Headaches | Headache NewsBlog

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.

Hemicrania continua is a very disabling headache and it is often misdiagnosed

By: Dr. Mauskop

08-11-2024

Botox, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, Trigeminal and other neuralgias

Hemicrania continua, a rare but severe headache condition, literally means “continuous one-sided headache” in Latin. This chronic condition manifests as an intense, unrelenting pain concentrated on one side of the head, typically around the eye area. It is more common in women.

The condition often presents with distinctive features beyond the constant one-sided pain. Patients frequently experience:

Redness and tearing of the affected eye
Nasal congestion and runny nose
Forehead and facial sweating
Eyelid swelling
Pupil size changes
Restlessness or agitation

The diagnosis of hemicrania continua can be particularly challenging, especially when the only symptom is a one-sided headache. Doctors often misdiagnose it as migraine or tension headache because of its rarity and overlap with other headache types.

What makes hemicrania continua unique is its remarkable response to indomethacin, a powerful non-steroidal anti-inflammatory drug (NSAID). The response to this medication is so dramatic that hemicrania continua is one of two headache types that are called indomethacin-sensitive headaches.

While indomethacin is highly effective, some patients may experience stomach-related side effects. For those who cannot tolerate indomethacin, several alternatives exist:

Other NSAIDs (though generally less effective)
Boswellia, an herbal supplement with anti-inflammatory properties
Botox injections

Chronic paroxysmal hemicrania shares features with hemicrania continua but differs in its pattern. It causes more intense pain attacks lasting minutes but occurring many times throughout the day. Like hemicrania continua, it also responds extremely well to indomethacin.

Having migraines does not lead to brain damage with age

By: Dr. Mauskop

17-10-2024

Brain disorders, Chronic migraine, Headaches, Migraine, Science of Migraine

If you’re one of the millions of people who suffer from migraines, you might be worried about the long-term effects on your brain. Recent studies have suggested that people with migraines might be at higher risk for structural brain changes, such as damage to small vessels in the brain and shrinkage of the brain or brain atrophy.

A recent study published in Cephalalgia by Dutch researchers examined the connection between migraines and brain health in over 4,900 middle-aged and elderly people. The researchers used magnetic resonance imaging (MRI) to study the brains of the participants and assess any structural changes.

The study found that people with migraines were not any more likely to have structural brain changes than those without migraines. There were no significant differences between the two groups in terms of:

Total brain volume
Grey matter volume
White matter volume
White matter hyperintensity volume (a marker for small vessel disease)
Presence of lacunes (tiny holes in the brain)
Presence of cerebral microbleeds (small bleeds in the brain)

This study suggests that having migraines may not increase your risk of developing structural brain changes as you age. This is reassuring news for people who suffer from migraines and are concerned about the long-term effects on their brain health.

New Daily Persistent Headache may respond to TMS

By: Dr. Mauskop

06-10-2024

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

Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial magnetic stimulation (rTMS).

NDPH is a type of headache that begins suddenly and persists daily without specific features, distinct MRI presentation, or blood test abnormalities. It can present similarly to chronic migraines or chronic tension-type headaches. While published reports suggest NDPH is difficult to treat, this is often not the case. However, patients who do not respond to initial standard treatments may become discouraged.

The Indian researchers conducted a pilot study with 50 NDPH patients who received 10 Hz rTMS sessions on the left prefrontal cortex of the brain for three consecutive days. They found that after 4 weeks:

70% of patients had at least a 50% reduction in headache severity
Patients gained an average of 11 headache-free days per month
76% had significant improvements in headache-related disability
Depression and anxiety scores also improved significantly

The treatment was well-tolerated, with only minor side effects in a few patients. The benefits seemed especially pronounced in patients who had NDPH that resembled chronic migraine.

I never give the diagnosis of NDPH, but diagnose it as a condition it most resembles and treat the person with a wide variety of available options. Many respond. For those who do not, we offer rTMS, a procedure that uses magnetic fields to stimulate nerve cells in the brain. An electromagnetic coil device is placed against the scalp near the forehead. The coil painlessly delivers a magnetic pulse that stimulates the brain with the goal of reducing headache symptoms. The FDA has approved it for the treatment of depression, anxiety, and OCD. We use it for various neurological conditions, including headaches that do not respond to standard therapies. To treat migraines and other types of pain, we usually stimulate not only the left prefrontal cortex, as was done in this study, but also two additional sites that have been reported to help with pain and migraines. These additional sites are either the motor cortex or the occipital cortex, on both sides.

Sometimes, we obtain a functional magnetic resonance imaging (fMRI) scan to better target rTMS. fMRI is a research procedure that is not available commercially (and is not covered by insurance).

A novel migraine drug shows promise

By: Dr. Mauskop

08-09-2024

Alternative Therapies, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments

Two sets of “designer drugs” have been developed based on our understanding of the neurobiology of migraines. The first, sumatriptan (Imitrex), introduced in 1992, was the pioneer in a class of seven triptan drugs, all targeting serotonin mechanisms. Erenumab (Aimovig), which targets the CGRP (calcitonin gene-related peptide) mechanism, was approved by the FDA in 2018. This class now includes four injectable, three oral, and one nasal drug. Additionally, many older drugs, although not specifically developed for migraine treatment, have proven effective for some patients. Despite these numerous options, a significant minority of patients do not respond to any of these treatments.

This is why the development of drugs targeting different parts of the migraine cascade is so promising. Danish neurologists, led by Dr. Mesoud Ashina, have published results from a phase 2 double-blind study of a new drug that blocks PACAP (pituitary adenylate cyclase-activating peptide).

In this study, patients were divided into two groups, receiving an infusion of a placebo or two different doses of the active drug, currently known as Lu AG09222, developed by the Danish company Lundbeck. In the final analysis, the reduction in migraine days was compared between 94 patients who received a placebo and 97 patients who received the higher dose of the active drug. The higher dose significantly reduced the number of migraine days in the month following the infusion (6.2 vs. 4.2 days reduction). The side effects reported were mild and infrequent.

Phase 2 studies are relatively small and short in duration. The FDA typically requires two large parallel studies involving a total of 1,000 or more patients before considering approval. Therefore, even if Lu AG09222 is found to be safe and effective, it may not receive approval for another 2-3 years.

Another MRI study attempts to diagnose migraine

By: Dr. Mauskop

22-07-2024

Brain disorders, Chronic migraine, Headaches, Migraine, neurostimulation, Science of Migraine

The diagnosis of migraine still relies on the patient’s description of symptoms. We do not have an objective test to confirm the diagnosis.

Several studies using functional MRI (fMRI) attempted to identify people with migraines. A new study published by Korean doctors in The Journal of Headache and Pain used a different imaging technique to achieve this goal.

The researchers used diffusion MRI, a technique that focuses on the movement of water molecules within the brain’s tissues (fMRI measures blood flow to different areas of the brain). It is particularly useful for mapping the brain’s white matter tracts, which are the pathways that connect different brain regions.

47 patients with migraine were compared to 41 healthy controls

Significant differences were found in brain regions such as the orbitofrontal cortex, temporal pole, and sensory/motor areas.

Changes in connections between deeper brain structures (like the amygdala, accumbens, and caudate nuclei) were also noted.

Using machine learning, the researchers could distinguish between migraine patients and healthy individuals based on these brain connectivity features.

Hopefully, larger studies and easier access to advanced imaging techniques may eventually lead to an objective test of migraines. More importantly, identifying specific connectivity patterns may lead to more individualized treatments. These could be treatments with pharmaceuticals or neurostimulation techniques such as transcranial magnetic stimulation (TMS), which we use in our clinic.

Some people’s genes prevent them from having migraines

By: Dr. Mauskop

09-07-2024

Brain disorders, Headaches, Migraine, Science of Migraine

Given enough triggers, almost anyone can develop a migraine. There is a very good chance that even someone who has never had a migraine to become sleep-deprived, dehydrated, drunk, and stressed will develop a migraine headache. However, I have encountered people who told me that they have never had a headache and cannot even imagine what a headache would feel like.

Scientists have discovered why some people never get headaches. Researchers studied the DNA of nearly 64,000 people in Denmark, including about 3,000 who reported never having had a headache. The researchers found a specific area in a gene called ADARB2 that seems to protect against headaches. People with a certain variation in this gene were 20% more likely to be completely headache-free. ADARB2 is mostly active in the brain, particularly nerve cells that reduce brain activity. However, scientists don’t fully understand how this gene works yet.

While this discovery is exciting, more research is needed to confirm how ADARB2 helps prevent headaches. This study is the first to examine the genetics of being headache-free rather than focusing on what causes headaches. It opens up a new approach to understanding and potentially treating headache disorders.

Creatine is good for your brain, not just muscles

By: Dr. Mauskop

23-06-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine

Athletes have been using creatine supplementation for over 30 years. It seems to improve the energy supply to muscle tissues and increase fat-free mass. Creatine also supplies energy to nerve cells in the brain. Taking a creatine supplement increases the levels of creatine in muscles and the brain.

A review of six studies suggested that creatine improves short-term memory, intelligence, and reasoning. Creatine did not improve any cognitive abilities in young people. Vegetarians benefited more than non-vegetarians in memory tasks.

A study by Taiwanese researchers published in Cephalalgia showed reduced creatine levels in the thalamus (the pain-processing area in the brain) in patients with medication-overuse headaches.

Greek doctors published a report, Prevention of traumatic headache, dizziness and fatigue with creatine administration. A pilot study. They studied 39 patients who sustained a severe traumatic brain injury. There were 19 patients in the control group and 20 in the active group. The active group was given 0.4 g/kg of creatine. Treatment was administered within 4 hours of injury and was continued for 6 months. This treatment improved the duration of post-traumatic loss of memory, the duration of being on a respirator, and the duration of stay in an intensive care unit. They also showed improvement in headaches, dizziness, and fatigue. No side effects were reported.

Some studies suggest that creatine can improve bone health. Here is what WebMD says about creatine:

“While most people get low amounts of creatine by eating seafood and red meat, larger amounts are found in synthetic creatine supplements. Your pancreas and kidneys can also make around 1 gram of creatine each day. Creatine is one of your body’s natural energy sources.

Nearly 95% of the creatine in your body is stored in your skeletal muscles and is used during physical activity. As a dietary supplement, creatine is commonly used to improve exercise performance in athletes and older adults.”

There is not enough evidence to routinely recommend creatine for the treatment of migraine headaches. I do, however, recommend to my older patients taking 5 to 7 grams of creatine an hour before or after exercise. I am 67 and do take it when I exercise.

Abnormal functional connectivity in patients with post-traumatic headaches

By: Dr. Mauskop

03-06-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation

A new study from Mayo Clinic researchers, published in The Journal of Headache and Pain, has examined the brain changes associated with acute post-traumatic headaches (PTH). These headaches can occur after a head injury or trauma and can be debilitating. The study involved 60 participants with acute PTH and 60 age-matched healthy controls. Using functional MRI (fMRI), the researchers found two key differences in the brains of PTH patients compared to healthy individuals.

Increased Iron Accumulation in Specific Brain Regions

First, the PTH patients showed higher levels of iron deposition in two brain areas: the left posterior cingulate and the bilateral cuneus regions. These areas are involved in various functions, including pain processing, attention, and visual processing. The accumulation of iron in these regions may disrupt normal brain function and contribute to the development and persistence of post-traumatic headaches.

Abnormal Functional Connectivity Patterns

Secondly, the researchers observed stronger functional connectivity between the bilateral cuneus (the visual processing area) and the right cerebellum (a region involved in motor control and coordination, and other functions) in PTH patients compared to healthy controls. Functional connectivity refers to the communication and synchronization between different brain regions. The abnormal connectivity patterns seen in PTH patients suggest disruptions in the brain networks responsible for processing sensory information, including pain signals.

Implications for Targeted Therapy

While these findings may have lacked utility in the past, they now have important implications for the treatment of post-traumatic headaches. We have been treating patients with repetitive transcranial magnetic stimulation (rTMS), a non-invasive technique that can modulate brain activity in specific regions. By stimulating the areas with abnormal connectivity, rTMS may help restore normal brain function and alleviate headache symptoms and other neurological and psychiatric symptoms. When possible, we perform fMRI scans on individual patients to identify the specific brain regions involved in their headache disorder. However, fMRI is still only a research tool, and when individual fMRI data is not available, studies like this one provide information on common brain changes associated with post-traumatic headaches that can be targeted with TMS.

Abnormal functional connectivity in brains of patients with vestibular migraine

By: Dr. Mauskop

27-05-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, post-traumatic headache, Science of Migraine

Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain regions like the insula, thalamus, somatosensory cortex, as well as visual cortex. Some patients also have changes in the default mode and salience networks involved in attention and stimulus processing.

A study published this month by Chinese researchers in the Journal of Headache and Pain reports on connectivity changes in people with vestibular migraines.

They found abnormal resting-state functional connectivity in brain regions involved in multi-sensory and autonomic processing as well as impaired ocular motor control, pain modulation, and emotional regulation.

Until now, there has been little practical application for fMRI findings. However, with the help of Omniscient Neurotechnology, we have just started using fMRI data to better target our treatment with transcranial magnetic stimulation (TMS). TMS applied to motor and visual cortices has been reported to help relieve migraine headaches. We have also found it effective in a significant proportion of patients who did not respond to various other treatments. We have not yet accumulated enough data to determine if fMRI-guided TMS treatment is superior to TMS administered over a predetermined set of targets.

The main obstacle to wider use of TMS in clinical practice is the cost. TMS is approved by the FDA and is covered by insurance for the treatment of anxiety and depression, but not migraines or pain. fMRI is an expensive research tool and is also not covered by insurance. Hopefully, the NIH and other research foundations will provide the funds needed to study this promising treatment.