Alternative Therapies | Headache NewsBlog

Meditation is more effective than placebo

By: Dr. Mauskop

18-12-2015

Meditation is growing in popularity and deservedly so. Several of my previous posts mentioned the benefit of meditation in migraine headaches. Scientists are conducting rigorous studies that repeatedly show the profound effect meditation has on the brain. The most recent study was done at the Wake Forest Baptist Medical Center and it compared the effect of meditation and placebo on pain.

The study was published in the recent issue of the Journal of Neuroscience. It showed that mindfulness meditation not only provided greater pain relief than placebo, but the brain scans could differentiate patterns of brain activity during meditation from that induced by placebo.

The study involved seventy five healthy, pain-free volunteers who were randomly assigned to one of four groups: mindfulness meditation, placebo meditation (“sham” meditation), placebo analgesic cream or control.

Pain was induced by heat applied to the skin. The mindfulness meditation group reported that pain intensity was reduced by 27 percent and the emotional aspect of pain (how unpleasant it was) by 44 percent. In contrast, the placebo cream reduced the sensation of pain by 11 percent and emotional aspect of pain by 13 percent.

Mindfulness meditation reduced pain by activating brain regions associated with the self-control of pain while the placebo cream lowered pain by reducing brain activity in pain-processing areas.

Another brain region, the thalamus, was deactivated during mindfulness meditation, but was activated during all other conditions. This brain region serves as a gateway that determines if sensory information is allowed to reach higher brain centers. By deactivating this area, mindfulness meditation may have caused signals about pain to simply fade away, said Dr. Zeidan, one of the researchers.

Mindfulness meditation also was significantly better at reducing pain intensity and pain unpleasantness than the placebo meditation. The placebo-meditation group had relatively small decreases in pain intensity (9 percent) and pain unpleasantness (24 percent). The study findings suggest that placebo meditation may have reduced pain through a relaxation effect that was associated with slower breathing.

This study is the first to show that mindfulness meditation does not relieve pain the way placebo does. This study confirms previous observations that as little as four 20-minute daily sessions of mindfulness meditation could enhance pain treatment. Another study has shown that an 8-week course of mindfulness meditation not only relieved pain but also made certain parts of the brain cortex measurably thicker.

IV magnesium reduces post-operative pain and opioid use

By: Dr. Mauskop

24-11-2015

Alternative Therapies, Pain

Magnesium infusion given before or during surgery reduces the amount of opioid analgesics (narcotics) needed in the 24 hours following surgery. Doctors at the Saint Barnabas Medical Center in Livingston, NJ reviewed 14 of the most rigorous clinical trials which involved 910 patients. Half of those patients were given intravenous magnesium and the other half, placebo. During the first day after surgery there was a significant reduction in the need for morphine by those receiving magnesium compared with placebo.

Another study published in 2013 reviewed 20 clinical trials of magnesium for post-operative pain. These trials included 1,257 patients. This review also concluded that magnesium improved pain and reduced the need for narcotic pain killers.

Prescription narcotics are frequently in the news because of the epidemic of prescription drug abuse. However, the advantages of not using as much of these drugs after surgery are far greater than just a reduction of the risk of addiction. These drugs cause constipation, which is a problem after surgery even without opioid drugs, and it makes recovery more difficult. They can also cause confusion, difficulty breathing, and other side effects.

There are many possible explanations for the pain-relieving effects of magnesium. We know that it regulates the function of several receptors involved in pain, including serotonin and NMDA. It also relaxes muscles, opens constricted blood vessels, and reduces excitability of the brain and the entire nervous system. Both mental and physical stress depletes magnesium and they are very much present with surgery.

Magnesium is a natural pain blocker, which is effective for many patients with migraine and cluster headaches, as well as those with fibromyalgia, back pain, neuropathy, and other types of pain. Here is a recent blog post on magnesium and migraines.

Sphenopalatine galnglion block for migraine and cluster headaches

By: Dr. Mauskop

14-11-2015

Alternative Therapies, Blocks

Sphenopalatine ganglion (SPG) block has been used for the treatment of headaches and other pain conditions for over 100 years. The original method involved placing a long Q-tip-like cotton swab dipped in cocaine through the nose and against the SPG.

SPG is the largest collection of nerve cells outside the brain and it sits in a bony cavity behind the nasal passages. These nerve cells are closely associated with the trigeminal nerve and include sensory nerves, which supply feeling to parts of the head and autonomic nerves, which regulate the function of internal organs, blood vessels, as well as tearing and nasal congestion. Considering that these nerve cells produce such a wide range of effects, it is logical to expect that blocking these nerves might help headaches.

For obvious reasons we no longer apply cocaine, but instead use numbing medicines, such as lidocaine or bupivacaine. A small study suggested that just putting lidocaine drops into the nose can relieve an acute migraine. I’ve prescribed lidocaine drops to some patients with cluster headaches and a small number reported relief. The problem with nasal drops is that we are not sure if lidocaine actually reaches all the way back to numb the SPG even if they are lying down with the head hanging back over the edge of the bed. Using long Q-tips is uncomfortable and in many patients the Q-tip may also not reach the SPG.

To solve the problem, two doctors developed thin intranasal catheters that appear to consistently reach the area of SPG. Dr. Tian Xia’s Tx360 device seems to be more comfortable for patients because his is a thinner and a more flexible catheter. The recommended local anesthetic is bupivacaine (Marcaine), which lasts longer than lidocaine. A small double-blind study of SPG block using Tx360 in chronic migraine patients showed it to be effective. The active group had a reduction of the Headache Impact Test (HIT-6) score, while the placebo group did not. In this study patients were given the SPG block twice a week for 6 weeks. We need larger and longer-term studies in chronic migraine patients before advising such frequent regimen, not in the least because of cost.

SPG block seems to be more appropriate (and this is what we use it for at the NYHC) for patients with an acute migraine that does not respond to oral or injected medications and for those with cluster headaches. Since cluster headaches usually last for a few weeks to a couple of months (unless it is a patient with chronic cluster headaches), it is practical to try SPG blocks on a weekly basis. Theoretically, because there is so much autonomic nervous system involvement in cluster headaches (tearing, nasal congestion, and other), SPG should be particularly effective for cluster headaches.

Another way to affect the SPG is by stimulating it with electrical current, which seems to be effective for chronic cluster headache patients, according to a small study. This method requires surgical implantation of a device into the area of the SPG. See my previous post on this.

Below is an illustration of the SPG and the Tx360 device.

Acupuncture and Alexander technique relieve neck pain

By: Dr. Mauskop

03-11-2015

Alternative Therapies, Pain, Psychology of headaches

Acupuncture and Alexander technique appear to be equally effective and significantly more effective for the treatment of chronic neck pain than routine care, according to a study by British researchers published in the latest issue of the Annals of Internal Medicine.

The doctors divided 517 patients who suffered from neck pain for at least 6 years into three groups. The first group received an average of 10 50-minute acupuncture treatments, the second had an average of 14 30-minute Alexander technique lessons, and the third group received the usual care. The authors found that acupuncture and Alexander technique both led to a significant reduction in neck pain and associated disability compared with usual care at 12 months.

One possible explanation of such good efficacy beyond the direct effect of the treatments was that patients in the active treatment groups had improved self-efficacy. Self-efficacy is the belief that one’s actions are responsible for successful outcomes and it was measured by a standardized questionnaire.

It is possible that other forms of therapy that enhance self-efficacy, such as tai chi, meditation, and other can also improve long-standing neck pain, as well as headaches. There are many acupuncture studies that show a significant benefit for migraine headaches (here is one described in a previous post), however unlike this neck pain study most of them did not follow patients for such a long period of time. Alexander technique has been also helpful for some of my patients, but again, good studies are lacking.

You can’t get magnesium through the skin

By: Dr. Mauskop

11-10-2015

Alternative Therapies, Migraine

A report describing delivery of magnesium through the skin for the treatment of fibromyalgia has just appeared in the Journal of Integrative Medicine. The title of the report is, Effects of transdermal magnesium chloride on quality of life for patients with fibromyalgia: a feasibility study. It was conducted by doctors at the Mayo Clinic, which carries a certain amount of legitimacy. However, close reading of this report shows shockingly poor quality of this study.

It is true that magnesium deficiency has been found in patients with fibromyalgia (especially if levels other than serum or plasma are measured, i.e. ionized or RBC) Fibromyalgia is a syndrome of unknown cause, which is characterized by chronic pain, fatigue, depression, and sleep disturbances. Some studies have found that the lower the level of magnesium, the more symptoms patients were having. There is an association between fibromyalgia and migraine headaches and those of our patients who have both conditions often report relief of both migraines and fibromyalgia with oral magnesium supplementation or intravenous infusions.

Several companies promote products that promise to deliver magnesium into the body through the skin. The oldest one is Epsom salts, which is magnesium sulfate. Taking a warm bath with Epsom salts surely feels relaxing, but there is no evidence that magnesium penetrates through the skin.

The Mayo clinic study enrolled forty postmenopausal female patients with the diagnosis of fibromyalgia. Each was given a spray bottle containing a 31% solution of magnesium chloride (and “a proprietary blend of trace elements”) and asked to apply 4 sprays per limb twice daily for 4 weeks. They were also asked to complete various questionnaires. Only twenty-four patients completed the study, with 4 dropping out because of skin irritation. At week 2 and week 4 most were significantly improved.
The authors concluded that their study “suggests that transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia”. This was a very small and unblinded study with many dropouts, which means that no conclusions can be made. It is very surprising why the authors did not measure magnesium levels before and after the treatment, which would make the study much more valuable.

The company that sponsored the study has a product they’d like to sell to the unsuspecting public and it will certainly use this “study” and the Mayo Clinic name to sell their miracle spray. The Mayo Clinic is a highly respected institution and I hope they will not allow its name to be associated with such poor quality marketing studies.

Meditation improves quality of life in drug-resistant epilepsy, reduces seizures

By: Dr. Mauskop

30-09-2015

Alternative Therapies

Epilepsy and migraines share many features and those with epilepsy have a higher risk of developing migraines, while those with migraines are more likely to develop epilepsy. Anti-epilepsy drugs are commonly used for the preventive treatment of migraines.

A study just published in Neurology by Hong Kong researchers investigated the effectiveness of mindfulness-based therapy and social support in patients with drug-resistant epilepsy.

It was a blinded and randomized trial. Sixty patients with drug-resistant epilepsy were randomly allocated to mindfulness therapy or social support (30 per group). Each group received 4 biweekly intervention sessions. They measured quality of life, as well as seizure frequency, mood symptoms, and neurocognitive functions.

Following intervention, both the mindfulness and social support groups had an improved quality of life, but significantly more patients in the mindfulness group had a clinically important improvement. Significantly greater reduction in depressive and anxiety symptoms, seizure frequency, and improvement in delayed memory was observed in the mindfulness group compared with the social support group.

The authors concluded that even short-term mindfulness therapy in patients with drug-resistant epilepsy provides significant benefits.

It is surprising that even seizure frequency was reduced, although stress and lack of sleep can definitely increase seizure frequency. The study did not evaluate the quality or duration of sleep, but mindfulness meditation is know to improve sleep. It also improves migraine headaches (see my previous post).

To start meditating you can download a very popular app, Headspace or read a book by BH Gunaratana, Mindfulness in Plain English or download free podcasts at TaraBrach.com.

The dangers of Ayurvedic medicine

By: Dr. Mauskop

03-08-2015

Alternative Therapies, Headache medications

Ayurvedic medicine has many healthy aspects. However, a recent story on NPR described the risks involved with the traditional Ayurvedic medicines from India. A very high percentage of Ayurvedic supplements in the category called bhasmas sold in the US contains large amounts of lead and other toxic elements. There is a lot more to Ayurvedic medicine than these supplements, so it is important to separate dangerous parts from things like healthy diet, yoga, and other.

Unfortunately, the US government does not regulate supplements, so there is always a question of safety of these products, especially those made outside the US. The one exception is products made in Germany, where supplements are as strictly regulated as drugs (please note that Petadolex, a butterbur product is made in Germany, but is not allowed for sale there). Many patients ask me about not only Indian but also Chinese herbal medicines, which are often combined with acupuncture and other treatment methods. As a rule, I recommend avoiding products made in China or India, where quality controls are very poor. Instead, you should buy products made by major US manufacturers, although they do not make many traditional Chinese and Indian products. However, you cannot always count on products sold in major US store chains either – recently, herbal products sold at Walgreens, WalMart, Target and GNC were found to have no active ingredients. Thankfully, there were no toxic ingredients in those products.

The largest mass poisoning with a Chinese herbal dietary weight loss product occurred in Europe where 18 patients developed kidney failure and urinary cancer.

In summary, no matter how promising a Chinese or an Indian herbal product may sound, it is not worth the risk.

Treating concussion in children

By: Dr. Mauskop

22-06-2015

Alternative Therapies, Botox, Chronic migraine, Head trauma

Several presentations at the annual meeting of the American Headache Society held in Washington DC last weekend discussed the treatment of post-concussion symptoms in children (everything below also applies to adults). Among many topics, the speakers addressed the question of aerobic exercise after the concussion. Most experts agree that starting physical exercise too early can worsen the symptoms and delay recovery. At the same time, because aerobic exercise has so many benefits for the brain, it is prudent to begin aerobic exercise 2 to 4 weeks after the concussion. The child should begin exercising for short periods of time and at low intensity. Exercise should be stopped as soon as symptoms, such as headache or dizziness worsen. Brisk walking could be the first activity to be tried. The ideal duration is about 30 minutes and when this goal is achieved, the intensity of exercise can be gradually increased.

As far as the very common cognitive problems after a concussion, the experts also agreed that complete cognitive rest is not helpful. Just like with physical exercise, it is best to begin mild activities, such as reading for pleasure, and then slowly increase the load, as tolerated.

Several scientific presentations reported that the most common type of headaches that occurs after a concussion is migraine. When these post-concussion migraines last for more than 3 months and occur on more than 15 days each month, they are considered to be chronic migraines.

The treatment of post-concussion chronic migraines is the same as the treatment of chronic migraines that occur without a concussion. These treatments may include cognitive behavioral therapy, biofeedback, magnesium and other supplements (magnesium deficiency is found in up to 50% of migraine sufferers and magnesium is depleted by trauma), various preventive medications, and Botox injections.

Although the FDA has not yet approved Botox injections for the treatment of chronic migraines in children, Botox is safer than most drugs. We know about the safety of Botox in children because it has been widely used even in very young children who suffer from cerebral palsy and are unable to walk unless their stiff leg muscles are relaxed by Botox. Botox was approved by the FDA 26 years ago and some kids have been getting injections for over 20 years and so far there have been no long-term side effects observed.

Transcranial magnetic stimulation for migraine with medication overuse headache

By: Dr. Mauskop

01-06-2015

Alternative Therapies, Migraine

Transcranial magnetic stimulation (TMS) was approved by the FDA at the end of 2013 (see my earlier post) but it has not yet become available. This approval was for the treatment of acute migraine.

A new study just presented at the International Headache Congress suggests that TMS could be effective for the preventive treatment of migraines with medication overuse headache.

The study included only 28 patients and it was not a blinded study. However, these patients were severely affected and failed several other treatments. They were instructed to use the TMS device twice a day every day with an additional treatment at the time of a headache. Treatment lasted for at least 3 months, with an option to continue for another 3 months.

Of the 28 patients, 24 (86%) reported a reduction in their days of acute medication use per month, while 2 patients reported an increase in acute medication use. Nineteen patients (68%) experienced fewer migraine days per month, and 7 of the 19 had a 50% or greater reduction in migraine days. The number of patients with pain severity rated as excruciating or severe dropped from 19 at baseline to 3 at 3 months (84% reduction). Headache attack duration decreased in 15 patients, remained unchanged in 9, and increased in 4. The disability score (HIT-6) was severe at the beginning of the study in 26 of 28 participants. After 3 months, only 18 had severe disability.

The benefit was seen in patients who had migraines with and without aura.

After 3 months, five patients stopped using TMS because it was ineffective or inconvenient. Four were lost to follow-up. Of the remaining 19, 16 reported reduced days of acute medication use at 6 months, compared with baseline. Disability scores in the 19 patients who used TMS for 6 months were comparable to their scores at 3 months, suggesting that there was no additional benefit from longer-term use, but the benefit was maintained.

No side effects were reported, confirming the safety of TMS. Now we just have to wait for the company (eNeura) to release this product on the market.

Anti-histamine diamine oxydase for the prevention of migraines

By: Dr. Mauskop

22-05-2015

Alternative Therapies

Another supplement to consider for the preventive treatment of migraine headaches is diamine oxidase (DAO). It is an enzyme that breaks down histamine.

Histamine is released during an allergic reaction and is present in many foods. It is one of the neurotransmitters that is involved in the process of migraine. A quarter of the population has insufficient amounts of DAO, which leads to inefficient metabolism of histamine. The largest amounts of DAO in the body are found in the intestines and the kidneys.

A group of Spanish neurologists published a study that showed that of 137 patients with migraines, 119 (87%) showed impaired activity of the enzyme.

The normal enzyme activity is a score of at least 80 histamine-degrading units [HDU]/mL. In a survey which was conducted in 2006 and again in 2012, migraine symptom scores correlated with enzyme activity. Symptom scores rose progressively as enzyme activity dropped below 80 HDU/mL, with scores almost twice as high in the 30-40 HDU/mL range compared with enzyme activity >80 HDU/mL.

Dr. Izquierdo and his colleagues in Barcelona conducted a double-blind, placebo-controlled trial of DAO oral supplementation, for the prevention of migraines in patients with DAO activity less than 80 HDU/mL.

Participants were men or women age 18 to 60 years old with an attack within the previous 6 months. Most of the patients were women, with only 8 men in each group.

The supplement contained 4.2 mg of DAO which participants took with a glass of water before breakfast, lunch, and dinner. The supplement was associated with a similar reduction in the mean number of attacks per month in the placebo and DAO groups, but the group that took DAO used significantly fewer triptan drugs (such as sumatriptan, Imitrex). These results are not overwhelming, but they possibly hide the fact that some of these patients had a very good response while others had none, which averaged out to a modest benefit. Considering that this a very benign supplement with no potential for serious side effects (unlike prescription drugs), it may be worth trying.

Histamine intolerance is defined by an imbalance of histamine and the histamine degrading enzyme diamine oxidase (DAO), which is mainly produced in the small intestine. Excessive amounts of histamine in the body can cause not only migraine and other types of headaches, but also diarrhea, nasal congestion, asthma, rashes, and other symptoms. People who are prone to severe allergic reactions with anaphylactic shock often have lower DAO activity. Diamine oxidase activity can be measured in blood, but the test is expensive and not very reliable. Instead of doing this test, try a low histamine diet or taking a DAO supplement. This is particularly worthwhile for people who in addition to migraines suffer from colitis (such as Crohn’s), allergic conditions, asthma, and celiac disease.

Here is an informative post on this topic on The Daily Headache blog.

Neck weakness and tension-type headaches

By: Dr. Mauskop

13-05-2015

Alternative Therapies, Botox, Headaches

Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

Topical cream for migraine

By: Dr. Mauskop

05-05-2015

Alternative Therapies, Migraine, New treatments

A topical cream seems to be effective in treating migraine headaches. Achelios Therapeutics announced results from a Phase IIa placebo-controlled clinical trial in moderate and severe migraine sufferers treated with Topofen, the company’s proprietary topical anti-migraine therapy. This is a well-known non-steroidal anti-inflammatory drug (NSAID) ketoprofen, which is applied to the face and seems to provide relief for patients suffering from acute migraine.

The results of the clinical trial were presented at the American Academy of Neurology annual meeting in Washington, D.C. Surprisingly, this study showed that it may be possible to relieve severe migraine with a topical application to facial nerve endings. Topical application avoids potentially serious side effects of NSAIDs, such as stomach bleeding and ulcers. The randomized, crossover, double-blind, placebo-controlled study involved only 48 adults with a history of episodic migraine with and without aura. Of the severe migraine patients, 77 percent experienced relief of pain and migraine-associated symptoms and 45 percent had sustained pain relief from two to 24 hours compared to 15 percent on placebo. Also, 50 percent of patients who treated their severe pain with Topofen were pain free at 24 hours compared to 25 percent of placebo-treated patients. Some patients experienced application-site irritation, which was mild or moderate in severity. That was the only reported side effect, which resolved quickly.

Such a small study does not prove that this treatment is in fact effective. A typical drug trial required for an FDA approval usually involves hundreds of patients. However, you do not need to wait for this cream to appear on the market because there are creams containing an NSAID already available by prescription (Voltaren Gel) and over-the-counter (Aspercreme). It is possible that the cream tested in the study may be better because it is a different NSAID, but Voltaren Gel is already approved and you can ask your doctor for a prescription. It is possible that insurance companies will not pay for it since it is not approved for migraines. A tube of Voltaren Gel will cost you about $55 (go to GoodRx.com to get the lowest price).