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Brain disorders

TMS for medication overuse (rebound) headaches

By: Dr. Mauskop
28-01-2024
Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Medication overuse or rebound headaches can occur as the result of excessive intake of caffeine, opioid analgesics, and short-acting barbiturate drug, butalbital (contained in Fioricet, Esgic and similar drugs). These three substances not only worsen migraine headaches, they are also addictive.  Two of my patients with medication overuse headaches were able to stop the offending drugs with the help of repetitive transcranial magnetic stimulation (rTMS).

One patient, a 51-year-old man, had his migraines under control with Botox and infusions of eptinezumab (Vyepti) until he sustained a head injury with a skull fracture. His migraines worsened and he became disabled. A variety of therapies failed to reduce his pain. His pain was partially relieved by 60 mg of oxycodone a day, although he still was unable to work. After six weekly sessions of rTMS he was able to start reducing his oxycodone intake and after eight, he completely stopped it. He was able to return to work with the help of injections of fremanezumab (Ajovy).

Another patient, a 50-year-old woman, had been taking butalbital with caffeine and acetaminophen (Fioricet) for 20 years. The number of pills increased over time and for the previous several years, she had been taking 10 to 12 tablets every day. She was also receiving Botox injections, infusions of eptinezumab, and taking rizatriptan (Maxalt), 10 mg three times a day as well as 60 mg of nortriptyline, 12 mg of tizanidine nightly and atogepant, 60 mg. She had tried a wide variety of other treatments but was unable to reduce her Fioricet intake. Despite her persistent migraines, she was able to take care of her family. After three weekly sessions of rTMS she reduced her Fioricet intake to 3-4 a day, by the third month she was taking one a day, and after 6 months she was completely off it. She was also able to stop atogepant and tizanidine and reduced her nortriptyline to 25 mg.

In addition to helping relieve pain and migraines, rTMS has shown promise in the treatment of addiction, particularly in addressing withdrawal symptoms, depression, and cravings. While the use of rTMS for addiction is still relatively recent and not yet FDA-approved, some studies have demonstrated positive outcomes. For instance, a double-blind study showed that individuals receiving rTMS therapy for cocaine addiction had a higher rate of abstinence compared to those who received standard treatment. rTMS for addiction is still considered experimental, and more research is needed to fully understand its long-term effects and optimal treatment parameters.

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We now offer transcranial magnetic stimulation (TMS) for migraines and other neurological conditions

By: Dr. Mauskop
20-01-2024
Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Neurologists frequently find themselves managing patients resistant to standard treatments due to limited proven therapies for many neurological conditions. Some patients cannot tolerate or have contraindications to medications, particularly for such common disabling conditions like migraine and chronic pain. 

One promising treatment is transcranial magnetic stimulation (TMS). It is a proven procedure for anxiety, depression, obsessive-compulsive disorder (OCD), smoking cessation, and acute migraines. TMS utilizes magnetic fields to stimulate nerve cells in the brain that are underactive or reduce the excitability of overactive cells. TMS can change the flow of information between different parts of the brain in various neurological conditions. Published reports show the potential benefit of TMS in fibromyalgia, neuropathic pain, cluster headaches, facial pain, trigeminal and other neuralgias, back pain, insomnia, memory disorders, tinnitus, post-concussion syndrome, post-traumatic stress disorder (PTSD), restless leg syndrome, and long COVID. The evidence for the efficacy of TMS for these neurological disorders, however, is still limited.

Single-pulse TMS is approved by the FDA for the acute treatment of migraines with aura. The patient uses a portable device during the aura phase to self-administer a single pulse of TMS to the back of the head. This can abort the attack. Repetitive TMS (rTMS) has been studied for the prevention of migraines and other types of pain. It appears effective, but compared to depression trials, migraine studies were relatively small and the FDA has not cleared rTMS for the treatment of migraines. This means that insurance companies are not likely to pay for this “off-label” use of TMS.

rTMS is generally considered safe and well-tolerated, with side effects typically mild and temporary, including scalp discomfort, headaches, and facial twitching. More serious side effects like seizures and mania are very rare. 

Before starting TMS, patients undergo a physical and mental health evaluation. The coil placement and dose are determined in the first session. During a TMS session, patients sit in a comfortable chair with earplugs. An electromagnetic coil is positioned near the scalp, delivering short magnetic pulses to specific brain regions involved in processing pain and other information. Patients feel and hear rapid tapping on their scalp that continues, on and off. Patients are awake and alert during the entire procedure. There are no limitations to activities before or after the treatment.

Treatment length varies from 20 to 45 minutes, depending on the stimulation pattern and number of sites stimulated. The frequency of treatments also varies – anywhere from daily for several weeks, to once a week. After the initial period of more frequent sessions, some patients require weekly or monthly sessions to maintain the effect. It may take a few weeks to see noticeable effects. 

TMS is a good choice for people who have not responded to multiple standard therapies, people who do not want to take drugs, those who also suffer from depression and anxiety, and pregnant women. Sufficient evidence suggests that TMS is as safe in children as it is in adults, with studies indicating its effectiveness in treating depression in adolescents.

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More on the dangers of PPIs such as Prilosec, Nexium, Dexilant, et al.

By: Dr. Mauskop
14-01-2024
Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine

Proton Pump Inhibitors (PPIs) are a class of medications commonly used to treat conditions such as acid reflux, ulcers, and heartburn. They include omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), Dexlansoprazole (Dexilant), and pantoprazole (Protonix). Several of these are available without a prescription.

While PPIs are generally considered safe and effective, several studies have suggested a potential association between PPI use and several medical and neurological problems. These include osteoporosis, kidney problems, impaired hearing, vision, memory, and an increased risk of conditions such as migraines, dementia, peripheral neuropathies, and seizures. The evidence is circumstantial and not definitive. However, considering the large number of studies and a large number of conditions, PPIs are probably not safe for long-term use.

In the case of migraines, one study found that past and current use of PPI increased the odds of migraine by 2.56-fold and 4.66-fold, respectively. The exact reason for this link is still a mystery, but researchers are exploring several possibilities:

Nutrient deficiencies: PPIs can interfere with the absorption of important nutrients like vitamin B12, other B vitamins, and magnesium, which can contribute to headaches.

Gut microbiome changes: PPIs can alter the gut microbiome, which may indirectly impact brain function and migraine susceptibility.

Inflammation: Some studies suggest PPIs might trigger low-grade inflammation, a potential factor in migraine development.

This post was prompted by a recent study showing an association between PPI intake and the risk of dementia. Those who used PPIs for a cumulative four and a half years or longer had a 33% higher risk of developing dementia.

Stopping a PPI can cause severe rebound acidity. This is why people get stuck taking them for years. The way to try is by replacing the PPI with an H2 blocker such as famotidine (Pepcid, Zantac 360) along with an antacid such as Rolaids (it’s better than Tums because it contains not only calcium but also magnesium) or Gaviscon. After a few weeks, people can often stop famotidine and after another few weeks, stop the antacid. Famotidine does not cause problems associated with PPIs.

If you cannot stop or have a condition that requires long-term intake of a PPI (e.g. Barrett’s esophagitis), make sure to take a variety of vitamins and minerals. However, the lack of acidity can prevent the absorption of supplements. We usually do a blood test to check vitamin B12, RBC magnesium, vitamin D, and others. Some of our patients come in for monthly infusions of magnesium and other nutrients they are deficient in.

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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.

 

 

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Have your homocysteine level checked

By: Dr. Mauskop
01-01-2024
Alternative Therapies, Brain disorders, Chronic migraine, Migraine, Science of Migraine

Homocysteine, an amino acid crucial for cellular metabolism and protein synthesis, is naturally produced by the body. However, either too low or too high levels in the body can lead to significant health issues.

Insufficient homocysteine levels impair the production of glutathione, a vital substance for detoxifying the liver and the entire body. In some cases, patients are given glutathione infusions for its additional benefits.

Having too much homocysteine is also a problem. High levels are associated with an increased risk of cardiovascular disease, cancer, and migraine with aura. High homocysteine levels may also mean you have a Replacing these vitamins often helps return the homocysteine level to normal.

Some drugs may lead to increased homocysteine levels. These include cholestyramine, metformin, methotrexate,  nicotinic acid (niacin), and fibric acid derivatives (drugs that are used to lower lipids).

Besides migraine with aura, other symptoms of high homocysteine and low vitamin B12 levels may include memory difficulties, weakness, fatigue, tingling sensations in the hands, arms, legs, or feet, dizziness, mouth sores, and mood changes.

White matter lesions seen on the MRI scans of migraine patients are more common in those with high homocysteine levels.  High homocysteine levels may be responsible for the increased risk of strokes in migraine patients.

A recent large study of the role of pollution in the development of dementia revealed that pollution increases this risk only in those with high homocysteine levels.

The good news is that taking vitamins B12, folate, and B6 (pyridoxine) can lower homocysteine levels. Methylated forms of vitamin B12 and folate, methylcobalamin and methylfolate are better absorbed than cyanocobalamin or folic acid.

If you suffer from migraines, especially migraine auras (with or without headaches) you may want to have your homocysteine levels checked. In all of our migraine patients, we also check vitamin B12, folate, RBC magnesium, vitamin D, TSH (thyroid), and routine tests – CBC and CMP.

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Why sleep regularity is important

By: Dr. Mauskop
25-12-2023
Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Science of Migraine

Lack of sleep is a common migraine trigger. A less common trigger is getting too much sleep. I always recommend that patients try to go to sleep at the same time and get up at the same time. Even on weekends. Instead of sleeping in on the weekend, take a 30-minute nap in the afternoon.

A new study by Australian researchers published in Neurology reports another important reason for sleep regularity. This was a large and rigorous study involving 88,094 UK subjects. All subjects wore an accelerometer that detected their sleep patterns. The researchers controlled for variables that are known to predispose to dementia –  age, sex, ethnicity, material deprivation, retirement status, current shift work status, household income, highest level of education, smoking status, use of sedative, antidepressant, or antipsychotic medication, and genetics (APOE ?4 carrier status).

They “identified a nonlinear relationship between day-to-day sleep regularity and dementia risk such that dementia rates were highest in those with the most irregular sleep, dipped as sleep regularity approached the median, and then marginally increased at the highest estimates of sleep regularity.” In subjects who underwent brain MRI (n = 15,263), gray matter and hippocampal volume (area of the brain critical to memory) similarly tended to be lowest at the extremes of the sleep regularity index. This was surprising – subjects whose sleep patterns were extremely chaotic did slightly better than those with moderately irregular sleep.

Other sleep disorders that can contribute to migraines and increase the risk of dementia are restless leg syndrome, sleep apnea, and sleeping too much or not enough.

 

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fMRI scan can establish the diagnosis of migraine

By: Dr. Mauskop
02-12-2023
Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Science of Migraine

Neurologists diagnose migraine by the description of symptoms provided by the patient. We have not had an objective test to confirm that a person suffers from migraines.

A group of researchers led by Dr. Yiheng Tu in the department of psychiatry at Harvard Medical School developed an AI program that can diagnose migraine using fMRI (functional MRI) scanning. The AI program was first fed information on fMRIs of 116 individuals with migraines and then had this data compared to healthy controls.

The AI program had 93% sensitivity and 89% specificity. This means that it missed the diagnosis of migraine in only 7 out of 1oo patients and diagnosed migraine in 11% of patients who did not have it. These are very good numbers, but clearly, the method is not error-proof.

When they compared people with migraines to those with other types of pain, the sensitivity dropped to 78% and specificity, to 76%. This can be explained by the fact that similar functional changes in the brain probably occur with any type of pain.

A major obstacle to the wide use of fMRI scans is the cost. They are more expensive to perform than a regular MRI. Insurance companies are not likely to cover it since this is an experimental procedure. Another potential difficulty is that fMRI takes much longer to do than a regular MRI – an hour vs 20 minutes. During this time you have to lie inside a tube while trying not to move and hearing loud banging noises.

 

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More research on vitamin D and migraine

By: Dr. Mauskop
06-11-2023
Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments

There is growing evidence that vitamin D is important in the development and treatment of migraines. In the past 15 years, I have written a dozen posts on the role of vitamin D in migraines.

At the last meeting of the International Headache Society, Maria Papasavva and her Greek colleagues presented a study entitled, Genetic variability in vitamin D receptor and migraine susceptibility: a case-control study.

Their study aimed to investigate an association of three genetic variants of vitamin D receptor with the susceptibility to develop migraine. DNA sample was collected and extracted from 191 patients diagnosed with migraine and 265 headache-free subjects. According to their statistical analysis, a significant association between migraine susceptibility and abnormal variants of vitamin D receptors was found.  They also showed a significant association of two variants with migraine without aura. Their conclusion was that there is a clear association between migraine susceptibility and two vitamin D receptor variants. This further supports the role of vitamin D and its receptor in migraine.

Vitamin D is important not only for migraines but also for your immune system. Vitamin D deficiency increases the risk of COVID and other viral infections. Lower levels of vitamin D are associated with a higher risk of attacks of multiple sclerosis even if the level is still within normal range. There are many other reasons to maintain your blood vitamin D level at least in the middle of the normal range. The normal range is 30 to 100, so keep it well above 40. If your doctor tells you that your level is normal, ask for the actual number.

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New Daily Persistent Headache is very treatable

By: Dr. Mauskop
09-10-2023
Alternative Therapies, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments, Psychology of headaches, Science of Migraine

New daily persistent headache (NDPH) is condition that is defined solely by the fact that the headache begins suddenly one day and does not go away. There are no scientific studies to suggest possible underlying mechanisms or treatments. Some patients develop it after a viral infection while others, after a period of stress and many with no apparent trigger.

In my latest book, I mentioned how a seemingly benign idea of classifying medical conditions can cause harm. In case of NDPH, many anecdotal reports in medical journals indicate that this condition is not responsive to treatment. However, there are no controlled double-blind studies, only anecdotal reports. Many patients with this condition will look up this literature and conclude that there is no hope of getting better. I have seen many such devastated people. But this bleak picture is clearly wrong.

I have seen many patients with NDPH who responded to various treatments. In my 30 years of using Botox, I have found it to be one of the safest and most effective treatments for NDPH as well as migraine and other types of headaches.

At the recent meeting of the International Headache Society held in Seoul, two presentations described good responses of NDPH to Botox injections.

The first report was by S. Cheema and colleagues of Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK. They compared patients with NDPH (58) and those with chronic migraine (CM) with daily attacks (153) and chronic migraines without daily attacks (85). There was a 30% reduction in mean moderate and severe headache days in 33% of patients with NDPH, 43% with daily CM and 55% with non-daily CM.

The second report was by Shuu-Jiun Wang and colleagues of the Neurological Institute, Taipei Veterans General Hospital. They looked at the response of patients with NDPH who had predominately migraine features and those who had predominantly features of tension-type headaches. Of 228 patients diagnosed with NDPH, 199 patients (87%) had migrainous features and 29 patients (13%) had tension-type features. Their conclusion: “Through a mean follow-up duration of 2.5 years, around 40% patients with NDPH showed a favorable outcome at our headache center. Our results suggest NDPH might not be as grave as previously reported.”

Yes, these were also anecdotal reports rather than controlled trials, but they clearly show what I have also observed in my practice – NDPH is a very treatable condition. Hopefully, the next, fourth edition of the International Classification of Headache Disorders will no longer list NDPH as a diagnosis since it has no scientific basis.

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Gut bacteria and migraine

By: Dr. Mauskop
18-09-2023
Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, New treatments, Science of Migraine

Most people have heard about the gut-brain connection. Research published in The Journal of Headache and Pain examined this connection in relation to migraine headaches. The researchers looked at whether the collection of microorganisms living in our guts (called the gut microbiome) could be linked to the development of migraine headaches and its different types – migraine with and without aura.

To do this, the scientists used information from a big genetic study that looked at the genes related to the gut microbiome. They also used data from studies that explored the genetics of migraine headaches. They employed sophisticated methods to analyze this data, and they also checked for other factors that could affect the results.

In the analysis, they found that certain types of bacteria in the gut were connected to migraine headaches, including ones with and without aura. They also found that some specific types of bacteria were more likely to be associated with certain types of migraines. Even after doing some statistical adjustments, these connections still held up.

So, this study suggests that the mix of bacteria in our guts might actually influence whether we get migraines and what kind they are. It shows that there might be a link between our gut and our brain when it comes to migraines.

They found that while some bacteria seemed to contribute to migraines, one type appeared to be protective. This protective effect was linked to the Bifidobacterium family. You can find Bifidobacterium in many probiotics, including a well-known brand called Align. Additionally, various fermented foods like milk kefir, sourdough bread, sauerkraut, kimchi, and other fermented vegetables contain Bifidobacterium.

However, it’s important to note that this research doesn’t mean other types of bacteria aren’t helpful too. A healthy human gut microbiome consists of many different types of bacteria. When there is an imbalance of these healthy bacteria, it can lead to various health problems, not just migraines. This imbalance can come in many different forms and may require different probiotics to correct it. That is why I recommend that patients try different types of probiotics for a few months at a time. Besides Bifidobacteria, some patients respond well to Saccharomyces, Lactobacillus, or other types, or even a combination of several.

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Anxiety may facilitate transformation of pain from acute to chronic

By: Dr. Mauskop
07-09-2023
Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Psychology of headaches, Science of Migraine

Our thoughts and emotions can impact the development of chronic pain. However, there haven’t been many studies exploring what causes pain to transition from being short-term (acute) to long-lasting (chronic).

Australian researchers conducted a study to investigate how our thought patterns, anxiety related to pain, and the tendency to avoid pain affect both acute and chronic pain. They conducted two studies for this purpose. In the first study, they interviewed 85 individuals experiencing long-term pain to understand their thoughts and emotions. In the second study, they observed 254 individuals who had recently started experiencing acute pain and followed up with them three months later.

In both studies, they examined interpretation bias using a word association task and assessed pain-related anxiety, pain avoidance, pain intensity, and how pain interfered with daily life. In both cases, they discovered that the way people think about pain was linked to how much it disrupted their daily lives. In the second study, they also found that people’s thought patterns about pain were connected to increased anxiety about pain. This heightened anxiety, in turn, made the pain more severe and disruptive after three months. While anxiety about pain also led people to try to avoid it, this avoidance behavior didn’t seem to affect the level of pain they experienced later on.

This research provides valuable insights into how pain can transition from acute to chronic. It suggests that our initial thoughts about pain might trigger anxiety related to pain, which can contribute to the pain persisting and becoming more troublesome over time. This finding could be crucial in developing strategies to prevent chronification of pain by addressing how people perceive and manage their anxiety about pain during its early stages. Cognitive-behavioral therapy, meditation, and other mind-body techniques could be some of such strategies.

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A better fix for Benign Paroxysmal Positional Vertigo

By: Dr. Mauskop
21-08-2023
Brain disorders, Chronic migraine, Migraine, New treatments, Science of Migraine

People who suffer from migraines are twice as likely to develop benign paroxysmal positional vertigo (BPPV) than individuals without a history of migraines. BPPV, though benign, can be a terrifying experience, especially for those experiencing it for the first time. It has a sudden onset and is often accompanied by nausea and vomiting. The first thought that enters people’s mind is a stroke or a brain tumor.

The cause of BPPV is a loose crystal in one of the semicircular canals of the inner ear. Epley maneuver usually succeeds in trapping and immobilizing this crystal. I’ve had a patient who emailed me with a typical description of BPPV. I emailed her this link to a YouTube video with the instructions on how to perform the Epley maneuver. She emailed back 30 minutes later reporting that her vertigo stopped.

A new study by Dr. Michael Strup, a neurologist at the Hospital of the Ludwig-Maximilians University in Munich and his European colleagues compared two different maneuvers to relieve BPPV. They showed that Semont-Plus maneuver is more effective than the Epley maneuver.

Of the 195 participants 64% were women and the mean age was 63. Initially, the procedure was administered by a physician. Subsequently, patients were instructed to perform the maneuver independently—three times each in the morning, noon, and evening. The Epley group stopped having vertigo after an average of 3.3 days, while the Semont-Plus group, after an average of 2 days.

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