Cannabis for Migraine

What is cannabis?

Cannabis, also known as marijuana, is a plant native to Central Asia but is now grown worldwide. The plant is used for various purposes, including recreational and medicinal uses. The compounds found in cannabis that affect the human body are called cannabinoids.

THC vs CBD

The two main cannabinoids in cannabis are Tetrahydrocannabinol (THC) and Cannabidiol (CBD). THC is the compound that creates the psychoactive effects or the “high” associated with cannabis. CBD, on the other hand, is non-psychoactive and is known for its potential therapeutic effects. In medicinal applications, both of these compounds may play a role, depending on the condition being treated.

What is marijuana, hemp and hashish?

Marijuana, hemp and hashish are three products derived from the cannabis plant.

Marijuana refers to the dried flowers, leaves and stems of the cannabis plant. Compared to other parts of the plant, marijuana contains mostly THC and relatively low levels of CBD. This form of cannabis is preferred by recreational users but can also have medical uses, for example in treating chronic pain.

Hemp is made up of the plant seed and fibre. It has high levels of CBD and very low, essentially insignificant levels of THC. Hemp is used in many different ways, for example to make textiles, food (i.e. hemp seed oil, hemp protein powder), paper, ropes, and more.

Hashish is a more concentrated form of cannabis that contains high levels of THC. This is because it is made from the resin and sap of cannabis. Hash oil can contain about 90% THC, as compared to the 12% THC levels found in other cannabis products.

The endocannabinoid system

THC and CBD work by interacting with the endocannabinoid system in our body, which is responsible for maintaining balance and regulating various bodily functions like pain, mood, and sleep (1). When ingested, these compounds bind or influence cannabinoid receptors, potentially leading to symptom relief for various conditions. This includes anorexia in patients with AIDS, vomiting caused by cancer chemotherapy, cancer pain, epilepsy, and possibly migraine.

Strains & forms of cannabis

There are three main species or strains of the cannabis plant: sativa, indica, and ruderalis. There are countless other hybrid forms which are often created by farmers combining the sativa and indica strains.

Cannabis sativa is a species of cannabis which has high levels of THC and low levels of CBD. The strain tends to have more uplifting, energetic, and euphoric properties. For this reason it is often used during the daytime.

Cannabis indica contains a more balanced combination of THC & CBD. It has a moderate level of THC and very high levels of CBD. It has more calming, relaxing, and sedative properties. It tends to deliver a more full-bodied effect and may therefore be more appropriate for use at night as it can induce drowsiness.

Cannabis ruderalis is essentially hemp with very low-to-zero levels of the psychoactive THC. It contains slightly more CBD, but it often isn’t enough to produce any effects. Ruderalis is rarely used for either recreational or medicinal purposes.

Hybrid strains are created by crossbreeding sativa and indica. Farmers often combine these in ways with the intent to produce a certain effect. Perhaps in the future we could see strains that specifically provide relief from certain symptoms. 

Forms of cannabis

There are many different ways to consume cannabis, including:

• Smoking. Cannabis can be smoked using pipes, bongs, or hand-rolled cigarettes. The effects can be felt quickly, often within minutes. However, this method can harm the lungs and may not be suitable for people with certain health conditions.
• Vaping. Vaping heats cannabis without burning it, which can make it less harmful to the lungs than smoking. Like smoking, the effects are felt quickly. Vaping requires special equipment.
• Edibles. Cannabis can be added to food or drinks. The effects of edibles take longer to kick in (usually 1-2 hours), but they last longer. This method can make it harder to control the dose, and overconsumption is a risk.
• Oils and tinctures. Cannabis can be extracted into oils or alcohol-based solutions (tinctures) that are taken orally or sublingually (under the tongue). These methods allow for precise dosing and the effects typically occur within 15-60 minutes for sublingual use, or 1-2 hours if swallowed and absorbed through the digestive system.
• Topicals. Cannabis can be infused into creams, lotions, and balms that are applied to the skin. This method is often used for localised pain relief and does not provide the “high” associated with other forms of use.

The form of cannabis that you choose to use may depend on your personal preference, medical history, the effect you are looking for, amongst other factors.

What is medicinal cannabis?

Medicinal cannabis is a medicine that comes from the cannabis plant. It is different to recreational cannabis because it is controlled and developed specifically for treating medical conditions. Categories of medicinal cannabis products have been determined based on proportion of cannabidiol content compared with the total cannabinoid content of the medicine (2).

In Australia, recreational cannabis or marijuana is not controlled, so there is no guarantee of the quality or strength of the drug. The amount of active ingredients in recreational marijuana are unknown, and it could also contain other impurities.

Dosage and administration

There isn’t a one-size-fits-all dosage for using cannabis for migraine, as it depends on various factors like the individual’s body chemistry, the severity of symptoms, and the specific strain or product used. Some people may find relief with a small amount, while others may require more. Cannabis can be consumed in many ways, including smoking, vaping, edibles, oils, and topical applications. It’s essential to start with a low dose and gradually increase until you find the dose that works for you.

The typical starting dose for each form of cannabis is as follows:

• Smoking: one to two inhalations.
• Vaping: one to two inhalations.
• Edibles: 2.5-5 milligrams of THC.
• Oils and tinctures: 2.5-5 milligrams of THC.
• Topicals: dosage varies widely depending on the product.

It’s important to remember that responses to cannabis can vary based on factors like the individual’s metabolism, body weight, and the specific strain or product used. The general rule of thumb for starting cannabis use for medical purposes is “start low and go slow”. This means starting with a low dose and gradually increasing until symptom relief is achieved without unwanted side effects. 

Furthermore, you should always consult with a healthcare provider or a pharmacist experienced in medicinal cannabis before starting cannabis treatment, to ensure safe use and proper dosing.

Side effects

Like any medication, cannabis can have side effects. Common ones include dry mouth, dizziness, fatigue, and changes in appetite or mood. These effects are usually temporary and can lessen over time. More serious side effects can occur, particularly if cannabis is used in high doses or frequently. Always discuss potential side effects with a healthcare provider before starting any new treatment.

Safety and tolerability

In general, cannabis is considered safe and well-tolerated when used responsibly under the guidance of a healthcare provider. However, it can interact with other medications and is not suitable for everyone, such as people with certain mental health conditions or pregnant women. 

Cannabis, especially the cannabinoids THC and CBD, can interact with various other medications. These interactions can potentially alter the way the body metabolises these drugs, leading to increased side effects or reduced treatment efficacy. It’s important to note that the specific interactions can depend on numerous factors, including the dose of cannabis used and the specific drug involved. 

There are also concerns that cannabis use could worsen medication overuse headaches in patients with chronic migraine. A chart review of 368 patients in a single headache centre noted that cannabis use was significantly associated with increased prevalence of medication overuse headache in chronic migraine (3).

Some examples of medication classes that can interact with cannabis include:

• Sedatives. Since cannabis can have sedative effects, it may potentially increase the drowsiness caused by other sedative medications, like benzodiazepines and certain antidepressants.
• Anticoagulants. THC and CBD may affect how these drugs are processed in the body, potentially increasing the risk of bleeding.
• Antiepileptic drugs. There is some evidence to suggest that CBD can increase the levels of certain seizure medications in the body, potentially leading to increased side effects.
• CYP450 Metabolized Drugs. Many drugs are metabolised by enzymes known as CYP450 enzymes. Both CBD and THC can inhibit these enzymes, potentially leading to higher levels of these drugs in the body and increased side effects.
• Alcohol. Combining cannabis and alcohol can increase the effects of both, leading to increased impairment or potential for harm.
• Opioids. There is some evidence to suggest that cannabis can enhance the effects of opioids, potentially allowing for lower doses to be used. However, this can also increase the risk of side effects, including the risk of dependency or overdose.

This is not an exhaustive list and individual responses to drug combinations can vary. Therefore, it’s essential for anyone considering using cannabis, especially for medicinal purposes, to discuss it with a healthcare provider to ensure it’s safe and won’t interfere with any other medications being taken.

Benefits of cannabis for migraine

Studies suggest that cannabis could help manage migraine symptoms. It might reduce the frequency of migraine attacks and alleviate associated symptoms like pain, nausea, and light sensitivity. The exact benefits can vary from person to person, as everyone’s body responds differently to cannabis.

Efficacy of cannabis for migraine

Research is ongoing, but early findings indicate that cannabis may be an effective treatment for migraine for some people. However, it’s crucial to remember that cannabis is not a cure for migraine. Instead, it may help manage symptoms or reduce the frequency of attacks.

Cannabis has been studied as a potential migraine treatment, and while results are promising, they are often based on self-reported data, small sample sizes, or lack control groups. Further well designed research is needed to establish its efficacy. Below are several summaries of such studies.

D Rhyne et al, 2016, Effects of Medical Marijuana on Migraine Headache Frequency in an Adult Population.

In this study, 121 adults suffering from migraine used cannabis daily as a preventive measure. The frequency of migraine attacks reportedly decreased from 10.4 to 4.6 per month. Additionally, almost 40% of the participants reported positive effects, with a decrease in migraine frequency. However, 19.8% reported negative effects, primarily sleepiness and difficulty controlling the timing and intensity of migraines. DOI: 10.1002/phar.1673

E Baron et al, 2018, Patterns of medicinal cannabis use, strain analysis, and substitution effect among patients with migraine, headache, arthritis, and chronic pain in a medicinal cannabis cohort.

This study explored the use of a combination of THC and CBD for migraine and cluster headache treatment. They found that the THC-CBD combination was slightly better at reducing the frequency of migraine attacks compared to the commonly prescribed migraine drug amitriptyline. However, this effect was only seen in those participants who had migraine since childhood. DOI: 10.1186/s10194-018-0862-2

J Aviram et al, 2020, Migraine Frequency Decrease Following Prolonged Medical Cannabis Treatment: A Cross-Sectional Study.

In a study exploring the long-term use of cannabis as a treatment for headache and migraine, they found significant improvements in headache and migraine severity after cannabis use. They also noted a decline in the use of other medications, particularly opioids. DOI: 10.3390/brainsci10060360

C Cuttler et al, 2019, Short- and Long-Term Effects of Cannabis on Headache and Migraine.

This research focused on inhaled forms of cannabis. It found that a single inhalation of cannabis could reduce the perceived severity of migraine attacks and headache by nearly 50%. However, the study also noted that cannabis strains with higher levels of THC were more associated with a decrease in pain. DOI: 10.1016/j.jpain.2019.11.001

B Okusanya et al 2022, Medical Cannabis for the treatment of migraine in adults: a review of evidence. 

This review collated 12 publications (including Cuttler et al, Rhyne et al cohorts mentioned above) with a total of 1980 participants. It showed some gradience towards symptom relief of migraine headaches with reduced frequency and severity. However, of concern is the reported onset of tolerance to, and medication overuse headaches from medical cannabis after prolonged use. DOI: 10.3389/fneur.2022.871187

While these studies present potential benefits, they also underline the need for more robust, randomised, placebo-controlled trials to establish cannabis efficacy for migraine and to inform standardised treatment protocols. The use of cannabis for migraine should be discussed with a healthcare provider, considering all potential benefits, risks, and individual health circumstances.

Comparison to traditional treatments

Traditional treatments for migraine often include over-the-counter pain relievers, prescription medications, and lifestyle changes. While these can be effective, they don’t work for everyone and can have side effects. Cannabis offers an alternative for those who haven’t found relief from traditional treatments.

You can learn more about other treatments in the following articles:

• Acute Migraine Medication >
• New Preventive Treatments (2021) >
• Treatment Directory >

Legal status in Australia

In Australia, medicinal cannabis is legal. However, it can only be obtained with a prescription from a registered medical practitioner and must be accessed through special pathways available to patients. Recreational use of cannabis remains illegal in most parts of Australia, except for in the Australian Capital Territory where it has been decriminalised.

The TGA has made it possible for doctors to apply for approval to prescribe CBD oil and other medical cannabis products to their patients under certain conditions, such as when other treatment options have failed. The process is handled via the Special Access Scheme-B or through an Authorised Prescriber Scheme. You can learn more and see the latest information for your state on the HealthDirect website >

As for over-the-counter CBD oil, in late 2020, the TGA made a landmark decision to down-schedule low-dose cannabidiol (CBD) preparations from Schedule 4 (Prescription Only) to Schedule 3 (Pharmacist Only). This allows low-dose CBD oil (up to 150 mg/day) to be available over the counter at pharmacies without a prescription from February 2021. 

It’s also important to understand that while these changes make access to CBD oil easier, it’s still illegal to buy it from overseas or online sources without a prescription. Possession of cannabis products without a proper prescription can still result in legal consequences. Always consult with a healthcare professional before seeking out these products.

Further information & resources

Cannabis presents a promising alternative for people living with migraine who have not found relief through traditional treatments. Its potential benefits include pain relief and reduced frequency of attacks. As with any treatment, it’s essential to consult with a healthcare provider.

If you’d like to learn more about migraine, treatment options, or cannabis for migraine, you can access the following articles:

• Migraine – a comprehensive article about migraine symptoms, causes, treatments, and more.
• Treatment Options – migraine treatment options including treatment directory.
• Medicinal cannabis – an article on medicinal cannabis on HealthDirect

References

1. Zou et al, 2018, Cannabinoid receptors and the endocannabinoid system: signaling and function in the central nervous system. DOI: 10.3390/ijms19030833
2. Therapeutic Goods Administration, 2023, Medicinal cannabis products by active ingredients. Retrieved from: https://www.tga.gov.au/medicinal-cannabis-products-active-ingredients
3. Zhang et al, 2021, Medication overuse headache in patients with chronic migraine using cannabis: a case-referent study. DOI: 10.1111/head.14195