5 Things You Need to Know When Treating Gout
1. Your patients have been taking anti-inflammatory medications when you were not looking.
It's possible that your patients may have some kidney damage, so when they call you on Saturday night to report an acute attack of gout and your first instinct is to order indomethacin, take a pause and consider trying something else. My go-to medication is prednisone.
2. How much prednisone should you give your patient?
The secret in the world of rheumatology is to go slow. You can start with 40 mg/d of prednisone for 4 days, then taper down to 30 mg/d for 4 days, then 20 mg/d for 4 days, and continue to reduce in that fashion. That secret sauce is going to help you treat your patient's acute gout.
3. When should you start allopurinol?
You should not start allopurinol during an acute attack. Remember, allopurinol does not treat acute attacks. Allopurinol is there to help lower uric acid levels in the blood. It's useful for prevention and management, but you want to start allopurinol after an acute attack of gout has settled. If the patient is already on allopurinol, they can continue taking their medication without adjusting the dose. Simply treat the acute attack.
4. Women tend to get tophi in their fingers.
You may want to look closely if you have a female patient with suspected gout. Patients report that this acute pain feels like somebody smashed their finger with a hammer. That kind of complaint would give you insight that your female patient may actually be experiencing gout in her DIP joints or inside her Heberden nodes.
5. Remember that when patients have tophi, they may not be able to feel it.
Talk to your local radiologist to see if you can order a dual-energy CT (DECT) scan. It really helps differentiate between gout and pseudogout.
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"These fish are high in anti-inflammatory fats (EPA and DHA), which can reduce inflammation throughout the body, including in the vascular system and brain." Citing a 2021 randomized controlled trial, Church explains that because migraines are believed to involve inflammatory and vascular changes in the body, omega-3 fatty acids may help reduce their frequency or intensity when eaten regularly. "The study's findings also align with earlier data showing that omega-3s help regulate prostaglandins, which play a role in headache inflammation," says Church. Prostaglandins are hormone-like substances that impact bodily functions like inflammation, pain and menstrual cramps. Fatty fish also contain vitamin D, coenzyme Q10 and B vitamins like riboflavin, which support healthy brain metabolism. Kiran Campbell, a registered dietitian nutritionist at MyNetDiary, also mentions a 2024 meta-analysis revealing that omega-3 fatty acids can reduce the frequency, duration and severity of migraines. She adds that plant-based sources include chia seeds, walnuts, flaxseed and algae oil. Example foods: salmon, mackerel, sardines, chia seeds, walnuts, flaxseed and algae oil Chia and flax seeds are great sources of omega-3s. mikroman6/Getty Images 2. Magnesium-rich foods Daniel Redwood, the director of Human Nutrition and Functional Medicine at the University of Western States, explains, "Attention to the potential importance of magnesium in migraine grew in prominence with the discovery (Ramadan, 1989) that people with migraines had lower levels of this mineral in their red blood cells, serum and brain tissue." Dr. Paul Daidone, medical director at True Self Recovery, seconds this, stating that food rich in magnesium -- like pumpkin seeds, spinach and avocado -- may reduce the severity and occurrence of migraines. He cites a 2022 study examining the potential connection between magnesium deficiency and migraine, which describes how magnesium deficiency is implicated in migraine attacks due to processes like cortical spreading depression, oxidative stress, neurotransmitter imbalance and electrolyte imbalance. "Although clinical evidence of the acute dietary magnesium deficiency as a direct migraine trigger remains limited, scientists are investigating the involvement of intra- and extracellular magnesium levels in migraine pathogenesis," Daidone explains. Dr. Schonze Del Pozo, a board-certified internal medicine physician and medical director at East Sacramento Concierge, states that many of the patients she sees for headaches and migraines are deficient in magnesium. She also cites a 2012 study in the Journal of Neural Transmission entitled "Why all migraine patients should be treated with magnesium." As a result, she recommends a healthy diet of magnesium-rich dark leafy greens like spinach, kale, broccoli and Swiss chard. Example foods: pumpkin seeds, spinach and avocado, kale, broccoli and Swiss chard 3. Ginger "Many swear by ginger as a way to help with migraines," states Dr. Maria Knöbel, a general practitioner and medical director of Medical Cert UK. "Studies have proven that ginger reduces nausea and can decrease the inflammation that leads to migraine pain. Ginger has helped patients during my practice, whether they take it as ginger tea or in supplement form." She references a 2014 study that found ginger powder to be as effective as the medication sumatriptan in treating acute migraine attacks, but with fewer side effects. Ginger tea may be especially beneficial because, Knöbel states, "It's important to drink enough water, as well as eat ginger. Drinking enough water might stop your migraine from getting any worse." Church also recommends ginger because it contains natural anti-inflammatory compounds like gingerol. "I've had patients find relief from migraines or migraine-related nausea using ginger tea, powder or chews," he explains. A 2019 study also found that 400mg of ginger extract, in addition to 100mg of the non-steroidal anti-inflammatory drug ketoprofen, may help treat migraine attacks. Ginger tea combines the benefits of ginger with the hydration of water.4. Nuts and seeds "Another group of foods I recommend are nuts and seeds, including almonds, pumpkin seeds, sunflower seeds and walnuts," Church states. "Like leafy greens, these are rich in magnesium, and some also provide vitamin E, which has been shown to help with menstrual migraines and migraines with aura." A 2015 study reflected this. Example foods: almonds, pumpkin seeds, sunflower seeds and walnuts 5. Cinnamon "Cinnamon contains a high amount of antioxidants that may also reduce headache frequency," Campbell explains. "Stir it into your morning oatmeal or tea, or bake it into muffins and breads." She cites a randomized, double-masked, placebo-controlled 2020 trial, stating, "Studies suggest that cinnamon supplementation may lower inflammation, cutting down on migraine frequency, severity and duration." The antioxidants in cinnamon may help treat headaches and migraines. FreshSplash/Getty Images 6. Foods rich in vitamin B2 "A well-known [1998] randomized controlled trial found that 400 mg of riboflavin daily significantly reduced migraine frequency and severity over a three-month period," Church says. Though this high dose usually comes from supplementation, riboflavin-rich foods support the same metabolic processes in migraine prevention. These foods can include eggs, dairy and lean meats. "Riboflavin is essential for mitochondrial energy production, and many researchers believe that migraines stem in part from dysfunction in energy metabolism within brain cells," Church adds. Redwood adds, "There exists a small but promising body of research on the effectiveness of some nutritional supplements for migraines, especially riboflavin (vitamin B2), coenzyme Q10 and magnesium. The first research-based indicator of riboflavin's potential as a migraine treatment appeared in a small 1946 article by a medical physician, published in the Canadian Medical Association Journal, which reported dramatic effectiveness from what would now be considered low-dose B2 supplements." A 2022 systematic review and meta-analysis found that supplementation of 400mg/day of vitamin B2 for three months affected the duration, frequency and pain score of migraine attacks. Example foods: Eggs, dairy and lean meats 7. Turmeric Curcumin is the active compound in turmeric and, according to Campbell, is "high in antioxidant power and shines especially when paired with omega-3s." To add it to your diet, consider sprinkling it into smoothies, curries or teas. Campbell references a randomized, double-masked, placebo-controlled 2021 trial that concluded, "Present findings revealed that n-3 fatty acids and curcumin co-supplementation can be suggested as a promising new approach in migraine headache management." However, more studies are needed. When combined with omega-3s, turmeric may help with migraine headache management. Rawlstock/Getty Images 8. Whole grains Church mentions that whole grains like quinoa, brown rice and oats may also be beneficial since they "provide a steady release of glucose, preventing blood sugar crashes that can trigger headaches, and are good sources of fiber, B vitamins and trace minerals." He cites a 2023 cross-sectional study of 12,710 participants with all data collected from a 1999-2004 National Health and Nutrition Examination Survey. It found that for every 10 grams of fiber added to the diet, there was an 11% reduction in the odds of having severe headaches or migraines. "By providing magnesium, iron, and B vitamins, whole grains support brain health, oxygen delivery and a stable glucose supply, which are all relevant to migraine prevention," concludes Church. A 2023 comprehensive review also found that curcumin is a promising candidate for preventing and controlling migraines due to its anti‑inflammatory, antioxidative, anti-protein aggregate and analgesic effects. However, additional studies are needed. Example foods: quinoa, brown rice and oats 9. Water-rich foods Dr. Kimberly Idoko, a developmental neurobiologist and board-certified neurologist, reveals that dehydration can also trigger headaches, which is why staying hydrated can significantly improve migraine treatments. "Water-rich foods like cucumber, watermelon and citrus fruits also help you stay hydrated," adds Church. To prevent dehydration-caused headaches or migraines, enjoy more water-rich foods like watermelon. Anucha Muphasa/500px/Getty Images Foods that may trigger headaches or migraines Chocolate, cheese and alcohol: "In one [2007] study of over 500 migraine sufferers, 44% reported at least one food as a trigger. Among the most common triggers were chocolate, cheese and alcohol, " reveals Dr. Adam Lowenstein, a board-certified plastic surgeon who runs the Migraine Surgery Specialty Center. Gluten: "Gluten can be a highly inflammatory food substance, especially among those who are prone to sensitivities or gluten allergy," explains Trista Best, a registered dietitian at The Candida Diet, environmental health specialist and adjunct nutrition professor. "This inflammation causes a host of health conditions, including migraines." When it comes to caffeine, moderation is "The most fascinating study I've seen on the role of nutrition in the treatment of headaches (Hering-Hanit and Gadoth, 2003) was published in Cephalalgia, the premier headache journal. Over a 5-year period, doctors at a neurology clinic in Israel treated 36 children and adolescents (average age 9) with severe daily or near-daily headaches who drank an average of 11 quarts of cola drinks per week," says Redwood. "At the end of a gradual withdrawal period (because too speedy a withdrawal can trigger even worse headaches), 33 of these 36 young people were headache-free, a truly stunning result. Nearly all cola drinks contain substantial amounts of caffeine (Chou and Bell, 2007)." Note: 11 quarts of cola per week is extreme, and the average person doesn't consume this much caffeine. Moderate caffeine intake is still OK, according to Amelia Ti, a registered dietitian and diabetes educator in New York City who is also part of CNET's medical review board. However, when it comes to caffeine, Church notes, "Caffeine, used strategically, can enhance the absorption of pain relievers and constrict dilated blood vessels in the brain, which may ease migraine pain. This is why many over-the-counter headache medications include it. Studies have shown that 40–100 mg of caffeine (the amount in a small cup of coffee or strong tea) can reduce migraine or tension headache pain. But, chronic overuse can lead to rebound headaches, so moderation is key." Added sugars and highly processed foods: "Research has shown that people following a 'Western' diet, which includes substantial amounts of added sugars and other highly processed foods, are at greater than average risk for developing migraines, while the risk is significantly lower than average for those following a healthier diet," states Redwood. Dr. Joseph Mercola, a board-certified family physician and author of Your Guide to Cellular Health, adds that in addition to incorporating foods rich in specific nutrients like magnesium and B vitamins, you'll want to eliminate triggers like processed foods that contain nitrates, MSG, added sugars or yeast.
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