Alternative Therapies | Headache NewsBlog

It’s good to see the lasting impact of our research

By: Dr. Mauskop

16-11-2024

Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine

“Dr. Mauskop,

Congratulations on hitting a new milestone – over 3800 citations of your articles! This places you in the top 5% for citations within the Doximity community.”

Some of the most cited articles:

– Intravenous Magnesium Sulphate Relieves Migraine Attacks in Patients with Low Serum Ionized Magnesium Levels: A Pilot Study

– Botulinum toxin type A for the prophylaxis of chronic daily headache: Subgroup analysis of patients not receiving other prophylactic medications: A randomized double-blind, placebo-controlled study

– Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

– Effect of noninvasive vagus nerve stimulation on acute migraine: an open-label pilot study

– Foods and supplements in the management of migraine headaches.

Severe vitamin B12 deficiency can occur with normal blood levels of B12

By: Dr. Mauskop

15-10-2024

Alternative Therapies, Brain disorders, Migraine, Pain Research, Science of Migraine

Vitamin B12 deficiency is common in the elderly, vegetarians, people with diabetes, and other chronic conditions. This deficiency can cause neurological, psychiatric, hematological, and other symptoms. It can be a contributing factor to migraines, especially in people who experience visual auras.

If not treated, vitamin B12 deficiency can cause dementia, spinal cord damage, loss of vision, and permanent nerve damage. I check vitamin B12 levels in all of my patients. The blood test, however, is not always reliable. There are reports of severe deficiency with perfectly normal levels. This is why when a deficiency is suspected, additional tests are needed. These are homocysteine and methylmalonic acid levels. These tests can disclose the presence of a deficiency when vitamin B12 level is in the normal range.

To further complicate matters, a report by neurologists at UCSF described a patient with normal blood tests who nevertheless had a severe vitamin B12 deficiency in the brain. They discovered that this patient had antibodies to a receptor (CD320) that is necessary for the uptake of vitamin B12 from the blood into the brain across the blood-brain barrier. The spinal fluid of this patient completely lacked vitamin B12. Her presenting symptoms were difficulty speaking, unsteadiness, and tremor. She had no peripheral manifestations of vitamin B12 deficiency, only those related to the brain. She recovered with high doses of vitamin B12 supplementation and immunosuppressive therapy to reduce the amount of antibodies against the CD320 receptor.

The authors screened a few hundred patients with lupus, multiple sclerosis, and healthy controls. They found these antibodies in 6% of healthy controls, 6% of those with lupus without neurological symptoms, and 6% with multiple sclerosis. Antibodies were present in 21% of patients with lupus who had neurological symptoms.

This newly described condition is called autoimmune B12 central deficiency (ABCD). The role of these antibodies in healthy people is not clear. However, people with unexplained neurological symptoms should have a blood test for homocysteine, methylmalonic acid, and CD320 antibodies.

New Daily Persistent Headache may respond to TMS

By: Dr. Mauskop

06-10-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain

Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial magnetic stimulation (rTMS).

NDPH is a type of headache that begins suddenly and persists daily without specific features, distinct MRI presentation, or blood test abnormalities. It can present similarly to chronic migraines or chronic tension-type headaches. While published reports suggest NDPH is difficult to treat, this is often not the case. However, patients who do not respond to initial standard treatments may become discouraged.

The Indian researchers conducted a pilot study with 50 NDPH patients who received 10 Hz rTMS sessions on the left prefrontal cortex of the brain for three consecutive days. They found that after 4 weeks:

70% of patients had at least a 50% reduction in headache severity
Patients gained an average of 11 headache-free days per month
76% had significant improvements in headache-related disability
Depression and anxiety scores also improved significantly

The treatment was well-tolerated, with only minor side effects in a few patients. The benefits seemed especially pronounced in patients who had NDPH that resembled chronic migraine.

I never give the diagnosis of NDPH, but diagnose it as a condition it most resembles and treat the person with a wide variety of available options. Many respond. For those who do not, we offer rTMS, a procedure that uses magnetic fields to stimulate nerve cells in the brain. An electromagnetic coil device is placed against the scalp near the forehead. The coil painlessly delivers a magnetic pulse that stimulates the brain with the goal of reducing headache symptoms. The FDA has approved it for the treatment of depression, anxiety, and OCD. We use it for various neurological conditions, including headaches that do not respond to standard therapies. To treat migraines and other types of pain, we usually stimulate not only the left prefrontal cortex, as was done in this study, but also two additional sites that have been reported to help with pain and migraines. These additional sites are either the motor cortex or the occipital cortex, on both sides.

Sometimes, we obtain a functional magnetic resonance imaging (fMRI) scan to better target rTMS. fMRI is a research procedure that is not available commercially (and is not covered by insurance).

A novel migraine drug shows promise

By: Dr. Mauskop

08-09-2024

Alternative Therapies, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments

Two sets of “designer drugs” have been developed based on our understanding of the neurobiology of migraines. The first, sumatriptan (Imitrex), introduced in 1992, was the pioneer in a class of seven triptan drugs, all targeting serotonin mechanisms. Erenumab (Aimovig), which targets the CGRP (calcitonin gene-related peptide) mechanism, was approved by the FDA in 2018. This class now includes four injectable, three oral, and one nasal drug. Additionally, many older drugs, although not specifically developed for migraine treatment, have proven effective for some patients. Despite these numerous options, a significant minority of patients do not respond to any of these treatments.

This is why the development of drugs targeting different parts of the migraine cascade is so promising. Danish neurologists, led by Dr. Mesoud Ashina, have published results from a phase 2 double-blind study of a new drug that blocks PACAP (pituitary adenylate cyclase-activating peptide).

In this study, patients were divided into two groups, receiving an infusion of a placebo or two different doses of the active drug, currently known as Lu AG09222, developed by the Danish company Lundbeck. In the final analysis, the reduction in migraine days was compared between 94 patients who received a placebo and 97 patients who received the higher dose of the active drug. The higher dose significantly reduced the number of migraine days in the month following the infusion (6.2 vs. 4.2 days reduction). The side effects reported were mild and infrequent.

Phase 2 studies are relatively small and short in duration. The FDA typically requires two large parallel studies involving a total of 1,000 or more patients before considering approval. Therefore, even if Lu AG09222 is found to be safe and effective, it may not receive approval for another 2-3 years.

What can you do about long COVID

By: Dr. Mauskop

26-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments

Long COVID, also known as post-COVID conditions, can present with a wide range of symptoms that persist for weeks or months after the initial COVID-19 infection. The most common symptoms of long COVID include:

Neurological Symptoms

Headaches
Difficulty thinking or concentrating, often referred to as “brain fog”
Memory problems
Changes in smell or taste

Psychological Symptoms

Depression or anxiety
Mood changes

Other Symptoms

Fatigue or tiredness that interferes with daily life
Shortness of breath or difficulty breathing
Cough
Chest pain or heart palpitations
Sleep problems
Dizziness when standing up (orthostatic hypotension)
Joint or muscle pain
Fever
Stomach pain or other gastrointestinal issues
Changes in menstrual cycles

There is evidence of persistent inflammation in people with long COVID. This inflammation of blood vessels, brain tissues, and other organs is likely the cause of all of the above symptoms.

Receiving a COVID vaccination may prolong the symptoms of long-term COVID-19 in people who have already contracted COVID and now suffer from long COVID. However, vaccines seem to reduce the risk of severe COVID and long COVID.

Unfortunately, we do not have any proven therapies for long COVID. However, it is very important to make sure that nutritional deficiencies do not contribute to long COVID symptoms. I often find a deficiency of vitamin B12 and other B vitamins, vitamin D, magnesium, CoQ10, omega-3 fatty acids, zinc, and others. I recommend looking at your test results yourself since doctors may glance at the report and tell you everything is fine if nothing is flagged. The normal ranges for vitamins are too wide, and if you are at the bottom of the normal range, you are probably deficient. For example, vitamin B12 levels are considered normal between 200 and 1,200. Most neurologists will tell you that your level should be above 500. The same applies to RBC magnesium level – normal is 4.0 to 6.4, but you need to be above 5. Vitamin D should be well above 40, while 30 is still considered normal.

Another supplement I often recommend is NAC. A small study by Yale neurologists showed that 600 mg of NAC improved working memory, concentration, and executive functions. NAC helps the body produce glutathione, an important antioxidant. We sometimes give glutathione infusions along with other vitamins.

Supplements that reduce inflammation include ginger and turmeric extracts.

For brain fog and other neurological symptoms, we have had some success with transcranial magnetic stimulation (TMS). Other neurostimulation methods, such as tDCS, are also worth trying.

Some patients benefit from intravenous infusion of immune globulin, which is approved for some types of neuropathies.

Low-dose naltrexone (LDN) may also help, but no studies prove this.

Probiotics can help people with gastrointestinal symptoms.

Stimulants can be tried to treat fatigue and brain fog. They can also help with depression.

For headaches, we often give Botox injections.

Depression can be treated with antidepressants or TMS.

Some people respond well to physical therapy, acupuncture, herbs, meditation, cognitive-behavioral therapy, and other mind-body techniques.

Disruption of brain networks by chronic pain can be prevented.

By: Dr. Mauskop

18-08-2024

Alternative Therapies, Brain disorders, Pain, Pain Research, Psychology of headaches

Chronic pain is known to alter the brain’s default mode network (DMN). The DMN is a group of interconnected brain regions activated when a person is not focused on the external world. Key DMN functions include mind wandering (daydreaming, thinking about the past or future, imagining scenarios), self-reflection (considering thoughts, feelings, and experiences), theory of mind (understanding others’ thoughts and intentions), and memory (retrieval and processing).

A recent study published in the journal Pain by German researchers investigated the relationship between chronic back pain and DMN alterations. The study, titled “Beyond the chronic pain stage: default mode network perturbation depends on years lived with back pain,” examined patients with chronic back pain (CBP), subacute back pain (SBP), and healthy controls using fMRI.

Results showed that the DMN is significantly altered in CBP patients compared to healthy individuals. Importantly, the degree of DMN disruption increased with the duration of pain, suggesting that the brain adapts to persistent pain over time. This adaptation is influenced by cognitive coping strategies or how individuals mentally manage their pain.

The study found that coping attitudes mediate the link between DMN changes and pain duration. This implies that how people think about and handle pain impacts their brain’s adaptation to it. Effective pain coping strategies could potentially lessen the negative effects of chronic pain on the brain, emphasizing the importance of psychological interventions like meditation, cognitive behavioral therapy (CBT), and acceptance-commitment therapy (ACT).

These findings also provide a scientific basis for treatments like transcranial magnetic stimulation (TMS) and other brain stimulation methods, which aim to restore normal brain connectivity, including DMN function.

If two antidepressants fail, TMS may offer relief.

By: Dr. Mauskop

11-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headache medications, neurostimulation, Psychology of headaches

The FDA approved transcranial magnetic stimulation (TMS) to treat anxiety, depression, and OCD about 15 years ago. Most insurers cover this treatment. However, it remains highly underutilized.

A study just published by Dutch researchers in Psychiatry Online compared TMS with a third antidepressant in people who did not respond well to two different antidepressants.

Both treatments were combined with psychotherapy.

89 people with depression who hadn’t improved with at least two previous treatments took part.
They were randomly assigned to either TMS or a new antidepressant.
The treatment lasted eight weeks.
TMS involved 25 sessions of magnetic stimulation.
The medication group switched to a new antidepressant following standard guidelines.

The primary outcome measure was the degree of improvement in depression symptoms.

TMS was more effective than switching medications. More people responded well to MS (38% vs 15%) and more people’s depression went into remission with TMS (27% vs 5%).

TMS was better at improving symptoms of anxiety and lack of enjoyment (anhedonia)

Both treatments were equally effective for improving sleep, overthinking, and negative thought patterns. People’s expectations about their treatment were linked to how much their depression improved.

In conclusion, for people with depression that hasn’t responded well to a couple of medication attempts, TMS might be a more effective option than trying another antidepressant. The study also suggests that the choice between TMS and medication might depend on which specific symptoms a person struggles with most.

We started using TMS for people with migraine headaches if they do not respond to multiple standard therapies. About half of these patients respond well. However, we do not have large controlled trials to confirm that TMS effectively treats migraines.

Focused ultrasound to specific brain regions relieves pain

By: Dr. Mauskop

04-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments, Pain

The use of focused ultrasound to treat brain disorders was one of the topics discussed at the 2024 NYC Neuromodulation Conference in NYC.

Coincidentally, a study on this topic was published last month by Jan Kubanek and his colleagues in Pain, the journal of the International Association for the Study of Pain: “Noninvasive targeted modulation of pain circuits with focused ultrasonic waves”.

Researchers developed a technique that targets the anterior cingulate cortex, a deep brain region involved in processing pain. By using focused ultrasound, this region can be modulated without surgery. This breakthrough has the potential to revolutionize pain management.

Twenty patients with chronic pain participated in a randomized crossover trial. They received two 40-minute sessions of either active or sham stimulation and were monitored for one week. The results were remarkable:

60% of patients experienced a significant reduction in pain on day 1 and day 7 after active stimulation.
Sham stimulation only benefited 15% and 20% of patients, respectively.
Active stimulation reduced pain by 60.0% immediately after the intervention and by 43.0% and 33.0% on days 1 and 7.
Sham stimulation only reduced pain by 14.4%, 12.3%, and 6.6% on the same days.

The stimulation was well tolerated and the side effects were mild and resolved within 24 hours.

Since we have been using transcranial magnetic stimulation (TMS) to treat refractory migraines and other neurological conditions, it was good to read this part of the authors’ conclusion:

“The ultrasonic intervention is conceptually related to TMS applied to the motor cortex, which can provide improvements in chronic pain in certain groups of patients. The key difference is that ultrasonic waves can directly modulate the deep brain regions involved in chronic pain, including the anterior cingulate cortex. Transcranial magnetic stimulation is believed to modulate deep brain regions only indirectly, which may contribute to its variable response and the need for frequent re-administrations. Nonetheless, the effects of both modalities may be complementary, and their combined application may provide stronger effects than either approach alone.”

Creatine is good for your brain, not just muscles

By: Dr. Mauskop

23-06-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine

Athletes have been using creatine supplementation for over 30 years. It seems to improve the energy supply to muscle tissues and increase fat-free mass. Creatine also supplies energy to nerve cells in the brain. Taking a creatine supplement increases the levels of creatine in muscles and the brain.

A review of six studies suggested that creatine improves short-term memory, intelligence, and reasoning. Creatine did not improve any cognitive abilities in young people. Vegetarians benefited more than non-vegetarians in memory tasks.

A study by Taiwanese researchers published in Cephalalgia showed reduced creatine levels in the thalamus (the pain-processing area in the brain) in patients with medication-overuse headaches.

Greek doctors published a report, Prevention of traumatic headache, dizziness and fatigue with creatine administration. A pilot study. They studied 39 patients who sustained a severe traumatic brain injury. There were 19 patients in the control group and 20 in the active group. The active group was given 0.4 g/kg of creatine. Treatment was administered within 4 hours of injury and was continued for 6 months. This treatment improved the duration of post-traumatic loss of memory, the duration of being on a respirator, and the duration of stay in an intensive care unit. They also showed improvement in headaches, dizziness, and fatigue. No side effects were reported.

Some studies suggest that creatine can improve bone health. Here is what WebMD says about creatine:

“While most people get low amounts of creatine by eating seafood and red meat, larger amounts are found in synthetic creatine supplements. Your pancreas and kidneys can also make around 1 gram of creatine each day. Creatine is one of your body’s natural energy sources.

Nearly 95% of the creatine in your body is stored in your skeletal muscles and is used during physical activity. As a dietary supplement, creatine is commonly used to improve exercise performance in athletes and older adults.”

There is not enough evidence to routinely recommend creatine for the treatment of migraine headaches. I do, however, recommend to my older patients taking 5 to 7 grams of creatine an hour before or after exercise. I am 67 and do take it when I exercise.

Abnormal functional connectivity in patients with post-traumatic headaches

By: Dr. Mauskop

03-06-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation

A new study from Mayo Clinic researchers, published in The Journal of Headache and Pain, has examined the brain changes associated with acute post-traumatic headaches (PTH). These headaches can occur after a head injury or trauma and can be debilitating. The study involved 60 participants with acute PTH and 60 age-matched healthy controls. Using functional MRI (fMRI), the researchers found two key differences in the brains of PTH patients compared to healthy individuals.

Increased Iron Accumulation in Specific Brain Regions

First, the PTH patients showed higher levels of iron deposition in two brain areas: the left posterior cingulate and the bilateral cuneus regions. These areas are involved in various functions, including pain processing, attention, and visual processing. The accumulation of iron in these regions may disrupt normal brain function and contribute to the development and persistence of post-traumatic headaches.

Abnormal Functional Connectivity Patterns

Secondly, the researchers observed stronger functional connectivity between the bilateral cuneus (the visual processing area) and the right cerebellum (a region involved in motor control and coordination, and other functions) in PTH patients compared to healthy controls. Functional connectivity refers to the communication and synchronization between different brain regions. The abnormal connectivity patterns seen in PTH patients suggest disruptions in the brain networks responsible for processing sensory information, including pain signals.

Implications for Targeted Therapy

While these findings may have lacked utility in the past, they now have important implications for the treatment of post-traumatic headaches. We have been treating patients with repetitive transcranial magnetic stimulation (rTMS), a non-invasive technique that can modulate brain activity in specific regions. By stimulating the areas with abnormal connectivity, rTMS may help restore normal brain function and alleviate headache symptoms and other neurological and psychiatric symptoms. When possible, we perform fMRI scans on individual patients to identify the specific brain regions involved in their headache disorder. However, fMRI is still only a research tool, and when individual fMRI data is not available, studies like this one provide information on common brain changes associated with post-traumatic headaches that can be targeted with TMS.

Abnormal functional connectivity in brains of patients with vestibular migraine

By: Dr. Mauskop

27-05-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, post-traumatic headache, Science of Migraine

Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain regions like the insula, thalamus, somatosensory cortex, as well as visual cortex. Some patients also have changes in the default mode and salience networks involved in attention and stimulus processing.

A study published this month by Chinese researchers in the Journal of Headache and Pain reports on connectivity changes in people with vestibular migraines.

They found abnormal resting-state functional connectivity in brain regions involved in multi-sensory and autonomic processing as well as impaired ocular motor control, pain modulation, and emotional regulation.

Until now, there has been little practical application for fMRI findings. However, with the help of Omniscient Neurotechnology, we have just started using fMRI data to better target our treatment with transcranial magnetic stimulation (TMS). TMS applied to motor and visual cortices has been reported to help relieve migraine headaches. We have also found it effective in a significant proportion of patients who did not respond to various other treatments. We have not yet accumulated enough data to determine if fMRI-guided TMS treatment is superior to TMS administered over a predetermined set of targets.

The main obstacle to wider use of TMS in clinical practice is the cost. TMS is approved by the FDA and is covered by insurance for the treatment of anxiety and depression, but not migraines or pain. fMRI is an expensive research tool and is also not covered by insurance. Hopefully, the NIH and other research foundations will provide the funds needed to study this promising treatment.

EPA in fish oil prevents migraines

By: Dr. Mauskop

05-05-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Science of Migraine

Several studies have suggested that fish oil helps prevent migraine headaches. A new clinical trial by Taiwanese doctors provides the strongest evidence for this effect to date. The paper, “A 12-week randomized double-blind clinical trial of eicosapentaenoic acid intervention in episodic migraine” was published this month in the journal Brain, Behavior, and Immunity.

Unlike previous studies, this one used a high dose of one of the two omega-3 fatty acids found in fish oil, eicosapentaenoic acid, or EPA. 70 people with episodic migraine participated in a 12-week trial.

One group of 35 people took 2 grams of fish oil daily, which contained 1.8 grams of EPA. The other group of 35 people took a placebo of 2 grams of soybean oil daily. The researchers tracked several measures related to migraine frequency, severity, disability, anxiety/depression, quality of life, and sleep quality before and after the 12 weeks. The results showed that the EPA group did significantly better than the placebo group on multiple measures:

– They had 4.4 fewer monthly migraine days on average compared to 0.6 fewer days in the placebo group.

– They used acute migraine medication 1.3 fewer days compared to 0.1 more days in the placebo group.

– Their headache severity scores improved more than the placebo group.

– Their disability scores related to migraine improved more.

– Their anxiety and depression scores improved more.

– Their migraine-specific quality of life scores improved more.

Notably, women seemed to particularly benefit from taking the high-dose EPA supplement. Overall, the high dose of EPA from fish oil was able to significantly reduce migraine frequency and severity, improve psychological symptoms, and boost the quality of life for these episodic migraine patients over the 12 weeks. No major side effects were seen.

The cheapest and the highest quality product that will give you such a high amount of EPA is a prescription drug, icosapent ethyl (Vascepa). Most insurers will not cover it for migraines but a 60-day supply (120 capsules) will cost you $77, according to GoodRx.com. You do need a doctor to prescribe it to you.