Alternative Therapies | Headache NewsBlog

Intranasal ketamine for cluster headaches

By: Dr. Mauskop

20-01-2022

Alternative Therapies, Cluster headaches, Headache medications, New treatments

Cluster headaches are considered to cause the worst pain imaginable. We have a variety of medications – both acute and preventive – that help relieve the pain of cluster headaches. For some, none of these treatments work and we do need additional medications. Ketamine could be one such drug.

Ketamine has been in use for over 50 years. Its main indication is intravenous anesthesia. Recently, the FDA approved ketamine nasal spray for depression. It is also being widely used intravenously and by mouth for depression, chronic pain, and migraine headaches. A group of researchers at the Danish Headache Center in Glostrup, Denmark tested the efficacy of ketamine nasal spray for the acute treatment of cluster headaches.

Anja Petersen and her colleagues selected 20 cluster patients whose attacks did not respond sufficiently well to sumatriptan or oxygen – the two most effective acute therapies for cluster headaches. Patients treated a single cluster attack with 15 mg of intranasal ketamine. They could repeat this dose every 6 minutes, for up to 5 times. Four patients took another medication after 15 minutes. Of the 16 remaining ones, 11 had a drop in pain severity by an average of four points, to four or lower on a one to 10 scale. Half of the patients preferred ketamine to oxygen and/or sumatriptan injection. No patient had any serious side effects from ketamine during the trial.

Ketamine nasal spray that is approved for depression is a more potent version of ketamine called esketamine (Spravato). It is a patented and branded product and it is very expensive. Ketamine itself, however, is a cheap drug. A compounding pharmacy can prepare a nasal spray for as little as $60 for a month supply. Most insurers do not cover compounded drugs, so you’d have to pay for it.

Marijuana increases the risk of car accidents

By: Dr. Mauskop

13-01-2022

Alternative Therapies, Brain disorders, Migraine, New treatments, Pain

I’ve been prescribing medical marijuana (MM) since 2016 when it became legal in New York. We still lack controlled clinical trials of MM for the treatment of migraines. Most of my patients who find MM useful report that it relieves nausea or anxiety, helps them go to sleep and sometimes relieves pain. Others find that taking it daily prevents migraines. CBD alone can be also helpful, but most patients need a combination of CBD and THC as well in order to obtain a therapeutic effect.

Like any other drug, MM can have side effects. One of them is cognitive impairment. A study just published in the New England Journal of Medicine describes the effect of recreational marijuana legalization in Canada on injuries to car drivers. The researchers studied drivers treated after a motor vehicle collision in four British Columbia trauma centers from 2013 through 2022. They discovered that after legalization, the number of moderately injured drivers with a THC level above the legal limit doubled. The largest increase was seen in older and male drivers.

This is relevant to the users of MM as well. From now on, I will caution my patients not to drive after taking any THC-containing products. Just like with alcohol, you don’t need to have a blood level above the legal limit to slow your reflexes.

Pandemic worsens headaches in children

By: Dr. Mauskop

06-01-2022

Alternative Therapies, Brain disorders, Chronic migraine, Pain, post-traumatic headache, Psychology of headaches, Science of Migraine

Worsening of headaches in children is one of many deleterious effects of the pandemic and measures to control it. A survey of children in a headache clinic at the Children’s National Hospital in Washington DC by Dr. DiSabella and his colleagues showed that 46% of children had worsening of their migraine headaches during the pandemic.

They also reported much higher rates of anxiety, depression, and stress. Two-thirds of children reported that they exercised less. This could be one of the contributing factors since exercise has been shown to reduce the frequency and the severity of headaches.

What this survey did not explore is the effect of family stress and the presence of child abuse. Reports of child abuse have actually declined during the pandemic because most of these reports come from teachers. Chronic migraines and chronic pain are much more common in patients with a history of being physically, emotionally, or physically abused. PTSD from other causes has a similar predisposing effect and many children and adults have been traumatized by the pandemic.

Some children (as well as adults) report improvement of their headaches during the pandemic. My patients tell me that because they do not have to commute, they have more time to exercise, meditate, cook healthy meals, and get more sleep. I see this in a small proportion of patients. A larger group did worse with additional factors being worsening of headaches due to COVID and in a very small number, COVID vaccines.

Repetitive transcranial magnetic stimulation relieves migraines

By: Dr. Mauskop

18-12-2021

Alternative Therapies, Headaches, Migraine, neurostimulation, New treatments

Magnetic stimulation with a single pulse has been shown to be effective in aborting a migraine attack with the eNeura Spring TMS device.
Repetitive magnetic stimulation (rTMS) of the brain has been shown to relieve depression. A pilot study just published in the journal Brain Stimulation examined the effectiveness of repetitive magnetic brain stimulation for the prevention of migraine attacks.

German and Moldovan researchers conducted a double-blind, randomized controlled study in patients with episodic migraine. They compared real and sham stimulation in 60 patients. Participants received six treatment sessions over two weeks. The primary outcome measure was the number of patients whose migraine days dropped by 50% or more. The frequency and intensity of migraine attacks over a 12-week period were also assessed.

Real rTMS produced at least a 50% reduction in migraine days in 42%. This number was 26% in the sham group. The mean migraine days per month decreased from 7.6 to 4.3 days in the real rTMS group and from 6.2 to 4.3 days in the sham rTMS group. The reduction in migraine attack frequency was also higher in the real rTMS compared to the sham group. No serious adverse events were observed.

There are a couple of practical issues with this treatment approach. The rTMS equipment is already being used for depression, which in theory should make it easy to adapt for migraines. However, this treatment is time-consuming and expensive and is not likely to be covered by insurance. Another problem, which we also encountered in our study of transcranial direct current stimulation, is that there are many variables to consider. Placement of electrodes, the strength of stimulation, frequency, and duration of treatments are some of these variables.

Men with migraine and cluster headaches can also have hormonal issues

By: Dr. Mauskop

31-10-2021

Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Pain, Science of Migraine

The influence of estrogen on migraines in women is well established – women often experience migraines before or during menstruation and ovulation and their migraines usually subside during pregnancy and menopause.

According to a new study published this month by Dutch researchers, men who suffer from migraines often have a deficiency of male hormones.

Gisela Terwindt and her collaborators evaluated a possible deficiency of androgens or male hormones in 534 men with migraine and 437 men with cluster headaches. These men were compared to 152 healthy controls. Two validated questionnaires were used to measure androgen deficiency scores. The researchers controlled for age, weight (BMI), smoking, and lifetime depression. They also measured four sexual symptoms (beard growth, morning erections, libido, and sexual potency). These four symptoms have been shown to differentiate between hormonal deficiency from anxiety and depression. They did not perform blood tests to measure hormone levels.

Patients reported more severe symptoms of clinical androgen deficiency compared with controls. Both patient groups were more likely to suffer from any of the specific sexual symptoms compared to controls (18% migraine, 21% cluster headache, 7% controls).

The findings in men with cluster headaches are not surprising. Prior reports have documented low testosterone levels in this population. A small study by Dr. Mark Stillman suggested that those cluster patients who have low testosterone levels could benefit from hormone replacement therapy.

There are also reports of low testosterone levels in men with chronic migraines but the connection is less established.

This study may prompt me to pay more attention to sexual dysfunction in men with chronic migraines. I may also start checking testosterone levels in such patients.

If you see a friend respond to treatment, you are more likely to respond as well

By: Dr. Mauskop

21-10-2021

Alternative Therapies, Headache medications, Migraine, Pain, Pain Research, Psychology of headaches

The placebo effect is a bane of clinical trials. It is, however, a great tool in clinical practice. It is unethical to prescribe an actual placebo but there is no reason not to try to enhance the placebo effect when prescribing any treatment, pharmacological or non-drug.

A new and unique study that was just published in Pain, a journal of the International Association for the Study of Pain, suggests that looking at others who respond to treatment makes people more likely to respond to that treatment as well.

German researchers decided to study what is called social observational learning (SoL). This was a double-blinded randomized controlled clinical trial in 44 patients with chronic low-back pain (CLBP). They compared the effects of observing positive treatment outcomes in a sham or pretend patient versus hearing the same sham patient report neutral effects. In the SoL group, the sham patient told study patients about his improved pain due to amitriptyline and he also demonstrated his improved mobility by bending forwards and sideways. The same sham patient told the control group only that he was taking amitriptyline. The researchers collected data before and after the intervention and two weeks later. After the intervention, pain decreased in both groups with no difference between groups. The SoL group, however, showed a significantly larger decrease in perceived disability.

The authors concluded that “The CLBP patients’ direct observation of positive treatment outcomes in the sham patient appears to have enhanced the treatment effects, while indirect verbal reports of reduced pain did not.”

These findings are not surprising. I often have patients ask for a particular treatment because their friend or relative had a very good response to it. If it is a reasonable treatment for a particular patient, I usually oblige, hoping for an enhanced placebo effect.

Response to drugs is influenced by psychological factors

By: Dr. Mauskop

11-10-2021

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

To gain FDA approval a drug has to be shown to be better than a placebo. The placebo effect is a well-established psychological contributor to the efficacy of most treatments.

A group of Italian researchers just published an interesting study looking at other psychological factors that might influence the response to treatment.

They evaluated chronic migraine patients who were treated with erenumab (Aimovig). Erenumab is a monoclonal antibody that targets CGRP, a neurotransmitter involved in the development of migraine attacks.

Monthly erenumab injections were given for one year to 75 patients with chronic migraine who had already failed at least three other oral preventive drugs. A full psychological evaluation assessed personality disturbances, mood and anxiety disorders, as well as childhood traumas, and ongoing stressors.

After 12 months of treatment, 53 patients had at least a 50% drop in the number of headache days per month. The other 22 did not. When compared to responders, non-responders were more likely to have personality disorders with anxious-fearful, avoidant, dependent, and obsessive-compulsive features. Non-responders were also more likely to suffer anxiety disorders and had a higher number of current major stressors.

A very practical application of these findings is that doctors need to address anxiety when treating migraine and chronic pain patients. I’ve seen a number of patients whose migraines improved with an SSRI antidepressant such as fluoxetine (Prozac) or escitalopram (Lexapro). SSRIs do not possess pain-reliving properties. However, they are good at relieving anxiety and so can indirectly improve migraines. Most of the time, I prescribe SNRIs such as duloxetine (Cymbalta) or a tricyclic antidepressant such as nortriptyline (Pamelor) because they relieve anxiety and can have a direct pain-relieving effect.

The old dogma in psychology was that you cannot change your personality. We now know that such change is possible. Different types of cognitive-behavioral therapy (CBT) can be very helpful. Swedish researchers showed that even a brief internet-based CBT can produce long-term changes in personality traits.

A large study shows that the weather affects pain

By: Dr. Mauskop

27-09-2021

Alternative Therapies, Chronic migraine, Headaches, Migraine, Pain, Pain Research

Many migraine sufferers report that their migraines are brought on by the weather. High humidity, high temperatures, and changes in barometric pressure are the most commonly reported triggers. I’ve seen some patients for whom changes in the weather is the only trigger. Research studies looking at this connection, however, have been contradictory.

A very large study just published in Pain, the journal of the International Association for the Study of Pain examined a possible connection between the weather and pain tolerance.

The data from 18,000 Norwegians aged 40 years or older from the general population were examined. All of them underwent pressure pain tolerance (PPT) test using a blood pressure cuff and cold pain tolerance (CPT), tested by immersing the dominant hand in cold water.

The results showed a clear seasonal variation in CPT. Cold pain tolerance was worse during the warmer times of the year compared with January. There was no seasonal variation in PPT.

The authors also found that temperature and barometric pressure have “a causal and dynamic effect on pain tolerance, which supports the common belief that weather affects pain.”

There is not much you can do about the weather except for moving to a place with an unchanging and mild climate. Some of my patients with barometric pressure-induced headaches do respond to acetazolamide (Diamox). This is a diuretic that prevents mountain sickness in climbers. Patients do not need to constantly check the weather forecast. For more information on acetazolamide, see my previous blog post.

Julie Mauskop on David Zwirner’s Platform

By: Dr. Mauskop

11-09-2021

Alternative Therapies

Patients coming to the New York Headache Center have enjoyed seeing my daughter Julie’s artwork since she was 11. This was not just a childhood interest – Julie graduated from the Rhode Island School of Design with a degree in painting. She has continued to work hard as a painter and her perseverance and talent have led to wider recognition.

Julie is represented by a New York City gallery, SHRINE. A few days ago, her work was selected for Platform, a new online initiative by David Zwirner.

You can see more of Julie’s work on her Instagram page.

Placebo really works, even if you know it’s placebo

By: Dr. Mauskop

30-08-2021

Alternative Therapies, Headache medications, Headaches, Migraine, Pain, Pain Research, Psychology of headaches

The placebo effect is a bane of clinical trials. A drug is considered ineffective if it is only as good as a placebo. And placebo can be quite good. Intriguingly, the placebo effect in clinical trials has been getting stronger over the past few decades. Lately, placebo has been receiving a lot of attention from researchers.

A rigorous study just published in the journal Pain looked at the effect of a placebo when patients were clearly told that they are taking a placebo. These patients were compared to those who were given a placebo in a double-blind study of peppermint oil capsules for irritable bowel syndrome (IBS). These two different types of placebo were compared to a control group of patients who were not given any pills.

Participants treated with an open-label placebo and a double-blind placebo reported similar and clinically meaningful improvements in IBS symptoms. These improvements were significantly greater than in those who were not given any pills. The results were statistically significant for the primary outcome measure (IBS Symptom Severity Scale) as well as for mean global improvement scores.

Twice as many patients in the double-blind placebo group had side effects (mostly gastrointestinal, such as heartburn) than those in the open-label placebo. It is probably because the first group was told about the possible side effects of peppermint oil.

The authors concluded that an open-label placebo “could play a role in the management of patients with refractory IBS”.

Just like migraines, IBS involves central sensitization and hypersensitivity of the nervous system. And just like with migraines, placebo response in clinical trials of IBS tend to be high. This is not to suggest that these conditions are psychological. Especially with migraines, the biological basis is well documented. Psychological factors, however, cannot be ignored. About 40% of patients with chronic pain, including migraines, have a history of emotional, physical, or sexual abuse. Post-traumatic stress disorder of other types also causes hypersensitivity of the central nervous system. Psychological factors can even be the cause of such potentially deadly conditions as broken heart syndrome (Takotsubo cardiomyopathy). It is likely that the placebo effect is stronger in conditions where psychological factors are more pronounced.

It is considered unethical to prescribe a placebo to patients without telling them that they are getting a placebo. This latest study suggests that some patients may improve even if they know that they are taking a placebo.

I do prescribe herbal supplements such as feverfew and boswellia and on a rare occasion, a homeopathic remedy, all of which lack rigorous proof of their efficacy. For that matter, many drugs we prescribe for migraines lack such definitive proof. I would suggest that we should first prescribe less harmful unproven remedies rather than unproven prescription drugs.

More of the omega-3 and less of omega-6 fatty acids helps migraines

By: Dr. Mauskop

08-08-2021

Alternative Therapies, Migraine

Migraine can be triggered by many foods, including sugar, chocolate, smoked, pickled, cured, dried, and fermented foods. There are also foods that can help with migraines. These are magnesium-rich dark leafy vegetables and whole grains. Omega-3 fatty acids that are known to have anti-inflammatory properties is another option.

The British Medical Journal just published a randomized controlled trial of omega-3 and omega-6 fatty acids in the prevention of migraines. The same group of North Carolina researchers published a similar smaller study in 2013.

The new trial included 182 participants who had migraines on 5-20 days per month. They were divided into three groups. One group was supplemented with omega-3 fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The second group was also given the same amount of EPA and DHA but their diet also had a reduced amount of linoleic acid, an omega-6 fatty acid. The third group served as control.

Compared with the control diet, the first two diets decreased total headache hours per day, moderate to severe headache hours per day, and headache days per month. The diet that increased omega-3s and reduced omega-6 had a greater decrease in headache days per month than the diet that was only supplemented with omega-3s.

Supplementation also resulted in an improvement of inflammatory markers in the blood, a change that was not seen in the control group.

If eating more salmon or other fish rich in omega-3s is not practical, taking a good-quality supplement is a good alternative. To reduce your omega-6 intake avoid processed seed and vegetable oils and processed foods that contain them.

Magnesium can reduce the risk of aneurysm formation and rupture

By: Dr. Mauskop

02-08-2021

Alternative Therapies, Brain disorders

Many patients with headaches are concerned about having a brain aneurysm. It is rare for an aneurysm to cause ongoing headaches. An aneurysm usually causes one very severe headache when it ruptures and causes a brain hemorrhage. Half of the patients with a ruptured aneurysm die and many of those who survive have persistent neurological problems. This is why detecting and treating an aneurysm before it ruptures is the goal. Because aneurysms have a genetic component we do angiograms in close relatives of someone with a ruptured or unruptured brain aneurysm. About 2% of the population has brain aneurysms. It would be prohibitively expensive to subject everyone to a screening angiogram.

Aneurysms are the result of an outpouching of a weak spot in an artery. This process is very gradual and aneurysms tend to get bigger with age. People with small aneurysms and high blood pressure are advised to control their blood pressure in the hope that this will prevent or slow down the growth of the aneurysm. Small aneurysms rarely rupture. If an aneurysm is larger than 5 millimeters in diameter, however, the risk of rupture becomes significant and surgery or non-surgical obliteration is recommended.

Until now, there have been no interventions proven to reduce the risk of aneurysm formation and rupture.

In the current issue of Neurology, a group of Swedish researchers published a rigorous study entitled, Association of Serum Magnesium Levels With Risk of Intracranial Aneurysm.

They provided evidence showing that higher serum magnesium concentrations reduce the risk of intracranial aneurysm and aneurysmal rupture. This was only partly due to the blood pressure-lowering effect of magnesium. They speculated that the additional effects were due to the improved function of the blood vessel lining (endothelium) and a reduction in oxidative stress – proven actions of magnesium.

They concluded: “These findings add to the growing body of evidence highlighting a beneficial role of higher magnesium for preventing cerebrovascular and cardiovascular diseases.” These diseases include strokes, heart attacks, cardiac arrhythmias, and certainly, migraines. Besides these diseases, magnesium is very helpful in a host of other conditions such as asthma, diabetes, osteoporosis, obesity, and many others.

In 2012, I wrote an article, Why all migraine patients should be treated with magnesium. Considering that one-third of the population is deficient in magnesium, it would not be inappropriate to say that everybody should be taking a magnesium supplement.