Chronic migraine | Headache NewsBlog

fMRI changes in kids after a concussion; could TMS help?

By: Dr. Mauskop

13-04-2025

Brain disorders, Chronic migraine, Head trauma, Migraine, neurostimulation, New treatments, post-traumatic headache

Concussions in children are far more than just a bump on the head—they can trigger subtle yet significant changes in brain function that may linger long after the visible symptoms fade. A recent prospective, longitudinal study sheds new light on how pediatric concussion disrupts functional brain network connectivity over time.

In this large-scale study, researchers tracked 385 children with concussion and 198 with mild orthopedic injuries (used as a control group) across five pediatric hospitals in Canada. Each child underwent high-resolution fMRI scans shortly after injury and again at either three or six months. The focus was on resting-state functional connectivity (FC)—how different regions of the brain communicate when the brain is not engaged in a specific task.

While within-network connectivity remained largely intact, disruptions in between-network connectivity emerged over time in the concussion group. Key findings included:

– Reduced connectivity between the visual and ventral attention networks across all time points after concussion.

– Lower connectivity between the visual and default mode networks, specifically at six months post-injury.

– Age-dependent differences in connectivity between the frontoparietal and ventral attention networks at three months: younger children showed reduced connectivity, while older children showed increased connectivity.

– Sex- and symptom-related differences in attention network connectivity, with girls without persisting symptoms showing higher connectivity between dorsal and ventral attention networks than those with lingering symptoms.

These findings point to long-term changes in how different brain networks interact after pediatric concussion, even after most children appear clinically recovered. It suggests that functional connectivity may be a sensitive biomarker of lasting brain changes—possibly outlasting observable symptoms.

This study provides crucial evidence that brain network changes can persist for months after a concussion, particularly between regions responsible for attention, vision, and executive function. These disruptions are influenced by age, sex, and whether or not symptoms persist, highlighting the complexity of brain recovery in children.

The authors did not discuss potential therapies, but transcranial magnetic stimulation (TMS) is a potential treatment that could normalize the disrupted networks. It is a non-invasive neuromodulation technique that uses magnetic pulses to stimulate specific brain regions. Already FDA-approved for conditions like depression and anxiety in adults, TMS is gaining interest for its potential in treating brain network dysfunctions after a concussion and other neurological disorders. We use it primarily for refractory chronic migraines but also persistent post-concussion symptoms.

Zonisamide Shows Promise as a Preventive Migraine Treatment for Kids and Teens

By: Dr. Mauskop

05-04-2025

Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Science of Migraine

A new study suggests that zonisamide (Zonegran), a medication traditionally used to treat seizures, may help reduce migraine days in children and teens.

The research, led by Dr. Anisa Kelley of Northwestern University Feinberg School of Medicine, reviewed health records of 256 children and teens diagnosed with migraines who were prescribed zonisamide as a preventive treatment. Among these participants, 28% had difficult-to-treat migraines, defined as migraines that had not responded to at least two other medications.

The researchers found that the median number of headache days per month dropped from 18 to six across all participants after starting zonisamide.

The greatest improvement was observed in the subgroup that followed up two to six months after beginning the medication, suggesting zonisamide is most effective after at least two months of use.

Zonisamide appeared to benefit both those with difficult-to-treat migraines and those without.

Zonisamide shares similarities with topiramate (Topamax), the only FDA-approved preventive migraine medication for children and teens. Both drugs are anticonvulsants that can help stabilize neuronal activity linked to migraines. However, zonisamide may have an advantage: it tends to cause fewer side effects compared to topiramate. The potential side effects include cognitive issues like memory and concentration difficulties, fatigue, weight loss, and others.

Dr. Kelley emphasized that while the findings are promising, the study has limitations. It did not include a control group of participants who were not taking zonisamide, and it relied on health record reviews rather than randomized clinical trials. Further research is needed to confirm these results and establish zonisamide’s effectiveness more conclusively.

I have been preferring zonisamide over topiramate in both children and adults. Both drugs have similar mechanisms of action and similar side effects, but topiramate causes more cognitive side effects, irritability, and depression. Topiramate is also more likely to cause kidney stones and severe metabolic acidosis. In older adults, both can cause osteoporosis.

Medical Cannabis vs. Prescription Medications for Chronic Pain

By: Dr. Mauskop

23-03-2025

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared with traditional prescription medications for managing chronic pain.

The study involved 440 patients using medical marijuana and 8,114 patients treated with prescription medications (nonopioid or opioid) in the same healthcare system. Both groups received comprehensive pain assessments and treatment plans.

Key Findings

Response Rates: At three months, 38.6% of the medical marijuana group and 34.9% of the prescription medication group showed significant improvements in pain, function, or overall well-being. The response rate in the medical marijuana group remained stable at six months.

Opioid Reduction: Among the 157 patients in the medical marijuana group who were also prescribed opioids, there was a significant reduction in opioid use, with a mean decrease of 39.3% in morphine milligram equivalents over six months.

Comparative Effectiveness: The study found that medical marijuana was more effective than prescription medications for treating chronic pain, with patients being more likely to respond positively to medical marijuana.

This study suggests that medical marijuana may be at least as effective as, if not more effective than, conventional medications for chronic pain. It also highlights the potential of medical marijuana in reducing opioid use, which is a significant public health concern.

I prescribe medical marijuana to our migraine patients when prescription drugs and non-drug therapies are ineffective. For many, marijuana helps relieve nausea; for some, it helps with migraine-related anxiety and insomnia; and for a smaller proportion, it helps with pain. My observations are probably skewed by the fact that I prescribe medical cannabis only for people with more severe migraines. It may be more effective for people with mild migraines or migraines of average severity.

Meeting of the Headache Cooperative of the Northeast

By: Dr. Mauskop

09-03-2025

Alternative Therapies, Chronic migraine, Cluster headaches, Headache medications, Migraine, neurostimulation

It was an honor to participate in the 35th Annual Winter Symposium of the Headache Cooperative of the Northeast, held on March 7 and 8. Leading headache experts from across the country covered many interesting topics. I had the privilege of discussing a presentation by Dr. Chiang Chia-Chun of the Mayo Clinic on artificial intelligence in Headache Medicine.

Here is my PowerPoint presentation: Artifical Intelligence discussion (1)

Vitamin B12: “Normal” blood Levels are often not normal

By: Dr. Mauskop

27-02-2025

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, post-traumatic headache, Science of Migraine

A new study published in the Annals of Neurology by researchers at UCSF challenges our current understanding of what constitutes “normal” vitamin B12 levels, particularly regarding brain health. The findings suggest that even B12 levels currently considered adequate may not be optimal for maintaining brain function, especially in older adults.

Key Findings

The study examined 231 healthy older adults with B12 levels that would typically be considered normal. Surprisingly, those with lower B12 levels – though still within the “normal” range – showed several concerning signs:

Slower nerve conduction in visual pathways

Reduced cognitive processing speed, particularly in older participants

More white matter damage visible on brain MRI scans1

Why This Matters

The current normal levels for vitamin B12 were determined decades ago, and it is not clear how reliable the research that led to these values was. Quest and Labcorp, two major chains of laboratories, define normal levels as 200 – 1,000 pg/ml and 232 -1,245 pg/ml, respectively. The WHO considers 480 pg/ml to be the bottom of the normal range, while it is 500 pg/ml in Japan. Some experts suggest these higher standards may contribute to lower rates of Alzheimer’s and dementia in Japan.

What This Means for You

Your B12 levels might be worth checking if you are experiencing neurological symptoms like:

Mental fogginess

Memory issues

Balance problems

Numbness or tingling

Migraine headaches, especially with visual auras

Dizziness

If you have this blood test done, don’t accept “it’s normal” from your doctor, but ask about your actual level.

Why are so many people deficient

Ironically, a healthy diet is low in vitamin B12. Vegetarians are at a greater risk of becoming deficient. Another common factor is antacid medications such as omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and others. Genetic factors also play a role.

Special Considerations for Older Adults

The study found that older adults may be particularly vulnerable to the effects of lower B12 levels. This is especially important because:

B12 absorption tends to decrease with age

The impact of lower B12 on cognitive processing speed was more pronounced in older participants.

A Breakthrough in Migraine Diagnosis

By: Dr. Mauskop

10-02-2025

Chronic migraine, Headaches, Migraine, Science of Migraine

Recent advances in neuroimaging are bringing us closer to an objective diagnosis of migraines. Korean researchers have published groundbreaking findings showing that migraine sufferers exhibit distinctive structural and functional brain characteristics visible on MRI scans. Their report, A robust multimodal brain MRI-based diagnostic model for migraine: validation across different migraine phases and longitudinal follow-up data, was published last month in the Journal of Headache and Pain.

Currently, migraine diagnosis relies on patients reporting specific symptoms. These include one-sided head pain, moderate to severe intensity, throbbing sensation, nausea, sensitivity to light and noise, and worsening pain with physical activity. A diagnosis typically requires the presence of at least three of these symptoms.

This new research confirms that migraines affect multiple brain networks rather than one area. The study identified three key markers: reduced thickness of certain parts of the brain’s cortex, changes in cortical folding patterns, and abnormalities in the brain’s visual, sensory-motor, and emotional processing networks. These findings represent a significant step toward more precise diagnostic tools for migraines. In the future, we may see a comprehensive diagnostic approach combining clinical symptoms, neuroimaging, and potentially other objective measures to provide more accurate diagnoses and targeted treatments.

Suzetrigine: A Promising New Treatment for Pain

By: Dr. Mauskop

30-01-2025

Brain disorders, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be as effective as Vicodin (hydrocodone with acetaminophen) after surgery to remove a bunion and after a “tummy tuck”.

Suzetrigine is a selective NaV1.8 inhibitor, targeting a key sodium channel involved in pain signaling. The NaV1.8 channel is crucial in transmitting nerve pain signals to the brain. However, the drug does not enter the brain and works only on the nerves outside the brain and in the body.

Unlike traditional pain medications such as opioids, suzetrigine provides effective pain relief without addiction risk or severe systemic side effects. Early clinical trials suggest it may be beneficial for conditions like neuropathic pain, post-surgical pain, and chronic pain syndromes. Hopefully, it will also prove effective in the treatment of migraines and other types of headaches.

In clinical trials, about 37% of patients experienced adverse events, though most were mild. These included itching, rash, constipation, and muscle spasms.

As a non-opioid option, suzetrigine provides clinicians with an additional tool for acute pain management. The medication is expected to become available in the second quarter of 2025. The expected cost is about $15 a pill.

Magnesium given in pregnancy reduces the risk of cerebral palsy

By: Dr. Mauskop

19-01-2025

Alternative Therapies, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy

A new Cochrane meta-analysis has reaffirmed the significant role of magnesium sulfate in reducing the risk of cerebral palsy (CP) and death in preterm infants. This comprehensive review, which analyzed six randomized controlled trials involving nearly 6,000 pregnant participants, provides compelling evidence for the use of this inexpensive intervention in preventing lifelong disability.

The review revealed that magnesium sulfate administration to pregnant women at risk of premature delivery:

*Significantly reduced the risk of CP in children up to 2 years of corrected age (relative risk of 0.71)

*Decreased the combined risk of death or CP (relative risk of 0.87)

*Moderately reduced the risk of severe neonatal intraventricular (brain) hemorrhage

These findings underscore the importance of magnesium sulfate as a neuroprotectant for preterm babies, a recommendation that has been supported by the World Health Organization since 2015.

While not directly related to the CP study, it’s worth noting that magnesium also plays a crucial role in migraine prevention and treatment. Magnesium deficiency, which is present in almost half of migraine sufferers, leads to increased migraine frequency and severity.

Many neurologists recommend magnesium supplements as part of a comprehensive migraine prevention strategy. We sometimes check RBC magnesium levels (the more accurate test than serum levels) before recommending supplementation. Chelated forms of magnesium, such as magnesium glycinate, are better absorbed than magnesium oxide, which is the type most commonly sold in stores. Oral magnesium can help the majority of people who are deficient. About 10%, however, do not absorb oral magnesium. We have these patients come into our clinic for monthly infusions.

Both oral and intravenous magnesium are safe in pregnancy.

However, I have heard some doctors and patients express concern about the harmful effects of magnesium in pregnancy. Indeed, mothers who receive very large amounts of intravenous magnesium (thousands of grams) over a period of more than 5-7 days may deliver babies suffering from osteoporosis, bone fractures, and other problems.

The amount of intravenous magnesium we give our migraine patients is one gram. So, pregnant women can safely take oral magnesium and receive regular intravenous infusions of 1-2 grams of magnesium.

A new device to treat chronic migraines

By: Dr. Mauskop

14-01-2025

Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation, New treatments

The Chordate System, using a technique called Kinetic Oscillation Stimulation (K.O.S), has shown promising results in reducing monthly headache days for people with chronic migraines, according to a study just published by European neurologists in the journal Neurology.

The treatment involves gentle stimulation inside the nasal cavity using a specialized catheter that delivers precise pressure and vibrations. Each session lasts 10 minutes per nostril and is administered weekly. The device works by potentially modulating the trigeminal nerve pathways involved in migraine attacks.

Study design: The study was randomized, double-blind, and sham-controlled.

Participants: Patients with chronic migraine (defined as headaches occurring on 15 or more days per month, with at least 8 of those being migraine days). The active treatment was given to 67 patients and the sham to 65.

Treatment: Weekly K.O.S sessions for six weeks.

Primary Endpoint: Change in monthly headache days with moderate to severe intensity (MHDs) from baseline to the performance assessment period (days 14–42).

Secondary Endpoints: These included changes in monthly migraine days (MMDs), reductions in headache severity, use of abortive medications, and improvements in quality of life.

Key Findings

The results demonstrated that K.O.S provided significant benefits for patients with chronic migraine:

Reduction in Monthly Headache Days (MHDs):

Active treatment resulted in a reduction of 3.5 MHDs during the assessment period, compared to a 1.2-day reduction with sham treatment.

This improvement persisted into the follow-up period, with a 2.7-day reduction in MHDs compared to sham.

Reduction in Monthly Migraine Days (MMDs):

Patients receiving K.O.S experienced a 2.4-day reduction in MMDs during the assessment period with effects lasting into follow-up (2.9 days).

Responder Rates:

A significant proportion of participants achieved a 30% or 50% reduction in moderate-to-severe headache days, demonstrating the clinical relevance of K.O.S.

Safety Profile:

Adverse events were mild and similar between the active and sham groups, with nasopharyngitis, dizziness, and minor nosebleeds being the most common. Importantly, no treatment-related serious adverse events were observed.

This non-drug approach offers a new option for people suffering from chronic migraines, especially those concerned about medication side effects. The treatment’s effectiveness is comparable to current standard medications while offering a non-pharmaceutical alternative.

The Chordate System (Ozilia) is not currently available in the United States, as it has not yet received FDA approval. However, the company, Chordate Medical, is actively working toward getting it approved.

We do have several FDA-approved devices to treat migraines. The most effective, practical, and affordable are Cefaly and Nerivio. Relivion, Savi Dual, and gammaCore are less so.

Can Magnetic Brain Stimulation (rTMS) Prevent Pain?

By: Dr. Mauskop

02-12-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine, TMJ

Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of repetitive transcranial magnetic stimulation (rTMS) on pain sensitivity offers some intriguing insights.

What is rTMS?

rTMS is a non-invasive method of brain stimulation. It involves sending magnetic pulses to specific areas of the brain through a coil placed on the scalp. This technique has been used to treat conditions like depression and chronic pain, but researchers are now looking at its potential to prevent pain. We used rTMS at the New York Headache Center to treat chronic migraine, other pain and neurological conditions that do not respond to usual treatment.

In a controlled experiment, researchers led by Nahian Chowdhury examined the role of rTMS in reducing future pain in healthy volunteers. The results were published in the latest issue of Pain, a journal of the International Association for the Study of Pain.

The subjects were divided into two groups:

Active rTMS Group: Received high-frequency rTMS to the area of the brain responsible for hand movements.

Sham rTMS Group: Received a fake treatment for comparison.

Both groups were then given an injection of nerve growth factor (NGF) into their jaw muscles, which causes prolonged pain similar to temporomandibular disorders (TMD), a condition causing jaw pain and dysfunction.

Results:

Pain Reduction: Participants who received active rTMS reported significantly less pain when chewing or yawning than the sham group. This effect was more pronounced in the early stages after the injection but persisted for days and weeks.

Brain Activity: The study found an increase in what’s known as peak alpha frequency (PAF) after rTMS, which is linked to lower pain sensitivity.

What Does This Mean for Pain Management?

Preventive Potential: This research suggests that rTMS could be used prophylactically to reduce pain sensitivity when pain is expected, like before surgery.

Future Directions: While promising, this study opens the door to further research into how rTMS can be optimized for pain control, potentially exploring different frequencies, duration, and areas of stimulation.

Pre-Surgery: rTMS might be used to reduce postoperative pain, potentially preventing the transition to chronic pain.

Chronic Pain Management: For those already dealing with chronic pain, understanding how brain activity changes with rTMS could lead to more effective treatments.

Conclusion

While we are still in the early stages, this study of rTMS offers hope for pain sufferers. It suggests a future where we might not only treat pain more effectively but also prevent it from becoming a long-term problem. This could revolutionize our approach to pain management, making it less about reducing and enduring pain and more about preventing it from taking root in the first place.

A new textbook on headaches and facial pain.

By: Dr. Mauskop

21-11-2024

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Trigeminal and other neuralgias

It’s an honor to have contributed, alongside Andrew Blumenfeld and Sait Ashina, a chapter on Botox injections to the upcoming textbook Headache and Facial Pain Medicine. Edited by Sait Ashina of Harvard Medical School and published by McGraw Hill, the book is set for release in 2025 but is already available on Amazon.

The book includes chapters on Primary Headaches, Secondary Headaches, Facial Pain and Cranial Neuralgias, Special Treatments and Procedures, Special Populations, and Special Topics. It is an excellent textbook for health care providers.

It’s good to see the lasting impact of our research

By: Dr. Mauskop

16-11-2024

Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine

“Dr. Mauskop,

Congratulations on hitting a new milestone – over 3800 citations of your articles! This places you in the top 5% for citations within the Doximity community.”

Some of the most cited articles:

– Intravenous Magnesium Sulphate Relieves Migraine Attacks in Patients with Low Serum Ionized Magnesium Levels: A Pilot Study

– Botulinum toxin type A for the prophylaxis of chronic daily headache: Subgroup analysis of patients not receiving other prophylactic medications: A randomized double-blind, placebo-controlled study

– Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

– Effect of noninvasive vagus nerve stimulation on acute migraine: an open-label pilot study

– Foods and supplements in the management of migraine headaches.