April | 2016 | Headache NewsBlog

Intranasal ketorolac is as good as intranasal sumatriptan (Imitrex)

By: Dr. Mauskop

25-04-2016

Sumatriptan (Imitrex) and similar drugs (so called triptans) are “designer” drugs that were specifically developed for the treatment of migraine headaches. They are very effective, but do not help all migraine sufferers. Anti-inflammatory pain killers, such as aspirin and ibuprofen work well for some people and sometimes these drugs are combined with triptans to achieve better relief.

Many migraineurs experience nausea and sometimes vomiting as part of their migraine, which prevents or delays the absorption of medicine, making it ineffective or less effective. To address this problem, two of the triptans, sumatriptan and zolmitriptan (Zomig) are available in a nasal spray form. Sumatriptan can be also self-administered as an injection and recently a skin patch of sumatriptan (Zecuity) became available. An anti-inflammatory pain medicine, ketorolac is also available as a nasal spray, as does a narcotic pain killer, Stadol (butorphanol). While Stadol is addictive and has other serious side effects, intranasal ketorolac (Sprix) is a very good pain medication. Sprix works much better than the ketorolac tablet, but not as well as an injection of ketorolac (Toradol).

Intranasal ketorolac was compared with intranasal sumatriptan in a study that was recently published in the journal Headache. The study showed that ketorolac and sumatriptan nasal sprays were equally effective and both were better than placebo spray. Both drugs caused nasal irritation and unpleasant taste in some patients, but these were not severe.

The main problem with intranasal ketorolac is its cost. On GoodRx.com the price of 5 vials of Sprix (with a coupon) is about $1,000. Each vial is good for one day of use; it contains 8 sprays (15 mg each) and the usual dose is one spray into each nostril, repeated every 6 hours as needed. However, there is a way around the cost of this medication. Ten 30 mg vials of generic ketorolac for injections cost $15. You just need to buy a nasal spray bottle, empty the contents of the vial into it and use it as needed.

Botox is woefully underused in the treatment of chronic migraines

By: Dr. Mauskop

18-04-2016

Botox, Chronic migraine, Migraine

The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered that in this period of time only 100,000 chronic migraine sufferers received this treatment. According to the Migraine Research Foundation, 14 million Americans suffer from chronic migraines, so less than 1% of them have recieved this potentially life-changing treatment.

There are several possible explanations.
1. Botox is expensive and many insurance companies make it difficult for patients to get it. They require that the patient first try 2 or 3 preventive drugs, such as a blood pressure medicine, (propranolol, atenolol, etc.), an epilepsy drug (gabapentin, Depakote, Topamax), or an antidepressant (amitriptyline, nortriptyline, Cymbalta). Patients also have to have 15 or more headache days (not all of them have to be migraines) in each of the three preceding months. If these requirements are met, the doctor has to submit a request for prior authorization. Once this prior authorization is granted, the insurer will usually send Botox to the doctor’s office. After the procedure is done, the doctor has to submit a bill to get paid for administering Botox. This bill does not always automatically get paid, even if a prior authorization was properly obtained. The insurer can ask for a copy of office notes that show that the procedure was indeed performed. All this obviously serves as a deterrent for many doctors. Some of them find that the amount of paperwork is so great and that the payment is so low and uncertain, that they actually lose money doing it.

2. There are not enough doctors trained in administering Botox. This is becoming less of a problem as more and more neurologists join large groups or hospitals where at least one of the neurologists is trained to give Botox and gets patients referred to him or her. However, doctors in solo practices or small groups without a trained injector can be reluctant to refer their patients out for the fear of losing a patient. They may suggest that this treatment is not really that effective or that it can cause serious side effects.
The majority of doctors who inject Botox are neurologists, but there are only 15,000 neurologists in the US and many specialize in the treatment of strokes, Alzheimer’s, epilepsy, MS, and other conditions. This leaves only a couple of thousand who treat headache patients. Considering that there are 14 million chronic migraine sufferers, primary care doctors will hopefully begin to provide this service.

3. Chronic migraine patients are underdiagnosed. Many patients will tell the doctor that they have 2 migraines a week and will not mention that they also have a mild headache every day. The mild headaches they can live with and sometimes my patients will even call them “normal headaches”, which they don’t think are worth mentioning. Good history taking on the part of the doctor solves this problem. However, once doctors join a large group or a hospital, they are pressured to see more patients in shorter periods of time, making it difficult to obtain a thorough history.

4. Some patients are afraid of Botox because it is a poison. In fact, by weight it is the deadliest poison known to man. However, it is safer than Tylenol (acetaminophen) because it all depends on the amount and too much of almost any drug can kill you. Fifty 500 mg tablets of Tylenol kills most people by causing irreversible liver damage. Hundreds of people die every year because of an accidental Tylenol poisoning, while it is extremely rare for someone to die from Botox. Tens of millions of people have been exposed to Botox since its introduction in 1989. It is mostly young children who have gotten into trouble from Botox because the dose was not properly calculated. Kids get Botox injected into their leg muscles for spasticity due to cerebral palsy, although children with chronic migraines also receive it (the youngest child with chronic migraines I treated with Botox was 8).

In summary, if you have headaches on more than half of the days (not necessarily all migraines) and you’ve tried two or three preventive drugs (and exercise, meditation, magnesium, CoQ10, etc), try to find a doctor who will give you Botox injections. Botox is more effective and safer than preventive medications because it does not affect your liver, kidneys, brain, or any other organ.

Yoga, chiropractic and my neck

By: Dr. Mauskop

09-04-2016

Alternative Therapies

Yoga is the most impactful import from India to the US. Yoga has many documented health benefits, including relief of headaches. I have been practicing Bikram yoga about twice a week for nearly 12 years. About a year ago I started having some neck and left upper back pain. I thought that strengthening neck exercises, meditation, occasional massage, which is what I recommend my patients, would eliminate the pain (I probably should have also gone for physical therapy). The pain was never severe and would temporarily improve with massage, but because it persisted and became annoying, I decided to try chiropractic.

Many doctors’ attitude towards chiropractors is dismissive, disdainful or worse. When I tried to google the number of chiropractic manipulations done in the US, the first item that popped up was Medscape’s Deaths After Chiropractic: A Review of Published Cases (there were 26 cases in that report). I have personally treated an elderly patient who developed a subdural hematoma (bleeding inside the head) after chiropractic manipulation. My usual advice to patients has been to go for physical therapy and massage instead of chiropractic. If a patient really wants to see a chiropractor, I advise asking not have any high velocity adjustments. This adjustment is done by suddenly turning and lifting your head to one side and it is responsible for most of the complications. I also tell patients that a good chiropractor will always give you exercises to do, while those who don’t, just want you to keep coming for adjustments for years. Many people feel immediate relief from chiropractic, but it lasts only a few days and they have to go back for another treatment. In fact, regular stretching done by a chiropractor can loosen the ligaments around the cervical spine and cause habitual subluxation of the joints. Subluxation is a partial joint misalignment, which a chiropractor can fix, but repeated adjustments stretches the ligaments and make it easier for the joint to misalign again.

So, why did I take a chance with my neck if not life? First, I wanted to experience what a chiropractic manipulation is like (I’ve also tried Botox, intravenous magnesium, TMS stimulation, and other treatments I offer my patients). Second, I ran into (or rather gave a TV interview to) Lou Bisogni, a chiropractor who is the chiropractor for the New York Yankees. If Joe Torre, Yogi Berra, Wade Boggs, Derek Jeter, and other top Yankee players (dozens of their signed photos are on the office walls) have been entrusting their bodies to him, then obviously he must be very good.

Because my pain has lasted for almost a year, Bisogni first X-rayed my neck. I was not surprised to see that my C5-6 cervical disc was mildly degenerated and the C5 vertebra slipped slightly forward over the C6. This misalignment was what must have prevented my pain from going away. Treatment of such mild misalignments is what chiropractors are probably best at. I did tell him that I did not want high velocity adjustments and he reassured me that he wasn’t going to do any. Many chiropractors are fully aware of the risks and do avoid this type of adjustment. Instead, Bisogni would first apply TENS (transcutaneous electric nerve stimulation – an old technique often used by physical therapists as well), ultrasound, or massage, followed by a brief and gentle adjustment. The adjustment was so gentle and brief (5 minutes or so) that I was a bit skeptical about its efficacy. But to my surprise, after 5 – 6 sessions my pain dramatically improved. It is not completely gone, so I will go for a few more sessions.

I did cut back on Bikram yoga to once a week (but added some weight training instead) and modified my routine when I do it. It is possible that extreme flexion and extension of my neck, which is part of some yoga positions (rabbit, camel, pranayama breathing), might have caused my neck problem. So, I avoid flexing and extending my neck all the way as far as I can. Many yoga instructors push their students to achieve a full expression of the pose, but if your neck hurts or feels uncomfortable, tell the instructor that you’d rather not take a chance with your neck. You should definitely avoid head stands (unless you can do them without putting any pressure on your head and support yourself on the forearms) and shoulder stands, which put excessive pressure on your cervical spine. Also, the high heat in Bikram studios can be a headache trigger for some migraine sufferers and I usually recommend to my patients doing yoga at room temperature.

Sodium intake and migraines

By: Dr. Mauskop

02-04-2016

Alternative Therapies, Migraine, Science of Migraine

I have not been aware of any research indicating a link between salt intake and migraines. A study just published in the journal Headache by researchers at Stanford and UCLA looked at this possible connection.
This was a national nutritional study that examined sodium intake in people with a history of migraine or severe headaches.

The study included 8819 adults with reliable data on diet and headache history. The researchers classified respondents who reported a history of migraine or severe headaches as having probable history of migraine. They excluded patients with medication overuse headache, that is people who were taking pain medications very frequently. Dietary sodium intake was measured using estimates that have been proven to be reliable in previous studies.

Surprisingly, higher dietary intake of sodium was associated with a lower chance of migraines or severe headaches. This relationship was not affected by age or sex. In women, this inverse relationship was limited to those with lower weight (as measured by body mass index, or BMI), while in men the relationship did not differ by BMI.

This study offered the first scientific evidence of an inverse relationship between migraines and severe headaches and dietary sodium intake.

It is very premature to recommend increased sodium intake to all people who suffer from migraines and severe headaches. However, considering that this is a relatively safe intervention, it may make sense to try increased salt intake. I would suggest adding table salt to a healthy and balanced diet, rather than eating salty foods such as smoked fish, potato chips, processed deli meats, or pickles. These foods contain sulfites, nitrites, and other preservatives which can trigger a migraine attack.

People with high blood pressure and kidney or heart disease need to consult their doctor before increasing their salt intake.