurveda medication in managing Migraine with anxiety. Despite the lack of necessity for ongoing periodic assessments, the patient persisted in attending sessions to sustain the results they had achieved. This study recommends the importance of clinical protocol and evaluation with the clinical study for evaluation of efficacy and safety. REFERENCES 1 Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3 rd edition. Cephalalgia 2018;38:12018; 38:1 – 211. https://doi.org/10.1177/ 0333102417738202. 2 Uzun S, Frejvall U, Özkaya-Sahin G, Sahin G. A case report of a chronic migraine patient treated with three different anti- CGRP monoclonal antibodies: which parameters better represent the efficacy? Front Neurol 2023;14. https://doi.org/10.3389/fneur.2023.1176816. 3 Lipton RB, Bigal ME, Diamond M, Freitag F, Reed ML, Stewart WF. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:3432007; 68:343 – 9. https://doi.org/10.1212/ 01.wnl.0000252808.97649.21. 4 Migraine. Available from: http://www.namstp.ayush. gov.in 5 Sacco S, Amin FM, Ashina M, Bendtsen L, Deligianni CI, Gil- Gouveia R, et al. European Headache Federation guideline on the use of monoclonal antibodies targeting the calcitonin gene related peptide pathway for migraine prevention – 2022 update. J Headache Pain 2022;23. https://doi.org/10.1186/s 10194-022-01431-x. 6 Silberstein SD, Dodick DW, Bigal ME, Yeung PP, Goadsby PJ, Blankenbiller T, et al. Fremanezumab for the Preventive Treatment of Chronic Migraine. N Engl J Med 2017;377:21132017; 377:2113 – 22. https://doi.org/ 10.1056/nejmoa 1709038. 7 Tabrecta. Available from https://www.webmd.com /drugs/2/drug-179310/tabrecta-oral/details 8 Nitrofurantoin. Available from https://www.drugs.com /nitrofurantoin.html 9 Proptric. Available from https://www.practo.com/ medicineinfo/cita-s-10-mg-tablet-17179 10 Trøstheim M, Eikemo M, Meir R, Hansen I, Paul E, Kroll SL, et al. Assessment of Anhedonia in Adults Withwith and Without Mental Illness. JAMA Netw Open 2020;3:e 2013233. https://doi.org/10.1001/ jamanetworkopen.2020.13233. 11 Mihaiu J, Bodog F, Mohan A, Vieriu G, et al. Successful management of chronic migraine through manual therapy. A case report. JMedLife 2023;16:9532023; 16:953 – 6. https://doi.org/10.25122/jml-2023-0222. How to cite this article: Preeti Bhatt, D.B. Vaghela. Efficacy of Ayurvedic Medication on Anxiety-induced Migraine: A Case Study. J Ayurveda Integr Med Sci 2024;9:282-286. http://dx.doi.org/10.21760/jaims.9.9.45 Source of Support: Nil, Conflict of Interest: None declared.

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