Migraines are a very common and often debilitating, painful headache condition that affects some 39 million people in the United States, according to the Migraine Research Foundation. For those who experience them, the quest for relief can be lengthy.
While avoiding triggers and making other lifestyle changes are typically the first line of defense in treating migraines, there are many medications that have helped people cope with them. Still, for some people it's not enough, and increasingly, people who get migraines are turning to a compound called cannabidiol, more commonly known as CBD, to ease their aching heads.
Dr. Thinh Vo, director of quality and compliance at Koi CBD, a company that makes CBD products, says that "CBD is one of many cannabinoids, or molecules, produced uniquely by (plants in) the cannabis family. Unlike tetrahydrocannabinol or THC, the primary psychoactive element in marijuana (another name for cannabis), CBD is non-psychoactive -- meaning it doesn't have a strong effect on cognitive brain activity and doesn't cause the high associated with marijuana."
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Despite these differences, "CBD, like THC, works by interacting with our body's endocannabinoid system," which is a "regulatory system made-up of naturally occurring cannabis-like molecules. These endocannabinoids work like neurotransmitters to help maintain homeostasis," or balance in the body, Vo explains. "Cannabinoids, like CBD and THC, interact with the endocannabinoid system," and CBD "encourages the body to produce more of its own endocannabinoids," which some patients report helps reduce anxiety, pain and inflammation.
Dr. Jordan Tishler, a member of the medical advisory board for cannabisMD and president of the Association of Cannabis Specialists, says that there are upwards of 100 chemicals in cannabis, and THC and CBD are just two of them. "Frankly, CBD hasn't been researched nearly as much as THC," he says. Some of that is related to the fact that cannabis, the plant from which both CBD and THC derive, has long been illegal across the U.S., and much of the funding for new medicines comes from the federal government.
Changing Legal Landscape
But that legal picture is changing as the potential medical benefits of cannabis and its many compounds gain more widespread acceptance. By June 2019, 33 states and the District of Columbia had passed laws "broadly legalizing marijuana in some form," Governing Magazine reports . Medical marijuana is now permitted in most states under certain circumstances. "Some medical marijuana laws are broader than others, with types of medical conditions that allow for treatment varying from state to state," according to Governing Magazine.
At the federal level, however, medical marijuana remains a Schedule 1 substance under the Controlled Substances Act, which the federal government defines as drugs with no currently accepted medical use and a high potential for abuse.
In the states where medical marijuana is legal, some people are using it. And now that CBD has become more widespread, that's garnering attention too as a possible treatment for a range of conditions, from chronic pain and anxiety to side effects from cancer treatment. But there's not a ton of evidence to support the use of CBD for most medical conditions, or migraines in particular.
Daniele Piomelli, professor of anatomy and neurobiology at the UCI School of Medicine and director of the UCI Center for the Study of Cannabis at the University of California, Irvine, says that CBD may be effective in treating several conditions. In fact, in 2018, the Food and Drug Administration approved a prescription CBD medicine to treat severe forms of childhood epilepsy. But in order for it to be therapeutic, the FDA-approved CBD drug "must be given in very high dosages. We're talking about hundreds and hundreds of milligrams -- up to a gram per day -- of CBD."
CBD is a bioactive molecule that's broken down by the liver, similar to how alcohol is processed. That can be hard on the liver, especially if CBD is used at high doses or over a long period of time. "When the liver is overworked, sometimes it will happen that you have some small damage. That damage can accumulate, so you need to be careful when using CBD to treat conditions like migraine that are chronic."
CBD is now being sold in a wide variety of consumer products -- everything from vape oil and massage oils to edible gummies -- all with the promise of making people feel better from a number of ailments, including arthritis and treatment for cancer. Whether that's true or not is unclear.
Dr. Kevin Weber, a neurologist at The Ohio State University Wexner Medical Center, says that while there's promise that CBD might eventually be useful in combating migraines specifically, "unfortunately there is not enough research at this time. The studies that have been published have been limited to case reports and retrospective studies with THC included."
A 2017 literature review found that there could be some benefit to CBD for migraines. But for the science to be more widely accepted, more robust research needs to exist. "Optimally, there would be a double-blind, randomized, placebo-controlled trial studying CBD versus placebo for migraine treatment. There have been no studies at all with pure CBD and headache treatment," Weber says.
Piomelli says these types of studies are the gold-standard because they provide the best evidence for whether a certain medication is effective. "Double-blind placebo controlled studies mean that the drug is tried against a placebo that looks and smells like the drug."
Double blind means neither the researchers nor the participants know who's in the placebo group and who's in the group being given the active drug. This lack of awareness helps keep the results from being influenced by expectations from either the researchers or the participants. However, these types of studies take a long time to conduct and are expensive, Piomelli says. And because of marijuana's lengthy history of illegality in America, few large-scale studies have been conducted.
Vo agrees that more works needs to be done before anyone can definitively assert scientifically that CBD alleviates migraines, but anecdotally, some people are finding relief with CBD products. "Although specific health claims cannot be made, there are many testimonials claiming that CBD may reduce inflammation and pain. It very well may work in a similar way with migraines." He adds that more studies are being conducted "to evaluate the long-term tolerability and efficacy of CBD as it relates to patients with chronic and episodic migraines."
Should I Use CBD for Migraines?
If you're struggling with headaches or migraines, Weber recommends visiting your primary care provider. "If your migraines become refractory (meaning it stops responding to treatment) or too much for your PCP to be comfortable with, request a referral to a neurologist or even a headache specialist."
These days there are many different medications that are used to treat migraines. "Migraines are typically treated with acute treatments, such as triptans and NSAIDs," which are over-the-counter pain killers that reduce inflammation.
"Typically, if migraines are frequent (one a week or more), prophylaxis medications are prescribed. CBD can be used with these treatments," Weber says. That said, it's critical to check with your doctor before taking anything -- even vitamin supplements -- to be sure there will be no negative interactions with other medications you may be taking or other potential dangers.
Weber says that in his practice, "I do not discourage patients who want to use CBD or medical marijuana from doing so. I do warn them that there is very little evidence for marijuana (particularly pure CBD) and headache management." He also warns them that for people who work in certain occupations that are subject to drug testing, there can be repercussions to using marijuana. While pure CBD won't show up on a drug screening test, marijuana does.
Tishler says that there is some evidence that taking CBD in isolation may not be optimal. Using marijuana that contains THC as well as CBD might be a more beneficial option, he adds. "If you give pure CBD, in many cases it stops working after 6 to 8 months, and if you add back THC, it resumes working. We don't entirely understand why that happens," but more research is ongoing to try to unravel the interplay between the two compounds and all the other elements in the cannabis plant.
In addition, Tishler notes that much of the data that currently exists for CBD is based on animal studies, and that's not the same as human clinical trials. There's also an issue with some sources of CBD being contaminated with heavy metals or other dangerous substances such as pesticides. Dosages can vary significantly from one source to another because each state manages regulations a little differently and because CBD products are not regulated, save for that one epilepsy medication.
The alternative Tishler recommends is cannabis. While some states have legalized its use, it's still illegal at the federal level. "We have research on cannabis, and the literature on the use of cannabis for migraines is pretty good. Cannabis can be broadly effective, and it's non-specific," meaning that it can control pain most anywhere in the body, including migraine pain. One 2016 study found that medical marijuana could help reduce migraine frequency.
Still, Piomelli says that while "it's reasonable to speculate that cannabis could be useful in certain patients with migraines because it's a very intense form of pain, unfortunately, the science is far from being able to support this. Migraine is very different from neuropathic pain or inflammatory pain. We cannot simply extrapolate the clinical studies" from one condition to another.
"We certainly need more research," Piomelli adds. "Current federal legislation makes it very hard for researchers to study the various compounds and cannabis and ask the questions that the public wants to know."
Are There Risks?
From a medical perspective, starting any new treatment regimen for migraines can have risks. With CBD or medical marijuana, interactions with other drugs could be a problem and is something you should discuss with your doctor. It's also possible to have or develop an allergy to marijuana, as with any other organic item.
Although CBD is generally regarded as a safe compound, using excessive amounts of CBD over a long period could potentially cause problems to the liver.
Possible contamination of the product is also a top concern with CBD oil products. Many of the products you see cropping up on store shelves have not been through a rigorous testing and approval process, so buyer beware.
From a legal perspective, the laws surrounding medical marijuana and CBD are still complicated. At the federal level, marijuana is illegal. Your state might have regulations that diverge from federal laws. Since the passage of the 2018 Farm Bill, hemp-derived CBD products that contain less than 0.3% THC are legal federally. Just be sure you know what you're buying to avoid any potential issues.
For Tishler, the take-home message is that "cannabis is more than just CBD." He says it can be used effectively for migraines. "There's decades of data to support that," but it needs to be used properly in controlled doses. He recommends that people interested in trying this approach visit with a cannabis specialist. "The Association of Cannabis Specialists is the professional organization for cannabis providers," he says. The organization maintains a list of "vetted practitioners."
As both marijuana legalization and CBD product availability continue to grow, Vo says you can expect to hear more about the potential uses of CBD in the coming years. "The CBD industry is growing like wildfire as many people have reported amazing results. Articles and information on CBD are being published daily. It's clear that CBD is here to stay."