A case of oesophageal spasm, and the ‘unproven’ treatment that helped it

A couple of weeks back I was talking with a close family member, and he mentioned that for many years he had been getting digestive discomfort that tended to come after meals. When I asked to point to where his pain was, he indicated that it was in the middle of the abdomen just at the end of the breastbone. In medicine, this region is referred to as the ‘epigastrium’, and pain here is generally a sign of an issue in the stomach or lower end of the oesophagus (food pipe). Often, the issue is related to ‘reflux’, where acidic stomach contents come up into the oesophagus and cause pain here. Simple antacids or acid-suppressing medication will usually stop symptoms if that’s the case, but this approach hadn’t worked here.

In fact, closer questioning revealed no prior symptoms of ‘acidity’, reflux or regurgitation. The suggestion here being that excess ‘acidity’ in the stomach was unlikely to be the problem.

In natural medicine, some practitioners (including I) believe that symptoms of excess acidity can actually be the result of a low levels of stomach acidity (the medical term for which is ‘hypochlorhydria’). See here and here for more about this.

However, my family member did not have any symptoms that were particularly suggestive of this either (such as getting full quickly on eating, epigastric bloating immediately after meals or the feeling of food getting ‘stuck’ in the stomach for some hours after eating). All-in-all, this was not looking like his symptoms were due to over- or under-secretion of acid.

One other potential cause of discomfort in the epigastrium that comes from the digestive tract is ‘oesophageal spasm’. Here, any part of the oesophagus, including the sphincter at its lower end, can ‘cramp up’, causing quite intense pain and discomfort. It is, in my experience, quite a common problem, but one which tends not to be thought about much in conventional medicine.

I remember once attending a nutritional therapy course for doctors in the US, in which one of the facilitators (Dr Jonathan Wright) said, If it spasms, think magnesium (or something similar). And this sagely piece of advice was based on the idea that low levels of magnesium in the body tend to cause muscle to go into spasm. This might include so-called ‘smooth’ muscle in, say, the digestive tract, bladder on in the walls of the arteries. It might also include ‘skeletal’ muscle, say, in the legs. Ever since hearing learning this I’ve used magnesium generally very effectively to treat conditions like muscular cramps, ‘restless legs’, irritable bladder syndrome and oesophageal spasm.

So, with this I mind I suggested that my family member supplement with magnesium to see if this helps his symptoms. In short, it did. Within a day or two of taking magnesium, the epigastric discomfort that had plagued him on a daily basis for years disappeared, and has seemingly not returned some 10 days later.

Of course, we cannot be sure that it was the magnesium that did the trick. Maybe it was a spontaneous resolution (unlikely after years of consistent symptoms). Or perhaps it was just a placebo response? We’ll never know. But, then again, my family member is not inclined to know. All he really cares about is that a persistent, recurrent digestive discomfort he has had for years is now gone.

The main reason for writing about this issue is because I think it would be good if oesophageal spasm got more widespread recognition.

However, it also reminded me of how often in practice I and other health professionals can be faced with a health issue for which there is no ‘proven’ treatment. I don’t believe magnesium has been studied with regard to its impact of oesophageal spasm. However, in this case giving it appears to have worked to resolve longstanding symptoms. Even if this is down to nothing more than a placebo response, then few would deny that my family member is better off for taking the magnesium.

However, imagine for a moment that magnesium therapy had been studied for oesophageal spasm and not been found to be effective (compared to placebo). Does that mean that we should not use magnesium to treat oesophageal spasm? Some would argue we shouldn’t. However, even when a treatment has been shown to be ineffective compared to placebo in a study, that does not mean it cannot work in a single individual (including the person sitting opposite you in practice). The other thing worth bearing in mind that even when a treatment has been proven, if it appears to work in an individual in practice, we can never be sure if this is was because of some genuine action or a placebo response (or something else).

This recent experience with my family member reminded me of just how limited scientific evidence can be in real life. And how important it can be to be open to ‘unproven’ treatments if, as healthcare practitioners, we’re committed to doing our best for our patients and those we advise.

30 Responses to A case of oesophageal spasm, and the ‘unproven’ treatment that helped it

  1. Jack Billingsly 29 December 2009 at 8:44 pm #

    Dr. Briffa,

    Based upon your comments toward the latter half of this post, I wanted to get your take on the following question.

    In the exercise world, you’ll tend to find two camps regarding vairous types of supplementation- those who feel that everything (or almost everything) under the sun is merely a scam from a company trying to make a buck off of people who don’t stay up on research and those who are more accepting that certain things may be legitimately beneficial based upon certain evidence available.

    But if a person can afford “X” and based upon subjective and objective markers of health there is no reason to think “X” is having any negative impact, then wouldn’t X possibly be worth it even if its benefit is based upon perception as opposed to some actual “provable” benefit?

    Most would say that if it has no effect you’re being taken for a ride and parted from your hard-earned money. But the flip side is that oftentimes in sport, the athlete with a psychological edge is said to be the one who has the upper hand. So even if “X” is more of a psychological boost than anything else, why does it so often get panned as rubbish by those saying that you’d see the same results without it as opposed to celebrated as a geneuine boost that may actually enhance results even if it is in an indirect manner?

    I am not suggesting that companies perpetrate large scale scams based solely on what may amount to a placebo effect, but if people admit there can be a placebo effect, why is it always spoken about as if it is a loathsome bogeyman? If a person is seeing a desired result, it doesn’t seem to matter if the effect is placebo or otherwise so long as things move in whatever direction you want them to and there are no unintended negative side effects.

  2. Chris 1 January 2010 at 7:57 pm #

    John, I think this is an excellent piece. It would appear the burden of responsibility to practice evidence based medicine is a laudable, yet also a potentially limiting, constraint.

    I am old enough (just) to remember from my childhood days that Milk of Magenesia featured in the family medicine cupboard and was a popular remedy for indigestion. According to Wkipedia Milk of Magnesia dates to @1880 and so is a preparation that originates from a time before the age of the status of ‘scientific’ medicine aspirational of practitioners today and use persisted into the 1960s and 1970s. I don’t know if the preparation still sells today, certainly modern popular indigestion and antacid remedies now come in tablet or lozenge form. Knowledge and practice evolve. But I wonder might Milk of Magnesia still sell in less developed economies than our ow?

    Progress and accumulation of knowledge, science, technology, medicine etc., do positively impact on the quality of our lives improving the quality of the ‘tools’ available to, and the advice dispensed by, practitioners, but the commercial expediency inherent in the quest for advancement creates an imperative to adopt the new and innovative. New and innovative often being ‘good’, though not always. Advancement can have negative consequence. But as you say, you have to practice with an incomplete ‘economy of knowledge’ on matters. One consequence of the imperative is the demise of old wisdoms; wisdoms that might hold validity but lack supporting evidence to 21st c. standards. Another consequence of the imperative as would appear to afflict medical research is a willingness to treat symptom as a preference to address cause. In the case of your family member who responded to magnesium are his dietary choices deficient in magnesium or, perhaps more profoundly, is modern, intensively farmed produce deficient in magnesium?

    But just to wrap up with an illustration pertaining to old wisdoms. In the Q&A session at the close of the December (09) Food Standards Agency open board meeting a member of the public raised a question about ‘patterned eating’ and did this have implications for the FSAs health promotional advice. Research, apparently, shows babies’ biggest feed is early in the day and volumes decline as the day progresses. The questioner inferred there may be ‘mileage’ in patterned eating and solicited the opinion of the board. In an entertaining moment the board were nonplussed and a loss for any meaningful comment. Yet a phrase comes to mind that was once in fairly common parlance and has perhaps declined in use in the ambition for modernity, “Breakfast like a king, lunch like a prince, and dine like a pauper.”
    I note in the Winter 2009 edition of Optimum Nutrition Magazine (p12), Nicola Moore has constructed an article based upon studies underscoring the merits of eating breakfast citing references including this.
    Slightly off topic but also an amusing moment in the FSA meeting was examination of Commercial Director, Terrence Collis’ colon. Even now I’m anxious for news, did the colon remain or has Terrence suffered colectomy, typographically speaking?

  3. Jim Harwood 1 January 2010 at 9:33 pm #

    My wife had episodes of oesophageal spasm some years back. At first there was concern that the pain was of cardiac origin. She responded fully to magnesium supplementation. I find magnesium citrate the most effective form.

  4. Dr John Briffa 1 January 2010 at 9:51 pm #

    Jack

    “If a person is seeing a desired result, it doesn’t seem to matter if the effect is placebo or otherwise so long as things move in whatever direction you want them to and there are no unintended negative side effects.”

    Think this sentence kinda sums up my sentiments regarding this, though it’s really a hypothetical question, in that we’ll never know if any perceived/objective effect is down to a real effect, placebo, a mix of both or something else.

  5. Joanna 2 January 2010 at 12:29 am #

    I’ve tried magnesium (along with several other remedies) and it doesn’t work for my restless legs or difficulty swallowing.

    Magnesium may work for some but not for everyone, as each person is unique.

  6. Janet 2 January 2010 at 3:13 am #

    Some time ago I read in your column in the Observer that supplementing with magnesium was the way to go if muscle cramping was a problem. At the time I was in misery with cramp in toes, feet, ankles, calves, hamstrings, upper abs, hands and occasionally even down the side of my face. – not all at once, I hasten to add. Some nights I was up and down like a yoyo. BUT within days of beginning to take 250mgs per day it all subsided and now if it flares up I simply double the daily dose. It works. A big thankyou.

  7. audrey wickham 2 January 2010 at 1:23 pm #

    In my late twenties I suffered from painful spasms – not just painful but very frightening because they came and went for no reason and the spasms took over my whole throat.

    I have moved around a lot and had a few doctors. Only one, when I described to him a recent spasm, suggested it could be an Hiatus Hernia. Sure enough that was what was causing it.

    I was prescribed a milk tablet that would reduce the acid in my stomach – my GP said damage to the membrane caused by the acid could lead to cancer so I was motivated to take the tablets.

    I took the first lot of tablets but from then on I ate yoghurt or drank a glass of milk at the onset of the spasms and that seemed to work.

    As I got older the spasms reduced from about three a year to zero without any medication. A cousin by marriage told me he had an Hiatus Hernia and we compared our similar symptoms and the fact that as we got older the symptoms disappeared. I am eighty in three months and haven’t had a return to the spasm condition for 35 years. I love cream, yoghurt and milk so feel that I have coated my stomach sufficiently to cope with the Hernia.

    I was given, at the time, a diet sheet which included just about everything I eat on a daily basis. Wholemeal bread and Spring greens I wouldn’t give up so I didn’t give up any of them.

  8. Dr John Briffa 2 January 2010 at 4:51 pm #

    Joanna

    The form and dose of magnesium can be critical to success. Do you know the type of magnesium you tried, and the dose?

    Janey

    My pleasure!

  9. Martin Fox 4 January 2010 at 2:42 am #

    What form and level of Mg was used in the case noted above? How was it taken – before, with, after meals or when the stomach was empty? Thanks.
    Thanks

  10. Dr John Briffa 4 January 2010 at 2:55 pm #

    Martin

    The product in this case was magnesium chloride along with fumaric acid (Biocare’s Bio-Magnesium). Total dosage initially is 300 mg of elemental magnesium with 1500 mg of fumaric acid (3 caps of Bio-Magnesium each day) taken with meals. The view is to reduce this dosage to 2 caps a day.

  11. Martin Fox 4 January 2010 at 7:27 pm #

    Thanks. I wonder if you know of a company in the United States that has a similar product? I have look without results. The case you wrote about is an accurate description on what my friend is experiencing.

    If I cannot find a product with Mg and fumaric acid, I assume similar results might happen with magnesium choride and a separate tablet for fumaric acid?

    Do you think magnesium citrate at the doze recommended could be a useful option? Thanks again…

    Martin

  12. Dr John Briffa 4 January 2010 at 7:40 pm #

    Martin

    Don’t know of an equivalent product in the US, unfortunately. However, think taking magnesium and fumaric acid TOGETHER is a good ploy. And also think trying another quite absorbable form of magnesium (e.g. mg citrate) is also a good ploy.

    My advice is to avoid mg oxide:

    http://www.jacn.org/cgi/content/abstract/9/1/48

  13. Eva 4 January 2010 at 9:49 pm #

    Dear Dr Briffa

    I was very glad to see your article addressing the problem of oesophageal spasm! I get this periodically, usually at night or early morning, sometimes lasting a full day or two. I also tend get restless legs and even leg cramps (usually in the left calf or in the foot) sometimes. Since I take magnesium on a daily basis (with calcium), I presume that this cannot be the result of (only) a magnesium deficiency. I find that taking MagPhos tissue salts helps prevent restless legs, and that drinking a bit of salt water relieves my leg cramping almost immediately (placebo effect?).
    Leg cramping could also result from an iron deficiency, I hear, and a deficiency in kalium (potash?) is also named as a cause..
    On the whole, I suspect that in my case stress is the major cause of oesophagus cramping and that my restless legs could be caused by a pinched spinal nerve, as I have previously had a problem with a prolapsed disk.

  14. clare 18 January 2010 at 4:26 pm #

    hi Dr Briffa i have had oesophageal spasms for 2 yrs now and have tried numerous medications with no effect. I now taking oramorph when pain excruciating, i also have sphincter of oddi type 3 which i have been told by my gastroenterologist is a muscle spasm in the bile ducts in my stomach, he has admitted he does,nt know how to treat me but sympathises ! I have now been referred to a clinical psychologist for pain management as they dont know what to do with me. these conditions are ruining my life, could you please give me some advice as i came across your website this morning looking agin for information ! many many thanks

  15. Dr John Briffa 18 January 2010 at 5:20 pm #

    Clare

    I can’t give personalised advice remotely, but have you read the post and the comments that follow it?

  16. Arne 29 April 2010 at 4:50 pm #

    I have a number of GI spasm issues and I keep forgetting that, among other problems, I continue to be magnesium deficient despite 18+ months of supplementation (magnesium glycinate, 400mg tablet, three times a day). I ordered some magnesium malate the other day, hopefully it will make a difference.

    Also, I appreciate the open-minded and optimistic tone of this article. I am very pro-science but we have to remember that our knowledge is often very limited. Current technology and research methods can make it seem like contemporary medicine has all the answers, but in many ways we are still in the dark ages.

  17. Maureen 8 October 2010 at 12:39 am #

    I have been suffering with crippling spasms in my chest, jaw, throat etc, the pain is quite excrutiating at times and I have tried everything to help myself and have not really found anything that helps much. Could you advise me what to do. I have made drinks from ginger tablets, taken gaviscon, soda water etc and nothing has really helped. I take 40mg of esomeprazole daily.

  18. John Briffa 8 October 2010 at 1:03 am #

    Maureen

    Did you read the above post?

  19. Elizabeth Addison 5 February 2011 at 5:35 pm #

    After a very sudden onset of oesophageal spasm last
    October I have had investigations at the local
    Hospital. I have a Hiatus Hernia, & oesophagitis
    for which Nexium was prescribed. I have taken this for 3 months but have stopped recently due to the
    side effects. The oesophagitis seems fully healed
    but the Spasms coninued. Taking Magnesium (300mg)
    reduced the number but I still needed the Nitric
    spray for pain control. This week the Fumaric acid
    I ordered arrived & Im taking 500mg with Magnesium citrate each morning. The improvement is dramatic ! How much Fumaric acid is safe ?
    & for how long should it be taken ? Thank you
    for the relief from pain so far. E.M.A.

  20. lisa conlon 15 August 2011 at 11:54 pm #

    i have has spasm of the oesophagus for 4 years and have also got hiatus hernia which the doctor said that the hernia wouldnt be causing my pain. I feel like im having heart attacks and iv tried allsorts of tablets none have worked to help me with pain i now take tramadols like smarties my consultant has sent me to pain management to help me cope with the pain more coz its got that bad my partner has had to leave work to care for me (

  21. Frankie Smith 3 March 2012 at 10:56 pm #

    I used to suffer with oesophageal spasms about 15 years ago but started eating much smaller meals in a side plate, which did help enormously. They have returned I am still eating in a side plate. I have had a gastroscopy which confirms I still have a hiatus hernia and the valve into my stomach does not close properly. I am on medication to reduce the acid in my stomach. I was really pleased to read about the magnesium. I will try to get some bio magnesium. I have a very high paid threshold, but find the pain caused by the spasms quite debilitating, knowing the symtoms of the onset of a spasm, find I panic, which probably makes things worse.

  22. Bradeno 14 January 2013 at 4:28 am #

    Where can I get magnesium fumarate in the US? Doesn’t seem like BIO-CARE makes the 300mg/1500mg product you speak of in your story any longer (it says it is 200/1000 now). Can you please link to it and let me know which magnesium and fumarate product I could use in place of BIO-CARE?

    Thanks!

  23. Bradeno 14 January 2013 at 4:34 am #

    (By which I mean, which type of magnesium and which type of fumarate should I buy separately in order to get the same results)
    Also, I have recently begun taking Skullcap and melatonin and it seem to mildly help the tightness/tension in my throat from my rib cage to the top of my esophagus, but it certainly has not solved the problem, especially in the upper portion. Just some information for your readers. Any other possible solutions?

  24. Angela 8 August 2013 at 4:29 pm #

    Ladies and gentlemen, I found this website by chance a week ago, after being diagnosed with oesophageal spasms (months earlier).
    Looking for a treatment to ease or even cure this horrendously painful condition I stumbled here, as my last attack was the worst to date.

    I ordered magnesium citrate that same day. I took them at the recommended dose (300mg 3 times per day)
    In less than a week I suffered from awful acid reflux and very painful gastritis.
    I wanted to post this to make others aware of the potential risk in using magnesium supplements.
    Have a look on the web and you’ll find many more just like me.
    These supplements do not come with any specific warnings, so if you are embarking upon this course, please be cautious and observant.

    • Thomas 9 May 2014 at 2:24 pm #

      Magnesium should be taken at bedtime otherwise it might go unabsorbed and cause dehydration. Dehydration impairs digestion and causes heartburn. Dehydration also means magnesium lost along with water. Beware, if you can’t tolerate magnesium supplements, try them at bedtime, at least two hours after your last meal (if it was normal). One and half if only fruits and still normal amount. Citrate is used as laxative, did you check your magnesium levels before and after? I would n’t recommend citrate, the point is magnesium to enter your cells, otherwise it will be lost in the urine. Try magnesium chloride, or better magnesium pidolate or magnesium oxide monohydrate a newer form with superior absorption.

  25. Frankie Smith 9 August 2013 at 9:44 pm #

    Hi have had several extremely painful episodes, visited the emergency room twice worried that it was my heart, it proved oesophageal spasms. Quite by accident I discovered if I had a gassy drink as the spasm starts, when the muscles in the throat start to sieze up, the act of burping from the gas seems to halt the spasm. It has to be within the first minute, after that the spasm does not respond. I always have soda water at hand these days. I have successfully halted the spasms on 3 occasions and it does not go into a full blown episode. Just wondered if anyone else has tried this.

  26. Bruce 20 October 2013 at 5:55 am #

    Thanks! Helpful contributions!

  27. Michelle 2 May 2014 at 4:11 pm #

    Has there been any research linking HRT to spasms in gut or bladder? When on HRT peristalsis and also strength of orgasmic contractions was very strong but then gut spasms started so came off HRT.Gut still bad but am convinced there is a link re muscle cramping.

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