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.

Caffeine is a well-know trigger of migraine headaches and I regularly write on this topic (my last post on this topic – caffeine causing headaches in adolescents – was three years ago). Caffeine can help migraines and other headaches, but in large amounts it worsens them due to caffeine withdrawal, which can occur in as little as 3 hours after the last cup of coffee. One of my patients was an extreme case. He told me that he figured out that his early morning migraines were due to caffeine withdrawal and he would set his alarm clock for 4 AM, so that he could wake up, drink some coffee and go back to sleep without the fear of a morning headache. A continuous intravenous drip of caffeine would also solve his problem. Most people opt for stopping caffeine, albeit it can be a difficult process. Going cold turkey is often easier than a gradual reduction in caffeine intake. To avoid severe withdrawal, prescription migraine drugs, such as sumatriptan (Imitrex), intravenous magnesium, nerve blocks and other interventions may be necessary in a small percentage of patients.

This post was prompted by a just published study that showed a higher risk of miscarriages in couples where either partner, male or female consumed more than 2 caffeinated beverages prior to conception. Caffeine has been long suspected but not definitively proven to increase the risk of miscarriages in women who drink large amounts of caffeine during pregnancy, but what is surprising is that consumption of caffeine by the male partner also increases the risk.

At the same time, recent studies widely publicized in the press have shown beneficial effects of consuming large amounts of caffeine. Caffeine supposedly lowers the risk of certain cancers, strokes, diabetes, and other conditions. However, if you suffer from headaches, heart burn due to reflux, or are trying to conceive, caffeine should be avoided.

Ketamine is a sedating agent used to induce anesthesia. It is also a drug of abuse with street names such as “Special K” or “Ket”.

Ketamine has many advantages, which makes it a very popular choice in anesthesia. It works fast, blocks pain, opens the lungs, it is easy on the heart, and has anti-inflammatory properties. It may also have anti-cancer properties. Ketamine is being extensively tested for the treatment of depression that does not respond to medications.

Because ketamine works on a receptor involved in transmitting pain messages in the brain (NMDA receptor), it has been studied in various painful conditions. The amounts being tested for pain are much smaller than those used to induce anesthesia or even those used recreationally.

Even though it is a drug of abuse, it appears to be less addictive than heroine and prescription narcotics.

There are only few small studies and reports about the use of ketamine for migraine headaches. One such report published in the leading neurological journal Neurology describes 18 patients with prolonged migraine auras who were treated with intranasal ketamine spray. The duration of their auras was not shortened by ketamine, but the severity was reduced.

Another study showed that severe disabling aura was relieved in 5 out of 11 patients with hemiplegic migraine.

Several anecdotal reports have touted the benefits of ketamine in chronic migraines, cluster headaches, and chronic paroxysmal hemicrania (a rare type of headache that often responds to indomethacin and at times to Botox). While such anecdotal reports are useful, we need to have controlled trials to make sure that placebo effect is not playing a major role. There is nothing wrong with utilizing the placebo effect, but only if the treatment is completely benign. Unfortunately, ketamine like any other drug can have potentially serious side effects. This is why before treating pain with ketamine intravenously patients must be screened for possible heart disease or psychiatric disorders such as schizophrenia. While intranasal ketamine can be given in an office setting, intravenous administration must be done under close monitoring. Another issue is the cost since insurance companies do not cover this treatment because it is considered experimental.

There has been some backlash against meditation with newspapers publishing articles claiming that meditation is overrated. Fortunately, serious scientists continue to publish solid objective data proving that meditation not only relieves pain and headaches and makes you feel better, but in fact changes the structure of your brain. In my recent post I wrote about one such a study published in the Journal of Neuroscience.

A new rigorous scientific study was just published in Biological Psychiatry. It looked at the benefits of mindfulness meditation and how it changes people’s brains and potentially improves the overall health.

The study was conducted at the Health and Human Performance Laboratory at Carnegie Mellon University.

The researchers recruited 35 unemployed men and women who were looking for work and were under significant stress. Half of the people were taught mindfulness meditation at a residential retreat center, while the other half were provided sham mindfulness meditation, which involved relaxation and distraction from worries and stress.

All participants did stretching exercises, but the mindfulness group was asked to pay attention to bodily sensations, including unpleasant ones. The relaxation group was encouraged to talk to each other and ignore their bodily sensations.

After three days, all participants felt refreshed and better able to deal with the stress of unemployment. However, follow-up brain scans showed changes only in those who underwent mindfulness meditation. The scans showed more activity among the portions of their brains that process stress-related reactions and other areas related to focus and calm. By four months after the retreat most people stopped meditating, however the blood of those in mindfulness meditation group had much lower levels of interleukin-6, a marker of harmful inflammation, than blood of those in the relaxation group.

These changes occurred after only 3 days of meditation. It is likely that an ongoing meditation practice will produce stronger positive effects. Personally, I try to meditate 30 minutes on at least 5 days a week and this is what I recommend to my patients. Even 10 or 20 minutes can have an impact on migraine headaches and general well being.

There are several excellent resources for learning meditation. Free podcasts by a psychologist Tara Brach is an excellent resource. My favorite book to learn meditation is Mindfulness in Plain English by B. Gunaratana. And of course, there is an app for that – Headspace.com and Calm.com.

Prilosec (omeprazole), Nexium, Prevacid, and other similar drugs in the family of proton pump inhibitors (PPIs) can cause headaches directly, but more often by reducing the absorption of vitamins such as B12 and D, and minerals such as magnesium, over a longer period of time. My previous post described a 26,000 patient study that convincingly showed that PPIs cause vitamin B12 deficiency. We also know that older women on PPIs have a higher risk of bone fractures.

A report just published in JAMA Neurology adds another dangerous association. This was also a very large study that involved over 73,000 older people, of whom almost 3,000 were taking PPIs. Those on PPIs had a significantly higher risk of developing dementia. This is possibly due to a direct toxic effect of these drugs, but more likely it is because these drugs cause vitamin and mineral deficiencies.

Three month earlier, the same journal published a study that showed that low vitamin D levels are associated with a significantly higher risk of developing dementia. A very important finding of this study was that even those who had what is considered a normal vitamin D level of between 30 and 50 had an increased risk of dementia, compared with those whose level was above 50. This is not surprising because a study of multiple sclerosis (MS) showed that those with low normal levels had many more attacks of MS than those who had high normal levels. Vitamin D seems to protect from many other diseases and to prolong life.

Many doctors will often tell you that your vitamin D level is normal if it is above 30, but you should ask what your actual level is and try to get it up to at least into 40s or 50s. The upper limit of normal is 100 (level higher than 125 can be harmful). This may require you taking 5,000 or more a day. Our government’s recommended daily requirement of 600 units is insufficient for most people. The same applies to vitamin B12 – many labs will consider a level between 200 to 1,100 to be normal, but in fact it should be at least 400.

If you take PPIs, try to get off them, which is not an easy task. Stopping such drug causes “rebound” increase in acid secretion, which makes symptoms worse than they were before PPI was started. The way to do it is to switch ot Zantac or Pepcid with antacids taken as needed. Then, you try to stop Zantac and keep taking antacids. After a while, with proper diet, you may be able to stop antacids as well.