Alternative Therapies | Headache NewsBlog

Migraine device, Cefaly no longer requires a prescription

By: Dr. Mauskop

03-12-2020

Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation

Cefaly is a neurostimulation device that was approved by the FDA in 2014. Until October of this year, it required a prescription. Several clinical trials proved the device to be not only effective but also very safe. Now it can be purchased without a prescription from the manufacturer’s website – Cefaly.com.

Cefaly is used for both prevention and acute treatment of migraine. It is applied to the middle of the lower forehead with an adhesive electrode. For acute therapy, the device is used for 60 minutes. For prevention, it is used daily for 20 minutes. Some of my patients find it effective on its own while others use it in conjunction with medications.

As far as side effects, the device is very safe. It can cause skin irritation from the adhesive or from the electrical current. Some of my patients reported worsening of their headaches. This tends to happen to patients who develop allodynia during their migraine attack. Allodynia means increased skin sensitivity. It can be so severe that sometimes a patient cannot even wear glasses or have a ponytail.

An electrical stimulation device that is better tolerated by patients with allodynia is Nerivio. It is applied to the upper arm for 45 minutes as needed. Nerivio requires a prescription but it is sometimes covered by insurance while Cefaly is not.

Virtual reality for pain relief

By: Dr. Mauskop

22-11-2020

Alternative Therapies, Headaches, Migraine, Pain

Many studies have shown that virtual reality experience can relieve pain. The first such study in burn patients was published 20 years ago. A comprehensive review of this topic, Immersive Virtual Reality and Virtual Embodiment for Pain Relief was published last year by Italian researchers.

A different group of Italian researchers tested the effects of visual distraction on pain in chronic migraine patients. They compared a classical hospital waiting room with an ideal room with a sea view. Both were represented in virtual reality (VR). They measured pain and brain responses induced by painful laser stimuli in healthy volunteers and patients with chronic migraine. Pain was induced in the hand of sixteen chronic migraine patients and 16 healthy controls. This was done during a fully immersive VR experience, where two types of waiting rooms were simulated. Patients with migraine showed a reduction of laser pain rating and brain responses during the sea view simulation. Control subjects experienced the same level of pain in both types of simulated rooms.

An older study of 30 patients with chronic pain showed that 20 patients had pain relief during a VR session. Ten of them reported complete pain relief. Of the 20 who had relief, 10 had continued relief after the VR session.

A combination of VR with biofeedback resulted in lasting benefits in 9 of 10 children with chronic headaches who completed 10 training sessions.

About 5% to 10% of people who try VR get cybersickness. This is a feeling of dizziness or vertigo, similar to motion sickness. This is why VR sessions are often limited to a maximum of 30 minutes.

It appears that there are several possible approaches to the treatment of pain using VR. One is by using VR for distraction. Another, by utilizing VR to facilitate biofeedback, which is proven to relieve migraine and tension headaches. The third way, yet to be proven, is by altering body perception.

Dry eyes and migraine

By: Dr. Mauskop

01-11-2020

Alternative Therapies, Migraine

People who suffer from migraines often have a variety of visual symptoms. These include seeing an aura prior to the onset of headache, blurred vision, difficulty reading on screens or even on paper, and eye pain.

Patients with migraines often have reduced visual quality of life (QoL). This is according to a study published in Headache by doctors at the University of Utah. They assessed the visual quality of life, headache impact, aura, dry eye, and photophobia in migraine patients.

The researchers concluded that “Dry eye seems to be the most important symptom that reduces visual quality of life and worsens headache impact.”

Research has consistently shown that dry eye disease has a significant impact on several aspects of patients’ QoL, including pain, vitality, ability to perform certain activities requiring sustained visual attention (e.g., reading, driving), and productivity in the workplace.

Some people may not be aware that their eyes are dry. Their eyes might just feel fatigued or irritated. Ophthalmologists perform the Schirmer test to detect dry eye disease. It is done by placing a strip of filter paper under the lower eyelid and measuring the length of the strip that gets wet.

It is not clear if treating dryness of the eyes will help migraine headaches but it is very likely to improve visual functioning and QoL. Some of the treatments for dry eyes include artificial tears, tear stimulation, and anti-inflammatory therapy.

Marijuana protects brain in trauma

By: Dr. Mauskop

05-10-2020

Alternative Therapies, Brain disorders, Head trauma

Frequent use of marijuana has a negative effect on the developing brain. Researchers at Tulane and Dartmouth medical schools looked at the possible protective effect of marijuana in severe head injury. The results were recently published in an article, Preinjury Use of Marijuana and Outcomes in Trauma Patients.

They examined records of adults who presented to two large regional trauma centers between 2014 and 2018. They included patients who had detectable levels of delta-9-tetrahydrocannabinol (THC) in the blood. They excluded those who had other illicit drugs present.

Of the 4849 patients, 1373 (28.3%) had THC present in the blood. These patients tended to be younger, more likely to be males, and more likely to be injured by “penetrating mechanism” than those who did not have THC present. Patients with THC had a shorter hospital stay, shorter need for ventilation, and a shorter stay in the intensive care unit. The mortality rate was somewhat lower in the THC-positive group (4.3% versus 7.6%) but this difference did not reach statistical significance.

The mechanism could be related to the anti-inflammatory effects of marijuana mentioned in the previous post. Head trauma is known to trigger an immune response that leads to inflammation that in turn worsens brain damage. The researchers did not measure any inflammatory markers so this is just a speculation. It is also possible that the THC-positive group did better because it was significantly younger than the THC-negative group.

In another very large chart review study that looked at older trauma patients, intoxication with alcohol predicted better survival and shorter hospital stay. On the other hand, the presence of cocaine or marijuana worsened the prognosis.

In the US, trauma is the leading cause of death and disability in 18 to 44-year-olds. This is also the age group that is more likely to use marijuana. Consuming marijuana may increase the risk of trauma as suggested by the fact that THC-positive patients were more likely to have a “penetrating injury”. Despite the protective effect of marijuana, it is very likely that reducing its use will lead to fewer injuries and more lives saved.

Anti-inflammatory effect of cannabis

By: Dr. Mauskop

01-10-2020

Alternative Therapies, Migraine, Pain

Cannabis has known anti-inflammatory properties. A group of researchers from UCSD published a study, Recent cannabis use in HIV is associated with reduced inflammatory markers in CSF and blood. They measured a variety of inflammation markers in the blood and cerebrospinal fluid (CSF) of people with HIV.

They showed that “Recent cannabis use was associated with lower levels of inflammatory biomarkers, both in CSF and blood, but in different patterns. These results are consistent with compartmentalization of immune effects of cannabis. The principal active components of cannabis are highly lipid soluble and sequestered in brain tissue; thus, our findings are consistent with specific anti-neuroinflammatory effects that may benefit HIV neurologic dysfunction.”

Translating this into English, smoking pot reduces inflammation not only in the body but also in the brain. Not all substances reach the brain because of the so-called blood-brain barrier. But the two main ingredients of marijuana – THC and CBD – easily dissolve in fat which allows their entry into the brain.

Obviously, not all of the effects of marijuana are beneficial. The most harmful is the inhalation of smoke which causes lung damage. Vaping medical-grade marijuana or taking it by mouth is much safer.

I’ve been prescribing medical marijuana for the past 6 years since it became legal in NY. In NY patients have a choice of capsules taken by mouth, tincture drops placed under the tongue, or vaping. I find it particularly useful for symptoms associated with migraines more than the actual pain – nausea, anxiety, and insomnia. For some, it relieves pain as well.

Marijuana seems particularly effective for pain in the elderly. One of the most dramatic responses I’ve observed was in a 95-year-old woman with severe arthritis pain. She was mentally sharp but upset about her inability to go outside and get around on her own. A small amount of marijuana produced a greater than 80% reduction in her pain. The anti-inflammatory effect of cannabis reported in the current paper could be the explanation of why it works better for arthritis pain than migraines. Inflammation does occur during a migraine process but to a lesser degree and of a different type than in arthritis.

An update on the Nerivio device

By: Dr. Mauskop

20-09-2020

Alternative Therapies, Migraine, neurostimulation

It’s been a year since the introduction of Nerivio, an electrical stimulation device for the acute treatment of migraines. One of the unique features of the device is that it is controlled by a smartphone app. This allows Theranica, the manufacturer of Nerivio, to collect data on its use. They just published real-world data on the use of Nerivio in the first 6 months after its introduction.

59% or 662 out of 1,123 patients treated by headache specialists and 74% or 23 out of 31 patients treated by non-headache specialists reported pain relief at two hours in at least half of their treated attacks. Complete pain freedom was achieved by 20% of the patients in the first group and 36% in the second group in at least half of their treated attacks. Only 0.5% of the patients reported device-related adverse events.

The number of patients treated by non-headache specialists is small. Nevertheless, because headache specialists tend to see patients who are more severely affected by their migraines, it is likely that the device will be more effective in the hands of non-headache specialists, or rather on the arms of patients treated by such doctors. Nerivio is a disposable device that is placed on the upper arm for 45 minutes.

My subjective impression correlates with this published data. Some of my patients use it along with their abortive medications such as triptans or NSAIDs. One patient finds that the stimulation not only relieves pain but is also very relaxing. Even though you can continue your normal activities, I recommend that patients try to relax or meditate during this treatment. The advantage of Nerivio is that is a drug-free treatment and is very safe. People who find Nerivio particularly appealing are those who have side effects from drugs, have multiple allergies, pregnant or nursing, and for whom drugs are ineffective.

Nerivio is available by prescription from your healthcare provider, by consulting (virtually or in-person) one of our headache specialists, or by connecting to a doctor on Cove, a telemedicine startup.

Disclosures: I have provided consulting services to both Theranica and Cove.

Benign paroxysmal positional vertigo – another benefit of vitamin D

By: Dr. Mauskop

16-09-2020

Alternative Therapies, Migraine

Vitamin D deficiency predisposes to or worsens many different medical problems. I’ve written at least a dozen blog posts on vitamin D.

A group of South Korean researchers just published in the journal Neurology a study, Prevention of benign paroxysmal positional vertigo with vitamin D supplementation. A randomized trial.

They selected 518 patients with confirmed BPPV who were successfully treated with canalith repositioning maneuvers (Epley maneuver) and who had a vitamin D level below 20. The primary outcome measure was the annual recurrence rate. Patients in the intervention group were given vitamin D 400 IU and 500 mg of calcium carbonate twice a day for 1 year. Patients in the observation group were assigned to follow-ups without further vitamin D evaluation or supplementation.

The intervention group had a significant reduction in the treatment group compared to the observation group.

The authors concluded that supplementation of vitamin D and calcium may be considered in patients with frequent attacks of BPPV, especially when serum vitamin D is subnormal.

BPPV, dizziness, vertigo, difficulty with balance are more common in people with migraines. Keeping your vitamin D level at least in the middle of the normal range may help prevent all these symptoms as well as migraines and other neurological problems.

Melatonin for migraines

By: Dr. Mauskop

11-09-2020

Alternative Therapies, Migraine, New treatments

Melatonin is a hormone produced by the pineal gland located in the brain. The release of melatonin helps us fall asleep. Melatonin supplements have been used to treat insomnia. The results of clinical trials, however, are contradictory. This may be because a wide variety of doses have been used. One study suggests that 3 mg of melatonin – a common dose sold in stores – is less effective than 0.3 mg. I usually recommend 0.3 mg (300 mcg) for both insomnia and jet lag.

Melatonin has been tested for the prevention and acute treatment of migraines.

Melatonin was not effective in a study by Norwegian doctors. They gave 2 mg of extended-release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo in a double-blind crossover trial. Migraine frequency did improve from an average of 4.2 a month to 2.8 in both the melatonin and the placebo groups.

Another blinded trial was done in Brazil by Dr. Mario Peres and his colleagues. It compared 3 mg of immediate-release melatonin with a placebo and with 25 mg of amitriptyline. The study involved 196 patients. The number of headache days dropped by 2.7 days in the melatonin group, 2.18 for amitriptyline, and 1.18 for placebo. Melatonin significantly reduced headache frequency compared to placebo. Amitriptyline did not. Not surprisingly, melatonin was much better tolerated than amitriptyline. Considering its safety and very low cost, it is worth considering a trial of 3 mg of melatonin for the prevention of migraine headaches.

It is possible that, unlike with insomnia, a higher dose is more effective for the prevention of migraines. And, the immediate-release form could be more effective than the sustained-release one.

Melatonin may be effective as an acute treatment for pediatric migraine, according to a study just published by Dr. Amy Gelfand and her colleagues at UCSF. This was an 84-patient trial, although only 46 children completed it. Both low and high doses of melatonin were associated with pain reduction. Higher dose and napping after treatment predicted greater benefit. The benefit was likely an indirect one – melatonin helped children fall asleep and sleep, often in children but also in some adults, can relieve a migraine attack.

Oxygen for migraines

By: Dr. Mauskop

29-08-2020

Alternative Therapies, Migraine

People who live at high altitudes tend to have lower oxygen levels in their blood. A higher percentage of them suffer from migraines than people who live at sea level.

Oxygen is effective for a significant percentage of patients with cluster headaches. It is much less effective for the treatment of migraines. Two small studies showed that oxygen under normal pressure is ineffective for the acute treatment of migraine but oxygen under pressure, or hyperbaric oxygen, is. The first study had 10 patients, the second, only eight.

Norwegian researchers conducted a double-blind, placebo-controlled study to assess the prophylactic effect of hyperbaric oxygen therapy on migraine. The effect of three daily sessions of hyperbaric oxygen was compared to the effect of three hyperbaric air treatments. Oxygen under pressure appeared to be more effective. However, because the number of patients was small – 19 in the oxygen and 15 in the air group – no statistical significance was found.

Even if proven effective, using hyperbaric oxygen for the acute treatment of migraines, is highly impractical. There are few hyperbaric chambers to be found. It is also a very expensive treatment.

Histamine and migraine

By: Dr. Mauskop

17-08-2020

Alternative Therapies, Headache medications, Headaches, injections, Migraine

Histamine is best known as a part of the defense against allergies. But it is also an important neurotransmitter – a brain chemical involved in arousal, anxiety, the stress-related release of hormones, activation of the sympathetic nervous system, pain relief, and other functions.

Increased sensitivity to histamine may lead to an excessive allergic reaction which is relieved by anti-histamine drugs. It can also increase pain. One strategy thought to reduce this over-reaction is desensitization – injecting small amounts of histamine which can lead to a reduced reaction.

This approach seems to help some migraine and cluster patients. It was first reported in 1941 by a Mayo clinic doctor, Bayard Horton in an article entitled The use of histamine in the treatment of specific types of headaches. Another article, Intravenous histamine in the treatment of migraine was published in 1946 by W.A. Thomas and S. Butler.

A group of Mexican doctors compared subcutaneous (under the skin) injections of small doses of histamine to injections of placebo in 60 patients. They found histamine to be more effective. The same group of doctors conducted three more double-blind trials of histamine injections. A double-blind study of 90 migraine patients compared twice-weekly injections of histamine with 100 mg of oral topiramate, which is an FDA-approved treatment for migraines. These treatments were equally effective. They then compared twice-weekly injections of histamine to 500 mg of valproate, which is also an FDA-approved migraine drug in 92 migraine patients. Histamine was superior to valproate. They compared histamine to the injection of a relatively small dose of Botox (50 units, while the standard dose is155 units) in 100 patients and found them to be equally effective.

These results would be more convincing if another group confirmed these findings. When I asked the opinion of an allergy specialist in NYC, Dr. Michael Chandler he told me that the idea of histamine desensitization has been discredited and that it is not being used to treat allergies.

Acetyl-leucine may help dizziness, vertigo and migraines

By: Dr. Mauskop

12-08-2020

Alternative Therapies, Chronic migraine, Head trauma, Headache medications, Headaches, Migraine, New treatments, Uncategorized

Acetyl-leucine (Tanganil) is an amino acid that has been available in France for over 60 years as a prescription drug. It is approved for the treatment of low blood pressure and dizziness. However, there are no published studies of this product for either low blood pressure or dizziness. There are some animal studies suggesting that acetyl-leucine works on brain cells responsible for the balancing of the body and motor control. It was also tested in animals whose inner ear balancing organ was destroyed on one side.

A group of German doctors, whom I know and respect, found it to be very effective in a prospective study of 10 patients with migraines. The dose was 5 grams daily. The usual recommended dose for dizziness and hypotension is up to 2 grams.

I occasionally recommend it to desperate patients with severe and persistent dizziness and vertigo that has resulted from a concussion or vestibular migraine.

While acetyl-leucine is not proven to be effective, it does not cause any side effects.

Acetyl-leucine is also being tested for some rare hereditary neurological disorders such as Niemann-Pick disease.

100 Migraine Drugs, A to Z: Low-dose naltrexone

By: Dr. Mauskop

06-08-2020

Alternative Therapies, Chronic migraine, Pain, Pain Research

Naltrexone is similar to naloxone, a drug used to reverse the effect of narcotic (opioid) overdose. Naltrexone is not used to reverse the effect of an overdose, but to treat opioid and alcohol dependence. (LDN) and is given as a monthly injection or a daily pill. Naltrexone blocks the body’s own endogenous morphine (endorphin) receptors. In theory, this should make the pain worse. However, low-dose naltrexone (LDN) seems to have the opposite effect. It is possibly explained by the fact that a small amount of naltrexone blocks the endorphin receptors for a short time, during which the body begins to make more endorphins in an attempt to overcome this block. After the effect of naltrexone wears off, this extra amount of endorphins provides relief of pain and by blocking other receptors (such as Toll-like receptor 4) and reducing inflammation, potentially produces other beneficial effects, most of which are not scientifically proven.

Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) do seem to respond to LDN.

A study of 27 patients with chronic central pain syndromes at the Stanford Pain Management Clinic published in The Journal of Pain concluded that “The significant findings of decreased average pain scores and depression and improved physical function after prescribing this well-tolerated, inexpensive medication provides justification for larger, controlled trials in patients with central sensitivity syndromes.” Some of these central sensitivity syndromes include migraine, fibromyalgia, irritable bowel syndrome, chronic back pain, and other.

Naltrexone is available only in a 50-mg tablet, while LDN is started at 1.5 mg nightly for a week, then 3 mg nightly for a week, and then, 4.5 mg nightly. This regimen requires a compounding pharmacy to make capsules containing 1.5 mg for the first two weeks and then, capsules with 4.5 mg. Some of my patients went up as high as 9 mg nightly. Compounded drugs tend to be more expensive than factory-made generics but because naltrexone itself is cheap, the cost of 30 capsules can be as low as $50.

Because the dose is low, side effects are rare. These include vivid dreams and insomnia and if these occur, the medicine can be taken in the morning.