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Chronic migraine

Sleep disturbances and fatigue are more common in patients with chronic migraine headaches than in people without migraines. Sometimes it is not clear what came first, migraines or the sleep problem with secondary fatigue.

A multicenter study performed in Australia, South Korea, and the US examined the effect of Botox injections given for chronic migraines on sleep and fatigue. This was a 108-week study of 715 adult patients who received Botox injections every 12 weeks. Their sleep quality was assessed by the Pittsburgh Sleep Quality Index and fatigue was measured by the Fatigue Severity Scale, both standard and proven measures of sleep and fatigue.

The authors presented their findings at the American Headache Society meeting held two months ago in Boston. While sleep quality was poor before injections were started, significant improvement was noted 24 weeks later and the improvement persisted for the rest of the study. The same was true for fatigue. These findings suggest that sleep difficulty and fatigue are more often the result of chronic migraine, rather than the other way around.

This does not mean that sleep issues should not be addressed while chronic migraine is being treated. Patients are advised to adhere to sleep hygiene, which consists of going to sleep and getting up at the same time, not reading or looking at any screens in bed, sleeping in a cool and quiet environment, exercising and eating at least 2 hours before bedtime, and avoiding caffeine after 1 PM. Regular practice of progressive relaxation and meditation can be very effective for sleep, migraines, and stress. Natural supplements for sleep, such as melatonin and valerian root are also worth trying.

As far as fatigue, we always check vitamin B12 levels, along with vitamin D, RBC magnesium, thyroid, and other blood tests.

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Concussion, even when it is mild, can result in a post-concussion syndrome. The main symptom is a headache and it is present in 60% of people within the first year after a mild traumatic brain injury. In people with personal or family history of migraines these headaches are often post-traumatic chronic migraines. Post-traumatic headaches and other symptoms such as dizziness and difficulty with vision, concentration and memory are often difficult to treat. However, an effective treatment of headaches often leads to an improvement in other symptoms as well.

Treatment with epilepsy drugs (Topamax, Depakote, Neurontin), blood pressure medications (propranolol), or antidepressants (Elavil, Cymbalta) can be effective in some, but not in all and not without side effects. Botox injections have been very effective without any serious side effects in many of my patients and similar results have been published by other doctors (see here and here).

Dr. Sylvia Lucas of University of Washington in Seattle presented her experience with the treatment of posttraumatic headaches with Botox at the annual meeting of the American Headache Society held in Boston last month. She described 15 patients who sustained a mild traumatic brain injury and suffered from chronic migraines for an average of 8 months prior to being treated with Botox. After a series of three Botox treatments given every 3 months most patients had a significant improvement in the number of headache days, as well as improved physical and social functioning, emotional well-being, energy level and a reduction in pain. As expected, no patient experienced any serious side effects.

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Stem cells hold great promise in the treatment of many conditions, possibly including migraines. In a post from 3 years ago I’ve written about a report from Australia that described 4 patients with refractory chronic headaches who had a very good response from stem cells. They were given stem cells for other conditions and coincidentally their migraines improved.

Since many patients come to our practice after seeing several other neurologists and headache specialists, we often have to resort to new, non-traditional, and unproven treatments. This is how I started using Botox 25 years ago (the FDA approved it for migraines only 6 years ago).

After reading the Australian report I decided to try stem cell treatment in some of my most refractory patients. Only patients who failed to respond to Botox and at least 3 preventive drugs were offered to participate in this pilot study. The only type of stem cells that the FDA allows to be injected are cells taken from patient’s own body without altering them. The richest source of stem cells in our bodies is fat. My colleague, Dr. Kenneth Rothaus who is a plastic surgeon, performed a liposuction to obtained fat tissue, from which we separated active cells.

We enrolled 9 patients and 3 did have significant temporary improvement. The results are obviously not dramatic, but it is possible that in less severely affected patients this treatment could work better. More importantly, using stem cells from an umbilical cord or placenta is more likely to be effective as these are younger and more active stem cells. There are many companies researching these cells for various indications, but not yet migraines. The reason why stem cells should help at least some migraine sufferers is the fact that they have strong anti-inflammatory properties while migraine involves neurogenic inflammation.

The results of our pilot study were just published in Case Reports in Neurology.

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The most satisfying part of our work is that we can help more than 95% of our patients. However, a small number of headache sufferers defy our best efforts and continue to have severe pain, which ruins their quality of life.

I just returned from my second visit to lecture at the Berolina Klinik, a rehabilitation hospital in Germany. It has an outstanding record in rehabilitating chronic headache and other types of patients. I wrote about this clinic after my first visit in 2014.

A report just published in Headache describes a successful rehabilitation program of chronic headache patients in an outpatient setting at the Cleveland Clinic. Drs. Krause, Stillman and their colleagues report on 379 patients who were admitted to the IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) program.

The program lasts 3 weeks, during which patients come to the clinic for 8 hours 5 days a week. Patients are informed that “the primary purpose of treatment is not to reduce pain, but rather to improve their ability to function during pain”. Despite this warning the average pain on admission was 6.1, while on discharge 3.5 and a year later, 3.3. Functional impairment, anxiety, and depression also improved and stayed improved a year after the treatment.

The program is clearly very effective and has an additional advantage of not requiring expensive hospitalization. Most patients stay at a hotel across the street from the clinic.

Here is an outline of the 3-week program:

Medical treatment:

1. History and initial medication adjustments on admission day.
2. Four days of intravenous therapy. Patients meet with the physician daily during infusions.
3. Two brief individual medical appointments per week during the second and third weeks.
4. All patients are drug tested at admission, and subsequent drug testing may be included if staff have concerns about illicit use.
5. Consultation with outside physicians as appropriate.

Psychological treatment:
1. One individual biofeedback session in each of the second and third weeks.
2. One individual psychotherapy session in each of the second and third weeks.
3. Psycho-educational group sessions spread throughout the three weeks. Topics include avoidance of pain displays, diminishing attention to headaches, cognitive-behavioral therapy for management of mood, activity pacing, time management, theories of pain, sleep hygiene, assertiveness training, relaxation training, self-esteem, management of headache flare-ups, and relapse prevention.
4. In the second and third weeks of treatment, patients’ families are requested to participate in a group family meeting, where the necessity of avoiding reinforcement of headache displays and disability is emphasized.

Nursing treatment:
1. Initial assessment, including current medication intake, document allergies, perform an EKG.
2. Patients receive at least 1-2 individual visits with a registered nurse during the second and third weeks of the program.
3. Nursing groups, including pathophysiology of headaches, proper use of a headache diary to track progress, dietary counseling, the impact of headaches and medications on sexuality, and medical communications. Nurses also train the patients in additional relaxation techniques beyond those covered in the psychology groups, and lead group relaxation practice.

Physical therapy treatment:
1. Physical therapy evaluation on their admission day, with particular attention paid to cranio-cervical dynamics. Data are used to develop an individualized, quota-based exercise plan including strengthening, flexibility, and endurance exercises.
2. Beginning on the day after admission, patients participate in daily group exercise sessions, where they learn and practice individually tailored exercise plans.
3. Twice weekly individual physical therapy sessions.

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Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days.

Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine.

The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to sleep restriction – not being allowed to sleep for more hours than the patients reported getting prior to treatment, in the hope that this will lead to better sleep in the long term. The sham group was instructed to eat some protein in the morning, eat dinner at the same time, keep up with their fluid intake, perform range of movements exercise, and regularly press on an acupuncture point above the elbow.

After two weeks of this intervention headaches improved in the sham group slightly more than the active group, but six weeks later, headache frequency dropped by 49% in the active group and 25% in the sham group. Improvement in insomnia symptoms strongly correlated with the headache frequency. The cognitive-behavioral group had a significant increase in the total sleep time and the quality of sleep.

This was a relatively small study, but there is a large body of evidence that behavioral therapies do relieve insomnia. And it is no surprise that better sleep is associated with fewer headaches since sleep deprivation is a common migraine trigger. Sleep restriction is the only part of this treatment that has contraindications – it should be avoided in patients with bipolar disorder or epilepsy.

Another simple method, which I’ve used over the years whenever I cannot fall asleep, is visualization. You have to use not only visual images, but engage all of your senses. For example, imagine yourself in a place where you tend to feel relaxed (lying on a beach, on a cool lawn, on a float in a pool, etc). See all the details and also hear the sound of the wind or waves, smell the ocean or the grass, feel the touch of the wind or sand. It takes an effort at first, but use the same image every time and after a while, as soon as you go to that place, you fall asleep in minutes. Here I found more detailed instructions for this method.

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About 6% of young children suffer from migraine headaches. After puberty, this number triples to 18% in girls and remains at 6% in boys. Several abortive drugs (drugs taken as needed), such as rizatriptan (Maxalt) and zolmitriptan (Zomig) are approved for migraines in children. Only topiramate (Topamax) is approved for children (over the age of 12) for the prevention of migraines. We do use preventive drugs approved for adults in children as well. These are divalproex sodium (Depakote), propranolol (Inderal), and botulinum toxin (Botox). Many other drugs, such as amitriptyline (Elavil), gabapentin (Neurontin), candesartan (Atacand) are used “off label”, meaning that they are not FDA-approved for migraines in adults or children. One of the reasons that more drugs are not approved specifically for children is the difficulty in conducting research in kids. Their are migraines are usually shorter in duration and often stop occurring for long periods of time without treatment.

A large multi-center 24-week study just published in the New England Journal of Medicine examined the efficacy of topiramate, amitriptyline and placebo in children between the ages of 8 and 17. It was a double-blind study with neither the children and their parents nor the doctors being aware of who was getting which drug or placebo. The study showed no statistically significant difference among the three groups. The main outcome measure was a 50% or higher reduction of headache days. Placebo achieved this result in 61% of children, while this number was 52% for those on amitriptyline and 55% on topiramate. Not surprisingly, side effects were much more common in children taking medications than placebo. Fatigue and dry mouth were the most common side effects from amitriptyline, while topiramate caused mostly tingling and weight loss. Serious side effects occurred in four – three kids on amitriptyline had a serious mood disorder and one on topiramate attempted suicide.

This study did not prove that amitriptyline and topiramate are ineffective since they did help half of the children they were given to, however the placebo worked at least as well. These findings are not surprising since placebo has a powerful effect, which is often more pronounced in children and because children’s migraines often stop on their own. Even in adults, placebo effect has often made clinical trials, particularly in migraines, very difficult. It took a couple of attempts to prove that Botox prevents migraines better than placebo, again not because Botox was ineffective, but because placebo also worked well.

The initial approach to treating migraines in children and adults should always involve looking for modifiable triggers, such as sleep schedule, regular meals with healthy food, elimination of caffeine and sugar, regular exercise, sleep hygiene, meditation or biofeedback, and so on. Our second step is trying supplements such as magnesium (which sometimes is given intravenously because of poor absorption of pills) and CoQ10, which have been proven to be effective both in children and adults. Other, less proven supplements, such as riboflavin, feverfew, and boswellia are also worth trying before starting a daily preventive medication. At the same time, since migraine often causes severe pain, we often prescribe abortive migraine medications, such as sumatriptan or rizatriptan, which are often more effective than ibuprofen and acetaminophen.

It is considered unethical for doctors to prescribe placebo, although we do sometimes prescribe very mild drugs in a small dose (cyproheptadine is one such drug), which is almost the same as prescribing a placebo.

An interesting study of placebo in patients with low back pain was just published in the journal Pain . One group was given the usual treatment and the other received the usual treatment as well as a placebo pill, but they were told that they are being given a placebo. The group that knowingly took placebo had a significant reduction in pain and disability. After three weeks of this trial, the first group was also given a placebo pill and they also had a significant drop in pain and disability. It is possible that the effect is just due to the act of taking a pill, which subconsciously sends a message to the brain that something is being done to fix the problem.

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It was a great privilege to know Elie Wiesel, survivor of Auschwitz, Nobel Peace Prize winner, author of 40 books, university professor, and most importantly, a tireless campaigner for human rights.

Mr. Wiesel suffered from severe daily migraines. Both of his parents and many members of his extended family suffered from headaches. The only year in his life without headaches was when he was in Auschwitz. He was highly functional with a very busy schedule despite his chronic migraines. I invited him to speak about his headaches at the First International Headache Summit held in Tel-Aviv, Israel, on November 16, 2008 and he generously agreed (here is a photo from the event). This is an excerpt from his presentation which was published in the journal Headache:

“Thank you very much, Dr. Mauskop. I’ve been thinking a lot about this topic, and when I consider a topic I tend to return to my primary source: do we find headaches in Scripture? Perhaps you remember the prophet Elishah, a very special man, the disciple of Elijah. The woman who was his host in a certain village was barren, and she was embarrassed to tell him this. Elishah’s servant knew of her distress, however, and he so informed the prophet whom he served. Elishah blessed her with a son. The son grew, and one day when he was in the fields with his father, he cried out, “My head, my head. I have a headache.” Thus, for the first time, headache enters old religious texts. The father asked his servants to bring the boy home, where he suddenly died. His mother ran to the prophet, to Elisha, and said, “I asked you for a living son . . . not for a dead one.” At that point we first bear literary witness to the act of mouth-to-mouth resuscitation. The prophet administered it resuscitation, and the boy lived once again.
When one poses a question, the Talmud may offer what amounts to advice. What happens if a person has a headache? What should he do? You or I would answer, Go to a doctor, but the Talmud advises, Go study Torah. Now, why should a person who has a headache go and study? Is it because when he or she studies, they forget their headache? or maybe they get a different headache. Everything is possible.
Now, I must tell you, Dr. Mauskop, you kindly asked me to come and see you for my headaches. I didn’t come because I did not want to embarrass you, to cause you to have to admit failure, because nothing has ever helped me. I began having headaches—I’m speaking to you as a patient—at age 7. At age 7, I already was taking pills for headache; everybody in my family was! My mother had headaches; my father had headaches; my grandfather had headaches. So I lived with headaches from my childhood on.
But then something bizarre happened: the day I entered Auschwitz, the headaches disappeared. I studied what you told me about pressure, about headaches as the result of pressure. But that seemed a contradiction. If ever I had pressure, it was there. In the camp. Every moment was pressure. But the headaches disappeared.
The moment I arrived at the first orphanage in France, after Liberation, they came back. The first doctor I went to I saw for my headaches. They are still with me. And they are not rare; they are still frequent. I get up every day with a headache, and once a week, I have what I call the “deluxe” version, a real headache. My problem is if I have to give a lecture that day—and I teach full time—or that evening, what do I do? If I take strong pills, I’m afraid it could affect my thought processes. I try to cope. I didn’t come to see you. I thought, why should I give you pain by realizing that you cannot help my own?
At my age, and rather suddenly, I’ve developed other kinds of pains that I didn’t have before. Back pains, hand pains. So I’ve been to all kinds of doctors for these various woes, and—I don’t have to tell you—the interesting part is, usually when you have a new pain, the old pain recedes. Not in my case. My headache is so faithful to me; it’s so loyal that it remains present always.
I got up this morning with a very, very bad headache. So, I said to my headache, “You won’t win.” I speak to my headache; I personalize it. I say, “I know who you are, and I know what you want, and it won’t work.” And the pain says to me, “Let’s see, Wiesel.” And so we fight.
Through my studies, I’ve discovered that many writers and artists and painters have suffered from headaches, and they have had their own distinctive methods of coping. Dumas used to place a wet cloth on his forehead. Hemingway used to do write standing, because this seemed to afford some relief. Many of the great writers had headaches. Perhaps writers have headaches because they are afraid of critics.
And to this day I have not found a way of handling my own headache except in my own fashion, which is to live with it. It hasn’t slowed down my work. I teach full-time, and I am a very obsessive professor. In some 40 years, I don’t think I’ve ever given the same course twice. I want to be the best student in the class. That’s how I learn and grow with the students. And all that with my constant companion, this headache.
Now maybe once I’ve finished, you will have a session and say, “Now what can we do for Elie Wiesel’s headaches?” But don’t bother; even if you were to try, I don’t think you could help. But perhaps you can use my example to encourage your patients. Patients will come to you and say, “Why can’t you help me?” And you can say, “Look. He couldn’t get cured, and nevertheless he works. He goes on, functioning, studying, teaching.”
Maybe psychologically I need the headaches to work? I’m sure some of you have had that idea in mind. Maybe he needs the added challenge . . . this extra burden. In that case, why did I have headaches at age 7? And 8 . . . 9 . . . 10? Hereditary? Sure. Pressure? No. What pressure? School pressure? I was a good student.
So do I need these headaches? Personally, I think not. I think I could work as well without them. Are they part of me? Are they part of my psyche? Is my headache part of who I am? If so, what a terrible analysis . . . what a terrible definition of self! Am I my own pain?
You know Descartes, the philosopher. As a young man I admired him because he was one of the great thinkers of the Middle Ages, helping us emerge from the darkness. He came out with the formula, and I’m sure most of you recall it from school, cogito ergo sum: I think, therefore I am. And later I discovered about Descartes things I didn’t admire that much. He had written a book on science. When he read about the tragic fate of Galileo, he was so afraid of the Inquisition that he didn’t publish his book. Hey, Descartes, that’s no way to behave. You, the philosopher, should be afraid of the tormentor? But he was. So I began reanalyzing, reevaluating Descartes, and concluding that maybe he’s wrong even with his cogito ergo sum! I’m a student of the Talmud. I encourage students to ask questions . . . even to question the questions. And so I thought, Maybe he’s wrong.
I think he is. I would say, “I think, therefore you are.” My thought must involve you. My life must involve you. I am who I am, not because of myself, but because of my attitude towards you. One also could say, “You think, therefore I am.” Your thought challenges mine. Your existence is a challenge to mine. Your life is maybe a question . . . and an answer in relation to my own. Alone, who are we? Nobody is alone.
So, how might I use even the pain of headache for the benefit of someone else? How can I do that? By doing my work, sure. So I go on; I’m a writer; I’m a teacher; I go around the world trying to do my best to improve some conditions here and there, always failing—but it doesn’t matter . . . I will go on trying.
One last thing to add, something perhaps to tell your patients: when a person says, Leave me alone, I have a headache, it’s wrong. Never leave me alone. Never think that you bother me. I may have the worst headache in my life, but if someone needs me, I have no right to say, “But I have a headache.” That is not a sufficient excuse.”

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The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered that in this period of time only 100,000 chronic migraine sufferers received this treatment. According to the Migraine Research Foundation, 14 million Americans suffer from chronic migraines, so less than 1% of them have recieved this potentially life-changing treatment.

There are several possible explanations.
1. Botox is expensive and many insurance companies make it difficult for patients to get it. They require that the patient first try 2 or 3 preventive drugs, such as a blood pressure medicine, (propranolol, atenolol, etc.), an epilepsy drug (gabapentin, Depakote, Topamax), or an antidepressant (amitriptyline, nortriptyline, Cymbalta). Patients also have to have 15 or more headache days (not all of them have to be migraines) in each of the three preceding months. If these requirements are met, the doctor has to submit a request for prior authorization. Once this prior authorization is granted, the insurer will usually send Botox to the doctor’s office. After the procedure is done, the doctor has to submit a bill to get paid for administering Botox. This bill does not always automatically get paid, even if a prior authorization was properly obtained. The insurer can ask for a copy of office notes that show that the procedure was indeed performed. All this obviously serves as a deterrent for many doctors. Some of them find that the amount of paperwork is so great and that the payment is so low and uncertain, that they actually lose money doing it.

2. There are not enough doctors trained in administering Botox. This is becoming less of a problem as more and more neurologists join large groups or hospitals where at least one of the neurologists is trained to give Botox and gets patients referred to him or her. However, doctors in solo practices or small groups without a trained injector can be reluctant to refer their patients out for the fear of losing a patient. They may suggest that this treatment is not really that effective or that it can cause serious side effects.
The majority of doctors who inject Botox are neurologists, but there are only 15,000 neurologists in the US and many specialize in the treatment of strokes, Alzheimer’s, epilepsy, MS, and other conditions. This leaves only a couple of thousand who treat headache patients. Considering that there are 14 million chronic migraine sufferers, primary care doctors will hopefully begin to provide this service.

3. Chronic migraine patients are underdiagnosed. Many patients will tell the doctor that they have 2 migraines a week and will not mention that they also have a mild headache every day. The mild headaches they can live with and sometimes my patients will even call them “normal headaches”, which they don’t think are worth mentioning. Good history taking on the part of the doctor solves this problem. However, once doctors join a large group or a hospital, they are pressured to see more patients in shorter periods of time, making it difficult to obtain a thorough history.

4. Some patients are afraid of Botox because it is a poison. In fact, by weight it is the deadliest poison known to man. However, it is safer than Tylenol (acetaminophen) because it all depends on the amount and too much of almost any drug can kill you. Fifty 500 mg tablets of Tylenol kills most people by causing irreversible liver damage. Hundreds of people die every year because of an accidental Tylenol poisoning, while it is extremely rare for someone to die from Botox. Tens of millions of people have been exposed to Botox since its introduction in 1989. It is mostly young children who have gotten into trouble from Botox because the dose was not properly calculated. Kids get Botox injected into their leg muscles for spasticity due to cerebral palsy, although children with chronic migraines also receive it (the youngest child with chronic migraines I treated with Botox was 8).

In summary, if you have headaches on more than half of the days (not necessarily all migraines) and you’ve tried two or three preventive drugs (and exercise, meditation, magnesium, CoQ10, etc), try to find a doctor who will give you Botox injections. Botox is more effective and safer than preventive medications because it does not affect your liver, kidneys, brain, or any other organ.

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A patient of mine just emailed me about a recent segment of the TV show, The Doctors, which featured a woman whose severe chronic migraines were cured by nasal surgery. The segment was shot a few weeks after the surgery, so it is not clear how long the relief will last in her case. The surgery involved removing a contact point, which occurs in people with a deviated septum. The septum, which consists of a cartilage in the front and bone in the back, divides the left and the right sides of the nose. If the bony septum is very deviated, which often happens from an injury, it sometimes touches the side of the nose, creating a contact point between the septum and the bony side wall of the nose.
contact point headache
Several small reports by ENT surgeons have described dramatic relief of migraine headaches with the removal of the contact point. If headaches are constant, then the constant pressure of the contact point would explain the pain. However, many of the successfully treated migraine sufferers had intermittent attacks. The theory of how a contact point could cause intermittent migraines is that if something causes swelling of the mucosa (lining) of the nasal cavity, then this swelling increases the pressure at the contact point and triggers a headache. This swelling can be caused by nasal congestion due to allergies, red wine, exercise, and possibly other typical migraine triggers.

This is a good theory, but it is only a theory and the dramatic relief seen after surgery could be all due to the placebo effect. The only way to prove that contact point headaches exist and can be relieved by surgery is by conducting a double-blind study, where half of the patients undergoes surgery and the other half does not. Giving both groups sedation and bringing them to the operating room will blind the patient while the neurologist who evaluates them will also not know who was operated on and who was not, making this a double-blind study. This design is also good only in theory because those who had surgery will have bloody nasal discharge and nasal packing, thus breaking the blind.

However, despite the fact that we will not see any double-blind studies in the near future, there is one way to predict who may respond to contact point surgery. An ENT surgeon can spray a local anesthetic, such as lidocaine, around the contact point during a migraine attack and if pain goes away, then surgery is more likely to help. I would not recommend anyone having surgery without such a test.

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Inpatient migraine headache treatment in the US is usually limited to a five-day course of intravenous DHE and other medications. Even such brief admissions are not always approved by the insurance companies. Many patients improve after these admissions, but often only for a short time because besides some reduction in pain intensity, very little else changes in the patient’s life and her brain. It makes sense that longer-term inpatient rehabilitation of chronic migraine and pain patients can lead to a major and lasting improvement, but it is almost unheard of in the US. However, it is available in Germany and other countries.

Last November I lectured at one of the leading German inpatient rehabilitation facilities, the Berolina Klinik. My blog post about the Klinik was read by an Englishman with severe chronic migraines who was recently treated there with a three-week program with excellent results. Here is one of the articles that appeared in German press – Westfalen-Blatt 27.10.15.

And, shockingly to us Americans, the cost of treatment is less than $7,000 for a three-week stay in this top facility. Even with travel costs, it’s a bargain. I have been mentioning Berolina Klinik to my patients, although haven’t had anyone make the trip yet.

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About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a higher risk than the general population of additional disability related to depression, anxiety, irritable bowel syndrome, fibromyalgia, and other conditions.

Fibromyalgia is a disorder of the central nervous system with increased brain excitability. It often manifests itself not only with muscle pains, but also fatigue, memory problems, and sleep and mood disturbances. Various studies estimate that anywhere from 2% to 8% of the general adult population suffers from fibromyalgia. Just like with migraine, women are more often affected than men. The likelihood of coexisting fibromyalgia increases with increasing frequency and severity of migraine attacks.

Both migraine and fibromyalgia have been individually linked with increased risk of suicide. However, it is not clear that the risk is more than additive.

A study just published in Neurology, reports that patients with migraine and coexisting fibromyalgia have a higher risk of suicidal ideation and suicide attempts compared with migraine patients without fibromyalgia.

The study looked at 1,318 patients who attended a headache clinic. Of these patients, 133 or 10% were found to also have fibromyalgia. Patients with both conditions had more frequent, more severe, and longer-lasting migraine attacks as well as higher use of abortive medications.

Compared with migraine patients who did not have fibromyalgia, those with fibromyalgia were more likely to report suicidal ideation (58% vs 24%) and suicide attempts (18% vs 6%).

This report suggests that migraine and fibromyalgia may magnify the risk of suicide compared with the risk of the individual conditions. However, because this data comes from a specialty headache clinic, many patients were severely affected by their migraines, with more than 35% having chronic migraine. It is likely that the results would be less dramatic among migraine sufferers in the general population. Almost half of the estimated 35 million migraine sufferers in the US do not consult a physician. Most of them suffer from milder migraines than those who do consult a doctor.

This study suggests that patients with migraine should be evaluated for other chronic pain conditions and for their mental health well-being. In particular, patients with chronic migraine should be screened for other painful conditions and mental illness. And patients with fibromyalgia should also be evaluated for migraine and potential suicide ideation. Patients often do not appear depressed, but simple questions can detect depression, which can lead to effective treatment. Our initial evaluation at the New York Headache Center includes two questions which are highly indicative of depression: 1. Have you been bothered a lot in the last month by feeling sad, down, or depressed? 2. Have you been bothered a lot in the last month by a loss of interest or pleasure in your daily activities?

Antidepressants have been proven to be effective for the prevention of migraines even in the absence of depression and are the best choice for people suffering from both conditions. Prozac, Lexapro and other SSRI antidepressants do not help migraines or pain, but SNRIs such as Effexor, Cymbalta, and Savella or tricyclics such as Elavil, Pamelor, and Vivactil do relieve pain and depression.

Magnesium deficiency is common in both migraines and fibromyalgia and we recommend an oral supplement to all patients. Some patients do not absorb magnesium and respond very well to monthly intravenous infusions of magnesium. Both their migraines improve as do fibromyalgia symptoms.

One interesting difference between migraines and fibromyalgia is the response to Botox. Botox is proven to be highly effective for the prevention of migraines and it works very well to relax spastic muscles. However, Botox appears to be ineffective for the treatment of muscle spasm in fibromyalgia. It is possibly explained by the fact that Botox interferes with the function of acetylcholine, a neurotransmitter involved in contracting healthy muscles. In fibromyalgia, studies suggests a deficit in acetylcholine, so further blocking it would be ineffective or even make the muscle pain worse (which I’ve seen in a few patients).

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Fluctuations in the female hormone estrogen have been proven to be involved in triggering menstrual and perimenopausal migraine headaches. Testosterone levels have been reported to be low in men and women with cluster headaches. Testosterone replacement therapy seems to help these patients, when other standard treatments for cluster headaches do not.

A study presented at the recent annual meeting of the American Headache Society reported on testosterone levels in men with chronic migraine headaches. A significant percentage of men with chronic migraines also have low testosterone levels. This study did not look at the effect of testosterone replacement therapy, but it is possible that it may help chronic migraine sufferers as it does those with cluster headaches. It seems prudent to check testosterone level in men with chronic migraine headaches who do not respond to standard approaches such as medications, Botox injections, magnesium, and other treatments. And if the level is low, replacement therapy should be tried.

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