Blocks | Headache NewsBlog

If you are healthcare provider, attend the annual meeting of the Headache Cooperative of the Northeast

By: Dr. Mauskop

10-02-2024

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Head trauma, Headache medications, Headaches, injections, Migraine, neurostimulation, Psychology of headaches

I am once again honored to participate in the annual meeting of the Headache Cooperative of the Northeast to be held March 7-9 at the Stamford Marriott Hotel and Spa in Stamford, CT.

You will get a chance to learn about the latest scientific breakthroughs from Rami Burstein, president of the International Headache Society. You will also hear from other prominent figures in the field, renowned for their pioneering work and extensive contributions over several decades – Drs. Steven Baskin, Elizabeth Loder, Thomas Ward, Morris Levin, Richard Lipton, Steven Silberstein, Allan Purdy, Alan Rapaport, Paul Rizzoli, Sait Ashina, and others.

Attend the Diamond Research & Educational Foundation’s course

By: Dr. Mauskop

06-01-2024

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, New treatments, Science of Migraine

The annual course, “The Shifting Migraine Paradigm 2024” will be held February 15-17, 2024 at the Plaza San Antonio Hotel & Spa. This three-day conference offers an excellent update on the treatment of migraine and other headaches.

It is always an honor to be invited to speak at this event. The topic of my presentation is Supplements and Medical Foods.

Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases

By: Dr. Mauskop

14-03-2023

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Psychology of headaches, Science of Migraine

Dr. Lisa Gfrerer to speak on migraine surgery at the NY Headache Club meeting on January 25

By: Dr. Mauskop

21-01-2023

Alternative Therapies, Blocks, Chronic migraine, Headaches, Migraine

Migraine surgery is controversial. I would not consider it until most of the less invasive options have been tried. In my latest book, I give migraine surgery a score of 3, on a 1 to 10 scale. This rating may not be fair because clinical trials suggest that it can be very effective for some patients.

So, when is a referral to a surgeon warranted? Dr. Lisa Gfrerer is highly qualified to address this topic. She will speak on January 25th at a dinner of the NY Headache Club, an informal gathering of headache specialists who practice in the greater NYC area. If you are a headache specialist and would like to attend, send me a message. The meeting is not open to the lay public.

Here is Dr. Lisa Gfrerer’s short bio.

Dr. Gfrerer is an Assistant Professor in Plastic and Reconstructive Surgery at Weill Cornell Medicine (WCM). She received her MD degree at the Medical School of Vienna prior to completing a PhD in Genetics at the Harvard Stem Cell Institute. She graduated from the Harvard Integrated Plastic Surgery Residency Program and completed the Advanced Peripheral Nerve and Microsurgery at the Massachusetts General Hospital (MGH). Clinically, her focus is peripheral nerve surgery including headache surgery, treatment of nerve pain and compression, breast reinnervation, as well as advanced nerve reconstruction for restoration of motor and sensory function after an iatrogenic and accidental injury. She has built a multi-institutional and multidisciplinary research program for headache surgery, breast/chest reinnervation, as well as functional nerve disorders and nerve pain. As an affiliate of the Massachusetts Institute of Technology (MIT) she has further focused on innovation and device development to enhance peripheral nerve regeneration.

Dr. Allan Purdy’s review of my new book

By: Dr. Mauskop

02-06-2021

Alternative Therapies, Blocks, Botox, Chronic migraine, Headache medications, Headaches, injections, Migraine, post-traumatic headache, Psychology of headaches, Science of Migraine

A publication of the American Headache Society, Headache, The Journal of Head and Face Pain, has just published Dr. Allan Purdy’s most generous review of my new book, The End of Migraines: 150 Ways to Stop Your Pain.

I am very grateful to Dr. Purdy and to my many colleagues who wrote endorsements for this book.

Self-publishing allows me to set a low price of $3.95 for the ebook version. It also makes it easy for me to regularly update it. Self-publishing, however, means that, unlike my previous three books, this one does not have the promotional help of a big publisher. If you read the book, please write a review on Amazon and spread the word to other migraine sufferers.

In a new study prednisone relieves cluster headaches

By: Dr. Mauskop

01-02-2021

Blocks, Cluster headaches, Headache medications

Cluster headaches are considered to cause the most severe pain of any type of headache. Once the cluster period begins, headaches occur once or several times a day with each attack lasting 1-3 hours. We do have a new preventive treatment for cluster headaches – monthly injections of a drug that was first approved for migraines, galcanezumab (Emgality). This drug, however, does not help everyone. Even when it does, it can take up to a week to begin helping.

For quick relief, we continue to use a 10-14 day tapering course of steroid medicine, prednisone. Prednisone often works only while the patient is taking it. It is a powerful drug with many potential side effects. This is why it is mostly used for a short time to serve as a bridge that allows another preventive drug to begin working. The most popular preventive medicine for cluster headaches besides Emgality is a blood pressure drug, verapamil.

German researchers just published the results of a double-blind controlled study of prednisone for cluster headaches. They started half of the 116 patients with cluster headaches on placebo and the other half, on 100 mg of prednisone. After five days on 100 mg, they reduced the dose by 20 mg every 3 days. At the same time, all patients were started on verapamil.

In the first week, those on prednisone had a mean of 7.1 attacks, while those on placebo had 9.5 attacks. Statistically, this was a highly significant difference. Having 2-3 fewer attacks in a week may not seem that significant, but only to those who’ve never had a cluster headache. And these mean numbers hide the fact that for some prednisone is highly effective, while for others, not at all. Also, the pain intensity was lower and the number of attacks in the prednisone group remained lower during the fourth week.

Clusters tend to occur once or twice a year or once every few years. Once we find a treatment that works well, including prednisone, it tends to work well for every subsequent attack

No serious side effects occurred in the prednisone group. However, this was a relatively small study and we know that serious side effects can happen even from a short course of prednisone.

About a quarter of my patients get very good immediate relief from an occipital nerve block and avoid taking prednisone. Some of these patients don’t even need Emgality or verapamil. They stay headache-free until the next cluster period.

Even when a preventive treatment is very effective, occasional attacks may still occur. This is why I also always prescribe treatment to stop an individual attack. This is usually sumatriptan injections and occasionally, zolmitriptan nasal spray or inhalation of oxygen.

Just published – The End of Migraines: 150 Ways to Stop Your Pain

By: Dr. Mauskop

17-01-2021

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, neurostimulation, Science of Migraine

My new book, The End of Migraines: 150 Ways to Stop Your Pain, was just published by Amazon. It is also available on Google Play and Kobo.
I am very grateful to all my colleagues who took the time to read the book and to provide advance praise for it.
This is a self-published book. This allows me to update it regularly and to set a very affordable price – the e-book version is only $3.95 and the paperback is $14.95. The e-book version has the advantage of having many hyperlinks to original articles and other resources.
If you read it, please write a brief review on Amazon or Google and spread the word about it.

Intravenous lidocaine for pain (and headaches)

By: Dr. Mauskop

28-02-2018

Blocks, Migraine, Pain

Lidocaine is an effective local anesthetic that is injected for dental procedures, minor surgeries, as well as nerve blocks, including nerve blocks for migraines, cluster, and other types of headaches. Since it is a numbing medicine, lidocaine has been also given intravenously in the hope of relieving widespread pain or pain that does not respond to local injections. Unfortunately, it is not as effective intravenously as it is for local injections and nerve blocks for either headaches or other pain conditions.

A controlled study of intravenous lidocaine for pain was just published by Korean researchers in the Regional Anesthesia and Pain Medicine – “Efficacy and Safety of Lidocaine Infusion Treatment for Neuropathic Pain: A Randomized, Double-Blind, and Placebo-Controlled Study“.

The researchers decided to examine whether pain relief from intravenous lidocaine can be sustained through repeated lidocaine infusions. This was a randomized, double-blind, placebo-controlled study of infusions of lidocaine (3 mg/kg of lidocaine administered over 1 hour) vs infusions of normal saline, given once a week for 4 consecutive weeks in patients with postherpetic neuralgia or complex regional pain syndrome (formerly called RSD, or reflex sympathetic dystrophy). The results were assessed by the change in pain score from baseline to after the fourth infusion and then again, 4 weeks later.

Forty-two patients completed this study and the percentage reduction in pain scores after the final infusion was significantly greater in the lidocaine group compared with the saline group. However, this pain reduction was not detectable at the 4-week follow-up. None of the study participants experienced serious complications from the treatment.

So, while repeated lidocaine infusions did provide effective short-term pain relief, the effect did not persist.

I have had several of my patients with severe chronic migraines respond to intravenous lidocaine, but their experience was similar – they had to get weekly infusions to maintain good relief. Because intravenous lidocaine can cause irregular heart beat (arrhythmia), cardiac monitoring is required. This makes weekly intravenous lidocaine infusions even more expensive and impractical for most pain and headache sufferers.

New information on cluster headaches

By: Dr. Mauskop

17-07-2017

Blocks, Botox, Cluster headaches, Headache medications

Cluster headache is one of the most painful conditions that has lead some patients call it a suicide headache. A new observational study done by researchers at the Eli Lilly company and Stanford University was presented at the recent annual scientific meeting of the American Headache Society.

Considering that cluster headaches are relatively rare, the major strength of this study is its size – 7589 patients. These patients were compared to over 30,000 control subjects without headaches. We’ve always known that cluster headaches are more common in men with previous studies indicating that male to female ratio is between 5:1 and 3:1. However, only 57% of patients in this new report were males. This does not reflect my experience – I see at least five times as many men as women. It is possible that I underdiagnose cluster headaches in women or the study used unreliable data. In fact, the study data was collected from insurance claims, so I suspect that the truth is closer to my experience and to the older published data.

The study did find that thoughts of suicide were 2.5 times more common in patients with cluster headaches compared to controls, while depression, anxiety and sleep disorders were twice as common. Cluster headache patients also were 3 times more likely to have drug dependence. The most commonly prescribed drugs were opiates (narcotics) in 41%, which partially explains high drug dependence rates, steroids, such as prednisone (34%), triptans, such as sumatriptan (32%), antidepressants (31%), NSAIDs (29%), epilepsy drugs (28%), blood pressure drugs, such as verapamil (27%), and benzodiazepines, such as Valium or Xanax (22%).

It is very unfortunate that over a period of one year only 30% of patients were prescribed drugs recommended for cluster headaches. We know that narcotics and benzodiazepine tranquilizers are not very effective and can lead to dependence and addiction. Drugs that are effective include a short course of steroids (prednisone), sumatriptan injections, blood pressure drug verapamil (often at a high dose), some epilepsy drugs and occasionally certain antidepressants. The report did not mention oxygen, which can stop individual attacks in up to 60% of cluster headache sufferers. Nerve blocks and to a lesser extent, Botox injections can also provide lasting relief. It is possible that the data on oxygen, nerve blocks and Botox was not available.

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.

About my migraines

By: Dr. Mauskop

09-11-2015

Blocks, injections, Migraine

Since my early 20s I’ve been getting visual auras without a headache several times a year. I still get them in my late 50’s and they still occur without a headache. In my 40s I started to have migraine headaches without an aura. My migraines are always left-sided and if I don’t treat them, I will develop sensitivity to light and nausea. Luckily, my migraines are not at all disabling because they remain mild for hours, so I have plenty of time to take 100 mg of sumatriptan, which works very well. The tablet works within one to two hours. When I want to have faster relief, I take a 6 mg sumatriptan injection. This usually happens at night when I want to go to sleep and I don’t want to wait for the pill to start working. I can’t fall asleep with a migraine, while for some, sleeps actually relieves the attack.

I am not happy about having migraines, but they do not interfere with my life and give me a better understanding of what my patients are going through. Also, I try to subject myself to treatments I offer my patients. I do not need to take a daily preventive medicine, such as topiramate or propranolol or Botox injections. However, since Botox is very safe, I did inject myself with Botox once to see what it feels like. It was not very painful, but obviously everyone has a different pain threshold (here are video 1 and video 2 of me injecting patients with Botox). I also gave myself an intravenous infusion of magnesium, which did make me feel warm, but had no beneficial effects since I am not one of the 50% of migraine sufferers who are deficient in magnesium.

The next thing I decided to try is a nerve block. Nerve blocks are injections of a local anesthetic, such as lidocaine or bupivicaine to numb the nerves around the scalp (here is a previous blog on nerve blocks). It is somewhat surprising that numbing a superficial nerve under the skin stops a migraine, which we know to originate in the brain. For the same reason a lot of scepticism greeted me at medical meetings over 20 years ago when I gave lectures on Botox for migraines. Now we know that although the migraine process begins in the brain, peripheral nerves send messages back to the brain closing a vicious cycle of brain activating the nerves and nerves feeding back pain messages into the brain. Disrupting this circuit with a peripheral nerve block for short-term relief and with Botox for long-term prevention seems to be very effective. Nerve blocks can be effective when drugs are not or when drugs are contraindicated because of an illness or pregnancy.

Sometimes, blocking the occipital nerve at the back of the head works well, but other patients need nerves blocked in their temples or forehead. Since my migraines are always localized to the left temple, I decided to give myself a block of the temporal branch of the left trigeminal nerve. The nerve block helped one of two times I tried it. Obviously, I do not recommend DIY nerve blocks or teach patients how to do it, but I did encounter one patient who learned how to give himself an occipital nerve block before coming to see me. There might be some exceptions, such as for people living in remote areas and who do not respond to any other treatments, or in not such distant future, for those traveling to Mars.

The next treatment I will try is a sphenopalatine ganglion block. I will describe this treatment in my next post.