September | 2014 | Headache NewsBlog

Stabbing headaches as a sign of MS

By: Dr. Mauskop

22-09-2014

Stabbing headaches can be a sign of acute multiple sclerosis, according to a report by German doctors in the journal Headache. Stabbing headache is a rare type of headache, although patients with migraines often report having occasional “ice pick” headaches. Some call these headaches “jabs and jolts”. In some people, stabbing headaches can be quite disabling. The pain lasts only a couple of seconds but can occur up to 100 times a day. Treatment usually involves indomethacin or another non-steroidal anti-inflammatory medication in the aspirin family (including our own Migralex). However, in this case where stabbing headaches were associated with MS, treating MS relieved headaches as well.

In a prior report in Clinical Neurology and Neurosurgery Italian physicians also found that of 26 patients with stabbing headaches they had seen over 10 years, more than half had autoimmune disorders, including multiple sclerosis, Sjögren’s disease, lupus, Behçet’s disease, autoimmune vasculitis, and antiphospholipid antibody syndrome. The authors speculated that stabbing headache may develop as a result of inflammation in the brain with loss of myelin around the nerve fibers, which is seen with MS and other auto-immune disorders.

Peripheral nerve blocks for an acute migraine

By: Dr. Mauskop

15-09-2014

Alternative Therapies, neurostimulation, New treatments

Peripheral nerve blocks can be very effective in stopping a severe migraine attack. We utilize them when a patient does not respond to oral or injected medications or when medications are contraindicated because of a coexisting disease or pregnancy.

Dr. Jessica Ailani and her colleagues at the Georgetown University in Washington, D.C. presented their experience with nerve blocks at the last annual meeting of the American Headache Society in Los Angeles. The study included 164 patients. Most patients received occipital and trigeminal nerve blocks using lidocaine or a similar local anesthetic.

Most patients were satisfied with the results, which lasted from several days up to 2 weeks. Only a small number of participants experienced side effects such as soreness at the site of injections, nausea and vomiting, and head and neck pain.

Dr. Ailani noted that more than 71% of patients rated their pain as 4 to 8 out of 10 before treatment with a nerve block. After a nerve block, nearly half (47.2%) said the pain had reduced to 1 out of 10.

“This is a very well-tolerated procedure and patients are very satisfied with the procedure,” said Dr. Ailani.

Nerve blocks can help keeps headache sufferers out of the emergency room and provide an alternative to systemic drugs, that is drugs that are injected or ingested. Systemic drugs affect the entire body while nerve blocks exert only local effects (unless one is allergic to local anesthetics).

Dr. Robert Kaniecki, a headache specialist in Pittsburgh uses nerve blocks for the prevention of chronic migraine headaches. He administers them into the same areas where Botox is injected. He finds that for some of his patients nerve blocks given every 12 weeks can be as effective as Botox. It is possible that such patients have milder migraines since the effect of nerve blocks lasts a very short time (lidocaine leaves the body after 4 hours or so) compared with the effect of Botox which lasts 3 months. Unlike Botox injections, nerve blocks have not been subjected to a rigorous scientific study comparing them to placebo (saline) injections.

Antidepressants for migraines

By: Dr. Mauskop

11-09-2014

Headache medications

Frequent attacks of migraine are best treated with preventive measures. Several categories of medications have been shown to be effective for the prevention of migraine headaches. These include Botox injections (for chronic migraine), epilepsy drugs (gabapentin, topiramate, divalproex), blood pressure medications (propranolol, atenolol, lisinopril, losartan, and other), as well antidepressants.

Antidepressants, like most other preventive drugs, were discovered to be effective for pain and headaches by accident. We have good scientific proof that you do not need to be depressed to obtain pain and headache relief from these drugs. The effect on pain and on anxiety or depression are independent of each other. However, many patients who have pain and headaches have higher rates of depression and anxiety and these drugs can relieve both conditions.

The oldest category of antidepressants are tricyclic antidepressants. Elavil or amitriptyline was introduced in the US in 1961. Amitriptyline has been extensively tested for a variety of painful conditions, including low back pain, neuropathy pain, migraines, and other. The main side effects of amitriptyline are dry mouth, drowsiness, constipation, and sometimes, weight gain. Other drugs in the family of tricyclic antidepressants often have fewer side effects. Many doctors always begin with nortriptyline or Pamelor, which is a derivative of amitriptyline and may have fewer side effects. Amitriptyline is broken down in the body into nortriptyline, which is less sedating. We also prescribe other tricyclics, desipramine (Norpramine), doxepin (Sinequan), and protriptyline (Vivactil), which also tend to have fewer side effects. When a patient has insomnia and is not prone to gaining wait, amitriptyline may be the better choice since it will also improve sleep.

The starting dose of amitriptyline, nortriptyline, doxepin, and desipramine is 10 or 25 mg taken at night. Then, if this starting dose is ineffective, the dose is gradually increased to 50 mg, then 75, and sometimes higher. Besides being very effective, tricyclics have another advantage – there is a blood test to measure how much of the medicine is absorbed and is circulating in the body. When a patient takes more than 75 – 100 mg without obtaining relief, we do a blood test to see if the blood level is low and we need to increase the dose or if the level is high and the drug is just ineffective. With protriptyline, the least sedating drug, the starting dose is 10 mg and the highest dose is around 30 mg. Treatment of pain and migraines usually requires a much lower dose of a tricyclic than for depression. All of the tricyclics are available in a generic form and are inexpensive.

Another category of antidepressants that relieve pain and headaches is serotonin and norepinephrine reuptake inhibitors, or SNRIs. Some of the SNRIs are FDA-approved for various painful conditions, such as neuropathy, shingles, fibromyalgia, and back pains. Most popular SNRIs are Effexor (venlafaxine), which is available in a generic form, Cymbalta (duloxetine), Pristiq (desvenlafaxine), Savella (milnacipran), and Fetzima (levomilnacipran). These drugs have fewer side effects than tricyclics, although they are sometimes difficult to stop because they can cause heightened anxiety and other withdrawal symptoms.

Nardil (phenelzine) is an antidepressant in the family of MAO inhibitors and it has also been used for the preventive treatment of migraine headaches. However, this drug has many potential serious drug-drug and drug–food interactions and most doctors avoid this medicine. Other MAOI drugs are Parnate (tranylcypromine), Emsam patch (selegiline) and other.

SSRIs are the most popular drugs for the treatment of anxiety and depression, but they are ineffective for the treatment of pain, migraines, and other headaches. These drugs include Prozac (fluoxetine), Paxil (paroxetine), Lexapro (escitalopram), Zoloft (sertraline) and other. They are very popular because they have fewer side effects than other antidepressants, although they probably cause higher rates of sexual dysfunction.

Online cognitive-behavioral therapy

By: Dr. Mauskop

01-09-2014

Alternative Therapies

Severe persistent migraines can affect emotional, interpersonal, social, and work-related functioning. It is difficult to learn how to cope with pain and improve your functioning on your own. Cognitive-behavioral therapy (CBT) has been proven to improve lives of people with pain, including migraine headaches and not only in adults, but also in children. One major problem with CBT is that it is not readily available in many areas and when available, it is expensive.

I’ve written about two online programs for CBT, which offer help to patients with anxiety and depression. Another online service painACTION.com offers free resources that have been shown to improve coping with pain, to decrease anxiety and depression, and to provide other benefits. The site offers help to patients with migraine, as well as cancer pain, back and arthritis pain, and neuropathic pain. The migraine section has five modules: communication skills, emotional coping, self-management skills, knowledge base, and medication safety.

I do have a problem with their medication safety section in that it does not mention caffeine and caffeine-containing drugs when describing rebound, or medication overuse headaches. These drugs include Excedrin, Anacin, Fiorinal, Fioricet, Esgic, and other. At the same time, they list aspirin, which actually may prevent medication overuse headaches and triptans, which rarely cause such headaches (one of my most popular posts is devoted to daily intake of triptans, which is not something I encourage, but which is the only solution for some patients).

But overall, this is a very useful resource for headache sufferers. To take full advantage of this site you need to go through multiple modules, preferably on a regular basis, say twice a week. It is also useful to keep going back to the old material since it is not easy to change faulty thought processes. The site has enough material to keep you engaged for many sessions. And if you do visit the site regularly you will find that your headaches may become more manageable and that they may have less of an impact on your life.