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Brain disorders

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

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A recent study published in the journal Pain showed that adding a non-painful stimulus at the end of a Pap smear can reduce pain recollection. The study, titled “Adding a Nonpainful End to Reduce Pain Recollection of Pap Smear Screening: A Randomized Controlled Trial,” was conducted by Taiwanese researchers and involved 266 women.

The study involved an intervention group that received a modified Pap test, where the operator kept the speculum still in the vagina for an additional 15 seconds after rotating it back, instead of immediately removing it. Participants in the modified Pap test group were unaware of this additional step, as they were behind a privacy curtain.

The outcomes of the study included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects, the modified Pap group experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale and on a 0 to 10 visual analog scale. Subgroup analyses showed that these results were not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Additionally, the modified Pap test attenuated 1-year recalled pain on both pain scales and increased the 1-year willingness grade to receive further Pap tests.

This technique could potentially be applied to many other painful procedures, including Botox injections, blood draws, vaccine injections, dental procedures, and more.

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The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate for this approach, several studies have suggested that an early return to activity after a concussion may lead to better outcomes.

Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations.

The latest pediatric study was done in Canada. It examined data for 1630 children aged 5 to 18 with a mean age of 12 and of whom 38% were girls. The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory. Missing fewer than 3 days after concussion was defined as an early return to school.

An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group.

Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental, as it can be challenging for many people to remain inactive for such an extended period. This approach, which involves refraining from activities such as reading, writing, screen time, and exercise, can lead to depression, increased anxiety, and may even delay recovery.

After a brief period of rest lasting 24 to 48 hours, I typically recommend a gradual return to full activities. The key is to monitor for any exacerbation of post-concussion symptoms such as headaches, dizziness, brain fog, or fatigue. If an activity does not worsen symptoms, patients can continue to increase the level of physical and cognitive activities at a steady pace.

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Most people are right in not wanting to take medications. They can have serious or just very bothersome side effects, they help only some people and can be expensive. Fortunately, there are many ways to control migraines without drugs. Here are the top 10 non-drug therapies for migraine headaches among several dozen described in my book, The End of Migraines: 150 Ways to Stop Your Pain.

Non-drug therapies

  1. Aerobic exercise
  2. Meditation
  3. Magnesium
  4. CoQ10
  5. Cognitive-behavioral therapy
  6. Acupuncture
  7. Nerivio
  8. Cefaly
  9. Riboflavin
  10. Boswellia
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In a recent blog post, I wrote about the benefit of different types of exercises for the relief of migraines and other types of headaches. It mentioned that strength training may be more beneficial than aerobic (cardio) exercise. A study just published in Nature Communications suggests that the time of day when you exercise also matters. Not specifically for headaches but for “all-cause and cardiovascular disease mortality”.

This was a very rigorous study of 92,139 UK participants over an average of 7 years of follow-up which added up to 638,825 person-years. The timing of exercise was recorded by an activity tracker (accelerometer). Moderate-to-vigorous intensity physical activity at any time of day was associated with lower risks for all-cause, cardiovascular disease, and cancer mortality. However, the morning group (5:00 – 11:00), midday-afternoon (11:00 – 17:00), and mixed timing groups, but not the evening group (17:00-24:00), had lower risks of all-cause and cardiovascular disease mortality.

This study suggests that exercising before 5 PM has more health benefits than exercising after 5. It is likely that this may also apply to the relief of migraines and other headaches.

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In a post last August, I mentioned that zinc could possibly extend the duration of the effect of Botox. A new report by Chinese neurologists in Headache describes their findings of an inverse association between dietary zinc intake and the occurrence of migraine in American adults.

The researchers used the data from a five-year study conducted by the CDC to assess the health and nutritional status of Americans. Data were collected using a computer-assisted dietary interview system which proved to be very reliable. Over 11,000 adults were included in the analysis of zinc intake. These subjects were divided into quintiles, according to their zinc intake. The data were adjusted for various confounding factors. These included age, sex, race, ethnicity, smoking status, body mass index, and others.

People in the lowest quintile were at least 30% more likely to suffer from migraine compared to people in the other four quintiles. Associaion does not mean causation and this study does not prove that taking zinc will prevents migraines. However, a few small studies did show the benefit of taking a zinc supplement in migraine patients.

Checking your blood for zinc levels before taking a supplement would be ideal. However, there is very little downside to taking 10-25 mg of zinc daily even if you don’t know your zinc level.

Zinc is very important for the normal functioning of the immune system, it possibly prevents macular degeneration, and has many other benefits.  Taking too much zinc can cause serious side effects. The effects of zinc toxicity are mostly due to the lowering of copper levels.

 

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Insomnia is a very common problem. Sleep aids, over-the-counter and prescription have been proven to be harmful if taken long-term. They even raise the risk of Alzheimer’s.

A small dose of melatonin (300 mcg, or 0.3 mg) can help better than the usual 3 mg dose sold in most stores. You can also try valerian root and definitely adhere to sleep hygiene. This includes no reading or watching TV in bed, no screens for at least an hour before bedtime, no eating or exercising within two hours of going to bed, and sleeping in a cold room (65 to 68 degrees). Going to bed at the same time also helps.

If you still can’t fall asleep, try visualization. Actually, you don’t just use your visual memory but engage all the senses. This post was prompted by a WSJ article on this topic, A Happy Memory Can Help You Fall Asleep, if You Know How to Use It.

I usually imagine myself on a beach in a hammock under a tree, feeling a warm breeze on my body, seeing a beautiful view of the beach and the ocean, smelling fragrant flowers, and hearing the sound of waves lapping at the shore.

Once you find your happy place and can vividly recreate it, always use the same setting without variation. This way you will fall asleep within minutes.

 

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Daily multivitamin use was compared to cocoa extract in more than 2,200 people over 65. After three years, taking a cocoa extract had no benefit while taking a multivitamin led to a significantly slower age-related cognitive decline. This included measures of global cognition, memory, and executive function.

Many physicians discourage their patients from taking a multivitamin. They should stop. There is little downside to taking a multivitamin. It is very inexpensive and safe. Many people also feel that if they eat a well-balanced healthy diet they should not need to take vitamins. Unfortunately, that is not the case. Even foods that are considered healthy are often processed, stored for a long time, or grown in depleted soil. Another problem is that as we age our body loses its ability to absorb vitamins and minerals (as well as protein, which is a different topic).

Taking a multivitamin should be a standard recommendation for those over 65. Many younger individuals need supplements as well. Ironically, a healthy diet (especially vegan or vegetarian) is often deficient in vitamin B12. Many young people whom I see for migraine headaches are deficient in vitamin D and magnesium. The role of vitamin D is also often underappreciated by primary care doctors. Multiple studies have shown that your vitamin D level should be not only within the normal range but in the upper half of the normal range for your brain to function normally. Most people who died of COVID had low vitamin D levels. And I’ve written many times about the importance of magnesium – just search this blog.

Ideally, to approach this problem scientifically, you should have your vitamin and mineral levels checked. This will allow you to take only those vitamins that you are deficient in. the difficulty is that there are too many vitamins to check and the insurance companies often refuse to pay for these tests. Taking at least a multivitamin is a reasonable alternative.

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Botox has been shown to relieve the pain of trigeminal neuralgia (TN). TN is an excruciatingly painful and debilitating condition. The most common cause of TN is compression of the trigeminal nerve by a blood vessel. This tends to occur in older people in whom blood vessels may harden with age. The definitive treatment of TN is surgical decompression of the trigeminal nerve. This is done by opening the skull and placing a Teflon patch between the nerve and the blood vessel. Several medications and invasive procedures directed at the peripheral nerve have been also proven effective. They are usually tried before surgery because of the risk of complications from surgery.

Besides the elderly, younger people with multiple sclerosis (MS) are also predisposed to developing TN. The mechanism is somewhat different. There is less or no compression of the nerve but rather there is damage to myelin, a sheath that covers the nerve inside the brainstem. Myelin prevents cross-talk between nerve fibers, which is the cause of the pain.

According to a report by Turkish neurologists that was recently published in Headache, Botox can relieve the pain of TN in MS patients as well. They compared the response to Botox in 22 patients with primary TN and 31 with MS-related TN. Ten patients of 22 in the first group and 16 out of 31 in the second group improved with Botox. Patients who had interventional treatments in the past did not respond as well. Those who had mild continuous pain between bouts of severe pain were more likely to respond to Botox.

Botox is not the first-line treatment for TN. Medications such as carbamazepine and oxcarbazepine are. However, Botox is a very safe treatment and should be tried before considering surgery and other invasive procedures.

 

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Multiple posts on this blog have described clinical trials that prove the benefit of exercise for the prevention of migraine headaches.

In a recent paper published in The Journal of Headache and Pain Stanford researchers compared the efficacy of aerobic and strength training exercises. They conducted a meta-analysis of 21 clinical trials that involved a total of 1,195 migraine patients.

Simplifying the statistics, compared to no exercise, strength training was 3.55 times more effective, high-intensity aerobic exercise was 3.13 times more effective, and moderate-intensity aerobic exercise was 2.18 times more effective.

For general health and for the prevention of migraines, 2-3 weekly sessions of strength training and 2-3 sessions of aerobic exercise would be an ideal regimen. As I mentioned in a recent post, an additional benefit of exercise is a larger brain volume. The only other intervention that has been shown to expand the brain and prevent its shrinkage with age is meditation.

Exercise and meditation are the first two recommendations on my list of top 10 treatments described in my latest book, The End of Migraines: 150 Ways to Stop Your Pain.

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According to a new report by Spanish researchers published in The Journal of Headaches and Pain, effective preventive treatment of migraines can improve cognitive impairment in patients with frequent attacks.

Patients with migraines often complain that their memory is not as good as it used to be, that they have difficulty concentrating, or can’t think clearly.

There are many possible causes of such symptoms. Stress is probably the most common reason people have trouble with memory and concentration. There is just too much on their mind. Certain drugs, most notably topiramate (Topamax), can cause pronounced cognitive impairment.  Nutritional deficiencies, particularly of vitamin B12 and other B vitamins, magnesium and vitamin D can cause brain fog and other cognitive problems. Alzheimer’s disease, which is what people fear most, thankfully is rare at the age when most people suffer from migraines.

I also see patients who do not have any of the above reasons. There are several possible explanations for why migraines alone can cause cognitive problems. We know that if a patient has only a few attacks a month, the brain remains hyperexcitable even between attacks. Some patients have a prodrome – one or two days of brain dysfunction prior to an attack. Others have post-drome – a feeling of exhaustion as if being hungover for a day or two after the attack. There is also a likely contributing effect of anticipatory anxiety – living in fear of the next attack.

Christina Gonzalez-Mingot and her colleagues in Lleida, Spain, compared 50 control subjects and 46 patients with chronic migraine. These patients were evaluated using a battery of tests prior to the use of preventive treatment based on botulinum toxin (Botox) or oral drugs and after 3 months of this treatment.

Compared with controls, patients with chronic migraine had lower scores on three standard tests of cognitive performance and had lower quality of life. Three months after the use of preventive treatment, improvement was observed in all but one cognitive parameters and in the quality of life.

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