Chronic migraine | Headache NewsBlog

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.

The role of a physical therapist in treating migraines

By: Dr. Mauskop

14-08-2023

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

Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their contribution can be profoundly impactful, provided they have a keen interest in the nuances of migraine care.

One such physical therapist to whom I refer patients, Pete Schultz, just co-wrote an article, A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist’s Perspective.

This article shows how experienced physical therapists approach migraine patients. They usually perform a very thorough examination and they can sometimes detect a serious problem that was missed by a physician.

The physical therapist often discovers general weakness, muscle tension, poor posture, diminished endurance, neck pain, teeth clenching, visual symptoms, dizziness, poor balance and coordination and high stress levels.

The interventions may include exercise directed at strengthening neck and upper back muscles, manual therapy, general conditioning exercise, biofeedback and mindfulness techniques, and vestibular therapy.

There is a wealth of data on the therapeutic effect of exercise in migraine patients. Interestingly, weight training seems to be more effective in the prevention of migraines than aerobic exercise.

Vestibular symptoms, such as dizziness and unsteadiness, are very common and are highly responsive to vestibular therapy.

Biofeedback is typically done by mental health professionals, but also by physical therapists. Over 100 clinical trials have been performed utilizing biofeedback in the treatment of headaches. The consensus is that this is a very effective technique.

An additional benefit that physical therapists can provide is what psychologist call a shift in locus of control, from internal to external. This means that instead of feeling like a victim of external uncontrollable circumstances, people acquire agency and cam actively do things to help themselves. This shift has been consistently shown to increase the efficacy of headache and pain treatment.

Depakote, oral and infusion, for migraines in children

By: Dr. Mauskop

10-08-2023

Chronic migraine, Headache medications, Headaches in children, Migraine, Migraine in pregnancy

A recently published study suggests that valproic acid (Depakene) given intravenously in an emergency room can relieve migraine headaches in children. The researchers also showed that giving these children an oral version of this drug, divalproex sodium (Depakote), does not reduce the frequency of future migraine attacks.

Divalproex sodium was first approved by the FDA in 1983 for the treatment of epilepsy. Subsequently, it was also approved for the treatment of mania and for the prevention of migraine headaches. Notably, the FDA-approved label does not place any age limit on the use of this drug. It took years to discover all the risks associated with this medication. In rare instances, the drug may lead to liver failure and severe pancreatitis, both of which can be fatal. Moreover, divalproex sodium can result in significant congenital malformations, as well as diminished IQ scores and neurodevelopmental disorders when the fetus is exposed to the drug in utero. It is strictly contraindicated in pregnant women. Women of childbearing age must use effective contraception. Divalproex can also cause many other less dangerous but unpleasant side effects.

With all this in mind, why would anyone want to take this drug? It is certainly not on the list of my top 20 or 30 drugs for the prevention of migraines. I do, however, have several patients whose migraines did not respond to many drugs but are significantly improved with divalproex sodium. Such patients must have proper monitoring with regular blood tests.

We do occasionally give intravenous valproic acid in the office but only if 5 or 6 other acute treatments fail to stop a severe persistent migraine. It works in about half of our patients. I am even more reluctant to give this drug to children.

Botox in pregnancy

By: Dr. Mauskop

24-07-2023

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

Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant women receiving Botox for various medical and cosmetic reasons, and no evidence suggests that the fetus gets harmed during this treatment. The botulinum toxin molecule is too large to cross the placenta and enter the circulation of the fetus, which further supports its safety during pregnancy.

An analysis of pregnancy outcomes after onabotulinumtoxinA exposure over a 29-year period was conducted to gain more insights into the safety of the treatment during pregnancy. The researchers examined data from the Allergan Global Safety Database from 1990 to 2018, focusing on pregnant women or those who became pregnant within three months of receiving onabotulinumtoxinA treatment. They analyzed the outcomes of these pregnancies to estimate the prevalence of birth defects in live births.

Out of 913 pregnancies, the study considered 397 with known outcomes. The majority of the mothers were 35 years or older, and most of the onabotulinumtoxinA exposures occurred before conception or during the first trimester of pregnancy. Among the 197 fetuses from 195 pregnancies, there were 152 live births and 45 fetal losses (including spontaneous and elective abortions). Four of the 152 live births had abnormal outcomes, with one major birth defect, two minor fetal defects, and one birth complication. The overall prevalence of fetal defects in live births was 2.6%, with a prevalence of 0.7% for major defects, similar to the rates seen in the general population. Among the cases with known exposure times, one birth defect occurred with preconception exposure and two with first-trimester exposure.

While the study has some limitations due to the nature of the data collected, the results indicate that the rate of major birth defects in live births exposed to onabotulinumtoxinA is consistent with the rates seen in the general population. However, it is important to note that there is limited data available for exposure during the second and third trimesters of pregnancy. Nevertheless, this updated and expanded analysis provides valuable real-world evidence for healthcare providers and their patients when considering Botox treatment during pregnancy.

I’ve treated more than a dozen pregnant women in my 30 years of using Botox for migraines. Some of them received Botox during more than one pregnancy. Some pregnant women sought Botox treatment specifically because they preferred to avoid taking any medications during pregnancy. Their decision was justified. When it comes to migraine drugs, including over-the-counter pain medications, they carry a higher likelihood of causing harm during pregnancy.

Controlled trial of meditation for migraines

By: Dr. Mauskop

17-07-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Psychology of headaches

Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to 45 minutes. I have found that sumatriptan has always been very effective and migraines have never disrupted my daily life, even when I experienced prolonged periods of daily headaches. Because of meditation I hardly ever need to take sumatriptan. My personal experience and that of many of my patients align with the viewpoint of a small group of headache specialists who believe that triptans do not cause medication overuse headaches.

Mindfulness has been gaining a lot of attention as a potential way to manage migraines, but there haven’t been many scientific studies to support this. A group of Italian researchers investigated whether a specific mindfulness-based treatment, consisting of six sessions of mindfulness practice and daily self-practice, would be effective when added to the usual treatment for patients with chronic migraine and medication overuse headaches.

They conducted a study with 177 patients. Half of the participants received the usual treatment alone, which included withdrawing from overused medications, education on proper medication use and lifestyle, and tailored prevention. The other half received the usual treatment plus the mindfulness-based intervention.

They looked at various factors to assess the effectiveness of the mindfulness-based treatment, including headache frequency, medication intake, quality of life, disability, depression and anxiety, sensitivity to touch, awareness of inner states, work-related difficulties, and disease-related costs.

After analyzing the data, they found that the patients who received the mindfulness-based treatment in addition to the usual treatment had better outcomes. They were more likely to achieve a significant reduction in headache frequency compared to their baseline (at least 50% reduction), and they also showed improvements in other areas such as quality of life, disability, headache impact, productivity loss due to headaches, medication intake, and healthcare costs.

They concluded that adding a six-session mindfulness-based treatment, along with daily self-practice, to the usual treatment is more effective than the usual treatment alone for patients with chronic migraine and medication overuse headaches.

Zavegepant, a new abortive migraine drug, is now available

By: Dr. Mauskop

05-07-2023

Chronic migraine, Cluster headaches, Headache medications, New treatments

Zavegepant (Zavzpret), the first CGRP nasal spray for the treatment of acute migraine attacks, was approved by the FDA in March and is now readily available in all US pharmacies..

Zavegepant belongs to the family of CGRP antagonists, which work by blocking excessive amounts of the neurotransmitter CGRP. Elevated levels of CGRP are known to contribute to the development of migraines. By inhibiting its action, zavegepant can effectively stop an ongoing migraine attack. While there are already two oral CGRP medications for the acute treatment of migraines (Nurtec and Ubrelvy), zavegepant is the first nasal spray option. Nasal sprays offer several advantages, including faster onset of action compared to tablets and the ability to bypass the stomach. These benefits are particularly valuable for individuals experiencing migraines accompanied by nausea and vomiting.

Clinical studies have demonstrated that zavegepant is superior to placebo in promptly eliminating all pain and the most bothersome symptom within two hours of administration. The most commonly reported bothersome symptoms associated with migraines are nausea, sensitivity to light (photophobia), and sensitivity to noise (phonophobia).

Side effects of zavegepant were generally mild and infrequent. Participants in clinical trials noted an unpleasant taste in 18% of cases, compared to 4% in the placebo group. Additional side effects included nausea (4% vs. 1%), nasal discomfort (3% vs. 1%), and vomiting (2% vs. 1%). Taste-related issues have been observed with other nasal sprays used for migraines, particularly among patients who experience nausea. However, this can be easily addressed by sucking on a hard candy while using the nasal spray.

Interestingly, even individuals who did not respond to other CGRP drugs may potentially benefit from zavegepant. While these drugs are similar in their mechanism of action, they are not identical, and patients often exhibit strong preferences for a particular medication within the same category. This preference phenomenon is common in other migraine drug categories such as triptans, NSAIDs, and oral CGRP drugs.

Effects of observational learning on placebo responses, or why sham remedies seem to work so well

By: Dr. Mauskop

19-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Pain, Pain Research, Psychology of headaches

Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied customers. Recent research suggests that these individuals might genuinely benefit from hearing others express positive experiences.

A study published in the journal Pain, titled “Learning pain from others: a systematic review and meta-analysis of studies on placebo hypoalgesia and nocebo hyperalgesia induced by observational learning” explores the impact of observational learning on placebo and nocebo responses.

Placebo hypoalgesia refers to when a fake treatment (placebo) reduces pain, while nocebo hyperalgesia is when the placebo actually increases pain. Learning processes, such as classical conditioning and operant conditioning, have been shown to play a role in these effects. Verbal suggestions and observational learning from others also influence placebo and nocebo responses. However, the magnitude of these effects can vary depending on the specific learning process used.

This meta-analysis of 17 studies showed that observational learning can effectively modulate pain and pain expectancies. However, the magnitude of these effects varies across studies. Observing a model in person resulted in larger effects compared to observing a videotaped model. The analysis also suggested that placebo effects can be induced through observational learning, but nocebo effects were not consistently observed. Empathy, specifically the empathic concern component, was found to be associated with the magnitude of observational learning effects.

The article concludes that observational learning can indeed influence pain experience and pain expectancies. Further studies possibly could lead to methods to enhance the treatment effects of proven therapies.

PTSD biomarkers

By: Dr. Mauskop

12-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, post-traumatic headache, Psychology of headaches

Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder (PTSD). These biomarkers could lead to more accurate methods of screening for PTSD, allowing for early intervention and prevention strategies. Additionally, they could help monitor treatment progress, identify different subtypes of PTSD, and enhance our understanding of the underlying mechanisms of the disorder.

The study was conducted by the PTSD Systems Biology Consortium, initiated by the Department of Defense, and involved approximately 45 researchers. The team analyzed blood samples from 1,000 active-duty Army personnel from the Fort Campbell Cohort (FCC), who were assessed before and after deployment to Afghanistan in 2014.

The researchers focused on four biomarkers: glycolytic ratio, arginine, serotonin, and glutamate. They categorized the participants into four groups based on their PTSD symptoms, resilience levels, and clinical assessments. The findings revealed that individuals with PTSD or subthreshold PTSD had higher glycolytic ratios and lower arginine levels compared to those with high resilience. Additionally, participants with PTSD exhibited lower serotonin and higher glutamate levels. These associations were independent of factors such as age, gender, body mass index, smoking, and caffeine consumption.

The study results require further validation. The researchers also aim to determine the optimal time to screen soldiers for PTSD, considering the psychological challenges that arise around 2 to 3 months post-deployment. Moreover, they recognize the need for gender-specific biomarkers to improve the clinical assessment of female soldiers, given the increasing number of women serving in combat roles.

Ultimately, these findings may apply to the civilian population experiencing PTSD.

Weather and headaches – AI confirms the connection

By: Dr. Mauskop

05-06-2023

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

The fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have investigated this relationship, but the findings have been inconsistent. The reported weather triggers range from humidity and strong winds to heat, cold, and barometric pressure changes.

In a recent study, Japanese researchers analyzed data collected from a smartphone app used by 4,375 individuals who experience headaches. By employing statistical and deep learning models, they aimed to predict the occurrence of headaches based on weather factors. The results of their study have been published in Headache, the journal of the American Headache Society.

The research confirms that headaches are more likely to occur under specific weather conditions. Low barometric pressure, barometric pressure changes, higher humidity, and rainfall were identified as factors associated with a higher occurrence of headaches.

This finding is not just a matter of curiosity; it has practical implications. There are several options besides moving to a place with a consistently mild climate, such as Southern California. For instance, low barometric pressure headaches can sometimes be prevented with the use of acetazolamide (Diamox), a medication commonly prescribed for mountain sickness. Setting up a Google Alert or using an app like WeatherX can provide warnings when barometric pressure drops. This allows individuals to take preemptive measures such as taking acetazolamide to prevent a headache the following day. Adopting general measures such as regular exercise, meditation, a healthy diet, and sufficient sleep can also help mitigate the effects of weather-related headaches.

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

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.

How long to rest after a concussion

By: Dr. Mauskop

03-04-2023

Botox, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine

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.