Archive
Alternative Therapies

Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the latest book on migraines, Understanding Your Migraines, the answer is a definite yes.

The book is written by two colleagues who for many years co-directed the Dartmouth Headache Clinic. Dr. Morris Levin is now the Director of the Headache Center and a Professor of Neurology at UCSF, while Dr. Thomas Ward is Professor of Neurology Emeritus at the Geiser School of Medicine at Dartmouth and the editor of the journal Headache. They are clearly highly qualified to write such a book, but qualifications are not enough – you need to be a good writer as well. And in fact, excellent writing style and case-based discussion are two of the major strengths of the book.

The book consists of 17 chapters, which cover diagnosis and our understanding of the underlying causes of this condition. What the readers will find most useful is the treatment approaches. Drs. Levin and Ward go into great detail about various non-drug options, including nutrition, exercise, meditation, acupressure, herbal products, vitamins and minerals. They also present pros and cons of various medications, nerve blocks and describe in detail the most effective and the safest preventive treatment for chronic migraines, Botox injections.

One chapter is devoted to specifics of migraines in pregnancy and another one to children and adolescents. The book also includes individual chapters on tension-type headaches, cluster and other less common headache types, and postconcussion headaches.

The authors also mention an exciting new treatment option, which we expect to be approved by the end of 2018. Four companies are racing to bring to the market CGRP monoclonal antibodies, which act like vaccines against migraines. A single injection will provide 1 to 3 months of relief with very few side effects. It is likely that this treatment will help about 60% of patients with both episodic and chronic migraines. Cluster headache patients might also benefit from these biologic drugs.

Reading so much information can make it difficult to understand how to actually use it and how to talk to your doctor about all these options. The authors successfully tackle this problem by providing many real-life cases and by including a chapter, How to Communicate with Your Medical Team.

I am sure that this book will help many migraine sufferers find relief. You can buy it on Amazon.

Read More

The most satisfying part of our work is that we can help more than 95% of our patients. However, a small number of headache sufferers defy our best efforts and continue to have severe pain, which ruins their quality of life.

I just returned from my second visit to lecture at the Berolina Klinik, a rehabilitation hospital in Germany. It has an outstanding record in rehabilitating chronic headache and other types of patients. I wrote about this clinic after my first visit in 2014.

A report just published in Headache describes a successful rehabilitation program of chronic headache patients in an outpatient setting at the Cleveland Clinic. Drs. Krause, Stillman and their colleagues report on 379 patients who were admitted to the IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) program.

The program lasts 3 weeks, during which patients come to the clinic for 8 hours 5 days a week. Patients are informed that “the primary purpose of treatment is not to reduce pain, but rather to improve their ability to function during pain”. Despite this warning the average pain on admission was 6.1, while on discharge 3.5 and a year later, 3.3. Functional impairment, anxiety, and depression also improved and stayed improved a year after the treatment.

The program is clearly very effective and has an additional advantage of not requiring expensive hospitalization. Most patients stay at a hotel across the street from the clinic.

Here is an outline of the 3-week program:

Medical treatment:

1. History and initial medication adjustments on admission day.
2. Four days of intravenous therapy. Patients meet with the physician daily during infusions.
3. Two brief individual medical appointments per week during the second and third weeks.
4. All patients are drug tested at admission, and subsequent drug testing may be included if staff have concerns about illicit use.
5. Consultation with outside physicians as appropriate.

Psychological treatment:
1. One individual biofeedback session in each of the second and third weeks.
2. One individual psychotherapy session in each of the second and third weeks.
3. Psycho-educational group sessions spread throughout the three weeks. Topics include avoidance of pain displays, diminishing attention to headaches, cognitive-behavioral therapy for management of mood, activity pacing, time management, theories of pain, sleep hygiene, assertiveness training, relaxation training, self-esteem, management of headache flare-ups, and relapse prevention.
4. In the second and third weeks of treatment, patients’ families are requested to participate in a group family meeting, where the necessity of avoiding reinforcement of headache displays and disability is emphasized.

Nursing treatment:
1. Initial assessment, including current medication intake, document allergies, perform an EKG.
2. Patients receive at least 1-2 individual visits with a registered nurse during the second and third weeks of the program.
3. Nursing groups, including pathophysiology of headaches, proper use of a headache diary to track progress, dietary counseling, the impact of headaches and medications on sexuality, and medical communications. Nurses also train the patients in additional relaxation techniques beyond those covered in the psychology groups, and lead group relaxation practice.

Physical therapy treatment:
1. Physical therapy evaluation on their admission day, with particular attention paid to cranio-cervical dynamics. Data are used to develop an individualized, quota-based exercise plan including strengthening, flexibility, and endurance exercises.
2. Beginning on the day after admission, patients participate in daily group exercise sessions, where they learn and practice individually tailored exercise plans.
3. Twice weekly individual physical therapy sessions.

Read More

Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated, they can cause strokes and kidney failure.

Fortunately, these conditions are very responsive to intravenous infusions of high doses of magnesium (5-6 grams at a time, while we give 1 gram to our migraine patients). A study recently published in Neurology suggests that even if preeclampsia is treated effectively, it can lead to persistent brain lesions. The researchers found these small white matter lesions (WMLs) in the healthy controls as well, but not as many as in women who suffered from preeclampsia 5 to 15 years prior to the study. We also see these lesions, which appear as small spots, on MRI scans of patients with migraines. The exact nature of these spots remains unclear, but the leading theory is that they are due to impaired blood flow.

The authors looked at a wide variety of factors that might have predisposed women to preeclampsia and subsequent WMLs, but did not find any. They did confirm previous findings indicating that age and high blood pressure increases the number of WMLs, but those with preeclampsia had more WMLs in the temporal lobes of the brain. They also found a decrease of the cortical volume, which means loss of brain cells on the surface of the brain.

Surprisingly, one of the factors they did not measure was magnesium levels. If preeclampsia responds so well to magnesium, it is possible that these women have chronic magnesium deficiency. Magnesium deficiency predisposes people not only to migraines, but also to heart attacks and strokes. The test that should have been done is red blood cell (RBC) magnesium since 98% of magnesium is inside the cells or in the bones. The most commonly used serum magnesium level measures the remaining 2% and is highly unreliable.

If you’ve suffered from preeclampsia or eclampsia, in addition to reducing other risk factors for vascular problems – control your blood pressure, sugar and cholesterol, stop smoking if you smoke, lose weight, and exercise, you may also want to ask your doctor to check your RBC magnesium level. If the level is low or at the bottom of normal range, take a magnesium supplement. A good starting dose is 400 mg of magnesium glycinate taken daily with food. If subsequent tests show no improvement, the dose can be increased to 400 mg twice a day and even higher.

Read More

Inhalation of pure oxygen under high flow is an effective treatment for an acute cluster headache, although not migraines. Headache is one of the most common symptoms of traumatic brain injury and postconcussion syndrome and there is evidence that oxygen under pressure can help those conditions.

A review article on the use of oxygen to treat mild and moderate traumatic brain injury and postconcussion syndrome was recently published in Neurology. THe authors reviewed 5 previously published studies and concluded that hyperbaric oxygen in fact does help patients with brain trauma and postconcussion syndrome.

While cluster headache patients can breathe in oxygen through a mask from a tank of oxygen delivered to their home, hyperbaric oxygen requires a special room or a chamber. Hyperbaric means that oxygen is under increased pressure, although the authors report that moderate pressure (between 1 and 2 ATA) may be better than high pressure. Even hyperbaric air, that is normal air under pressure, may have beneficial effects.

The authors conclude that, there is sufficient evidence for the safety and preliminary efficacy from clinical data to support the use of hyperbaric oxygen in mild to moderate traumatic brain injury and postconcussion syndrome. They also state that “It would be a great loss to clinical medicine to ignore the large body of evidence collected so far that consistently concludes that hyperbaric oxygen is effective in treatment of brain injuries.”

Fortunately, there are many hospitals and private clinics all around the country that offer hyperbaric oxygen. They often advertise its use for a variety of unproven indications, but if you suffer from a traumatic brain injury, this treatment may be worth trying. A major obstacle though could be the cost of treatment since insurance companies are not likely to cover this treatment.

Read More

The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other night I attended a lecture in NYC by the “father of cannabis”, Raphael Mechoulam.

According to Wikipedia, “Dr. Mechoulam is an Israeli organic chemist and professor of Medicinal Chemistry at the Hebrew University of Jerusalem in Israel. Mechoulam is best known for his work (together with Y. Gaoni) in the isolation, structure elucidation and total synthesis of THC (?9-tetrahydrocannabinol), the main active ingredient of cannabis and for the isolation and the identification of the endogenous cannabinoids anandamide from the brain and 2-arachidonoyl glycerol (2-AG) from peripheral organs together with his students, postdocs and collaborators.”

Dr. Mechoulam identified THC in 1964 and in his lecture he lamented the paucity of research into the many potential healing properties of cannabis in the past 50 years. He strongly feels that the two main active ingredients in marijuana, THC and CBD should be tested rigorously in large double-blind studies just like any other prescription drug. This will allow doctors to prescribe a proven medicine, rather than rely on anecdotal reports and go through trial and error, as we are doing now. His research suggests that cannabis ingredients could possibly help a wide variety of conditions, from diabetes and cancer to pain and nausea.

Prescribing medical marijuana is at least possible in New York and 20 other states, so that we do not have to wait, possibly up to 10 years, for a cannabis-based drug to be approved by the FDA (one CBD-containing drug might be approved soon for a rare form of epilepsy).

At this time we have to go through trials of various ratios of THC and CBD and various modes of delivery (inhaled, sublingual or oral) to determine the best treatment for each patients. Another obstacle is the fact that no insurance company pays for medical marijuana. After a year of prescribing medical marijuana for patients with migraine and other painful conditions it is clear that it works for a minority of my patients. However, I prescribe it only after more traditional methods fail, so my results may not be as good as if I used medical marijuana earlier. Our standard approach involves lifestyle changes, regular exercise, dietary changes, magnesium, CoQ10, and other supplements, followed by drugs and Botox injections. These are mostly well-studied treatments and with the possible exception of drugs, should precede the use of medical marijuana. Having said that, For a few of my patients medical marijuana dramatically improved their quality of life and I am very glad that we have this treatment option available.

Dr. Rafael Mechoulam and Dr. Alexander Mauskop
May 4, 2017, NYC

Read More

Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days.

Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine.

The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to sleep restriction – not being allowed to sleep for more hours than the patients reported getting prior to treatment, in the hope that this will lead to better sleep in the long term. The sham group was instructed to eat some protein in the morning, eat dinner at the same time, keep up with their fluid intake, perform range of movements exercise, and regularly press on an acupuncture point above the elbow.

After two weeks of this intervention headaches improved in the sham group slightly more than the active group, but six weeks later, headache frequency dropped by 49% in the active group and 25% in the sham group. Improvement in insomnia symptoms strongly correlated with the headache frequency. The cognitive-behavioral group had a significant increase in the total sleep time and the quality of sleep.

This was a relatively small study, but there is a large body of evidence that behavioral therapies do relieve insomnia. And it is no surprise that better sleep is associated with fewer headaches since sleep deprivation is a common migraine trigger. Sleep restriction is the only part of this treatment that has contraindications – it should be avoided in patients with bipolar disorder or epilepsy.

Another simple method, which I’ve used over the years whenever I cannot fall asleep, is visualization. You have to use not only visual images, but engage all of your senses. For example, imagine yourself in a place where you tend to feel relaxed (lying on a beach, on a cool lawn, on a float in a pool, etc). See all the details and also hear the sound of the wind or waves, smell the ocean or the grass, feel the touch of the wind or sand. It takes an effort at first, but use the same image every time and after a while, as soon as you go to that place, you fall asleep in minutes. Here I found more detailed instructions for this method.

Read More

I am certain that you will learn a lot of useful information from listening to the top headache experts in the world. The event is free during the week when it is held (April 23 – 29), but afterwards you will have to pay for full access to all interviews. The Migraine World Summit is in its second year and it again assembled excellent speakers to address a wide variety of headache-related topics. Last year I spoke on non-drug therapies and this year the speakers are again addressing not only medications, but many alternative treatments and self-care. In addition to many leading neurologists, the event features Ping Ho, MA, MPH, a UCLA expert on alternative therapies, meteorologist, Michael Steinberg of Accuweather, Vidyamala Burch, a mindfulness expert, an Australian psychologist, Paul Martin, a geneticist, Professor Lyn Griffiths of Queensland UT (the event is organized by an Australian migraine sufferer Carl Cincinnato, so there are many Australians represented), and over 30 other experts.

Here is a blurb from the organizers:

In it’s first year, The Migraine World Summit became the largest ever conference for migraine patients. In 2017, we’re back with 36 brand NEW interviews where you’ll discover even more about…

What are the best treatments for migraine?
What can I do when I’ve already tried everything?
What are the secrets to finding effective natural alternatives?
How can I cope with the anxiety, judgment and social stigma of chronic migraine?
What new treatments are coming that I should be aware of?
What are the most common challenges that could appear?
The 2017 Migraine World Summit is online and free from April 23 – 29, 2017!

Register for FREE now at the following link:

http://www.migraineworldsummit.com?afmc=4b

Read More

Photophobia, or sensitivity to light is one of the most common symptoms that accompany a migraine attack. Many patients remains photophobic even after the headache has resolved. In some, a prolonged exposure to bright light or as little as a momentary reflection of the sun in the window glass or water surface can bring on a severe attack.

It is not unusual for some of my patients to wear sunglasses indoors. Once, when I had a migraine while driving at night I had to put on my sunglasses because the headlights of oncoming cars made the pain worse (luckily, I had a sumatriptan injection with me and as soon as I got off the highway and to a traffic light, I gave myself a shot).

Dr. Kathleen Digre, a professor Neurology and Ophthalmolgy at the University of Utah, whose article on dry eyes and migraines I quoted a couple of years ago, recently stated that staying in the dark may actually make photophobia worse. It may be better to gradually expose yourself to more light when you are not in the middle of an attack.

A small study suggested that people who suffer from photophobia between migraine attacks are more likely to experience anxiety and depression than those without photophobia between attacks and those without migraines. It is not clear if anxiety and depression in these patients is due to more severe migraines.

Treatments for photophobia mentioned by Dr. Digre include botulinum toxin (Botox) injections, nerve blocks, medications such as gabapentin, and a natural supplement, melatonin. I should add that any effective acute and preventive treatment that leads to reduced frequency and duration of the attacks can lead to a reduction in photophobia. Effective treatment is also likely to improve phonophobia (sensitivity to noise) and osmophobia (sensitivity to smells), which are somewhat less common.

Read More

Postconcussion symptoms can be debilitating and can persist for long periods of time, both in kids and adults. Persistence of headaches, dizziness, difficulty concentrating and with memory is often compounded by depression and anxiety. The usual care consists of mild exercises, sleep medications, antidepressants, and other drugs.

A new study published in Pediatrics shows very promising results from cognitive-behavioral therapy (CBT) in teens with post-concussion symptoms. Children aged 11 to 17 years with persistent symptoms for more than a month after sports-related concussion were randomly assigned to receive collaborative care that included CBT (25 kids) or care as usual (24 kids). The children were assessed before treatment and after 1, 3, and 6 months.

Six months after the baseline evaluation 13% of children who received CBT and 42% of control patients reported high levels of postconcussive symptoms. Depression improved by at least 50% in 78% of the CBT group and 46% of control patients. Anxiety symptoms were at the same level in both groups.

CBT has been shown to be effective in children and adolescents with chronic migraines, so it is not surprising that it would also help with postconcussion headaches and other symptoms. And the effect is quite dramatic.

A major obstacle for wider adoption of CBT is the cost and difficulty in finding a qualified psychologist. In a previous post I mentioned two very effective and scientifically verified online programs, ThisWayUp and moodGYM. These do require persistence and discipline, which in case of teens, parents might be able to provide.

Read More

A new electric device is being tested for the treatment of migraine by an Israeli company, Theranica. Transcutaneous electric nerve stimulation (TENS) has been successfully used for the treatment of musculoskeletal disorders for decades. The theory behind it is the so-called gate theory of pain. It is thought that by stimulating larger nerve fibers we can block pain messages sent by smaller pain-sensing nerve fibers.

Cefaly is a TENS device which became available in 2014 and it provides electrical stimulation of the supraorbital nerves in the forehead. Only small studies have been conducted, so it is not clear how well Cefaly relieves migraines. As far as our experience, we at the NY Headache Center usually treat more severely affected patients, so it is possible that the results are better in people with less severe migraines.

The new wireless patch that is being developed by Theranica is applied to the upper arm. The results of the first study of this patch were published in Neurology, the medical journal of the American Academy of Neurology.

The study author, is a well-known neurologist and pain researcher, Dr. David Yarnitsky of Technion Faculty of Medicine in Haifa, Israel. He was quoted saying, “People with migraine are looking for non-drug treatments, and this new device is easy to use, has no side effects and can be conveniently used in work or social settings.”

The patch device is controlled by a smartphone app. It was studied in 71 patients with episodic migraine who had two to eight attacks per month and who were not on any preventive medications for migraines. The device was applied soon after the start of a migraine and kept in place for 20 minutes.

The devices were programmed to randomly give either a very weak stimulation to serve as placebo or different levels of stronger electrical stimulation.

A total of 299 migraine attacks were treated by these 71 patients. Two hours after the start of real treatment, pain was reduced by at least 50% in 64 percent of patients, compared to 26 percent of patients who received the sham stimulation.

Starting treatment early produced better results, which is similar to what we see with all migraine medications as well. None of the participants found the treatment to be painful.

The device is very safe and we hope that the ongoing trial that Theranica is conducting in the US will confirm its efficacy. It is not yet available in this or any other country.

Read More

Naltrexone, along with naloxone are narcotic (opioid) antidotes, that is they counteract the effect of narcotics and are used to treat overdoses with heroin, fentanyl, Percocet, Vicodin, and other opioid drugs. Surprisingly, low doses of naltrexone (LDN) seem to be effective in treating pain. LDN has been also used to treat symptom in conditions such as depression, fibromyalgia, Crohn’s disease, multiple sclerosis, complex regional pain syndrome (which used to be called reflex sympathetic dystrophy), and autoimmune disorders.

Low dose naltrexone is not a typical pain killer, but may be helping pain by reducing inflammation. Instead of opioid receptors, it works on Toll-like receptor 4 (TLR4) receptors on glial cells. Glial cells surround the nerve cells and play important functions in the brain, beyond just a supporting role that had been assigned to them for many years. Opioid drugs are known to promote inflammation through the brain immune system leading to worsening of pain over time. Recent discoveries have shown that the Toll-like receptors are involved in triggering these inflammatory immune events. These discoveries have led many researchers to look at ways to block TLR4, but so far no such drug has been developed. We do have several existing medications that seem to block TLR4. Besides LDN, amitriptyline (Elavil) and cyclobenzaprine (Flexeril) are two other drugs that block TLR4 and that have been used for years to treat pain.

No large controlled studies of LDN for migraines, pain or any other condition have been conducted to date. Despite the fact that the evidence is only anecdotal and that LDN my work purely through the placebo effect, advantages of LDN are that it is inexpensive and safe. Naltrexone is available in 25 and 50 mg tablets, while the amount used for LDN is between 1.5 to 4.5 mg. This means that it can be obtained only from a compounding pharmacy. Naltrexone is not a controlled substance, but it does require a prescription from the doctor.

Read More

Italian researchers published a study in the journal Headache that attempted to correlate the attachment style in children with migraines with headache severity and psychological symptoms.

Attachment style typically develops in the first year of life. The premise of the study was derived from the attachment theory which suggests that early interpersonal relationships may determine future psychological problems and painful conditions. Previous studies have shown that people with insecure attachment styles tend to experience more pain than people with secure attachment style.

The study involved 90 children with migraines. The mean age was 12 years and there were 54 girls and 36 boys in the study. The kids were divided into a group with very frequent headaches (1 to 7 a week) and those with infrequent attacks – 3 or fewer per month. They also grouped them into those with severe pain, which interrupted their daily activities and those with mild pain that allowed them to function normally. The children were tested for anxiety, depression, and somatization (tendency to have physical complaints as a manifestation of psychological distress). They were also evaluated for the attachment style and were assigned into “secure,” “avoidant,” “ambivalent,” and “disorganized/confused” groups.

Interestingly, the researchers found a significant relationship between the attachment style and migraine features. Ambivalent attachment was present in 51% of children with high frequency of attacks and in 50% of those with severe pain. Anxiety, depression, and somatization were higher in patients with ambivalent attachment style. They also showed an association between high attack frequency and high anxiety levels in children with ambivalent attachment style.

The authors concluded: “We found that the ambivalent attachment style is associated with more severe migraine and higher psychological symptoms. These results can have therapeutic consequences. Given the high risk of developing severe headache and psychological distress, special attention should be paid to children with migraine showing an ambivalent pattern of attachment style. Indeed, a prophylactic and psychological therapy could often be necessary for these patients.”

People who have an anxious–ambivalent attachment style show a high desire for intimacy but often feel reluctant about becoming close to others and worry that people will not reciprocate their feelings. It is possible to mitigate the negative effects of the ambivalent attachment style even in adulthood. It does require a major effort and help from a psychotherapist.

Read More