Headaches | Headache NewsBlog

Lasmiditan – another new drug for acute treatment of migraines.

By: Dr. Mauskop

02-02-2020

Lasmiditan (Rayvow) is the first (and probably the last) drug in the class of ditans. Just like the triptans (sumatriptan or Imitrex and other), it works through the serotonin system. However, it activates 5-HT_1F serotonin receptor, while triptans activate 5-HT_1Band 5-HT_1Dreceptors. This confers an advantage in that lasmiditan does not cause constriction of coronary arteries, which can happen with triptans . So patients with a history of a heart attack, angina or multiple risk factors for vascular disease who could not take triptans, now have another drug that is safe to use. The first acute migraine drug for this at-risk population, ubrogepant (Ubrelvy) became available a week ago. Lasmiditan will reach pharmacies in the next few days.

I will also prescribe lasmiditan to patients for whom triptans and ubrogepant are ineffective, partially effective, or cause side effects, which constitutes a sizable minority of my patients. .

Results of two large double-blind trials showed that 28-39% of patients achieved fast and complete elimination of migraine pain at two hours with lasmiditan as compared to 15% and 21% with placebo. 41-49% of patients achieved freedom from their most bothersome symptom of sensitivity to light, sensitivity to sound, or nausea at two hours with lasmiditan compared to 30% and 33% with placebo.

Lasmiditan is available in 50 mg and 100 mg tablets and the recommended dose is 50, 100, or 200 mg taken once a day.

Side effects were generally mild to moderate and the most frequent ones included dizziness, fatigue, tingling, drowsiness, nausea, and muscle weakness. Two driving studies showed that lasmiditan may cause significant driving impairment.

Lasmiditan is a non-narcotic medication, has low abuse potential and no evidence of physical dependence. It is a controlled substance but is in category 5, which indicates the lowest level of potential risk of abuse.

100 Migraine Drugs, A to Z: clopidogrel

By: Dr. Mauskop

10-11-2019

Headache medications, Headaches, Migraine

Clopidogrel (Plavix) was not on my original list of 100 migraine drugs, but I decided to add it after another mention of this drug at the last congress of the International Headache Society in Dublin (since I keep adding drugs and new ones are being released, the list will exceed 100).

Patients who suffer from migraines, especially those who have auras, have a higher incidence of a persistent opening between the left and the right side of their heart, called patent foramen ovale or PFO. PFO is found in 25% of the general population, is usually small and causes no symptoms. When it is large, it needs to be closed, which can be done through a vein in the groin. Unfortunately, studies that aimed to relieve migraines by closing the PFO did not show much benefit. However, blood thinners used after the procedure may have helped some patients.

I first mentioned clopidogrel in a blog post from 2007 when describing a British doctor’s experience with a few of his patients. In another blog post from 2015 I mentioned a study that showed that clopidogrel with aspirin was more effective in improving migraines than aspirin alone. A study comparing aspirin and clopidogrel showed them to be equally effective in improving migraines in patients with a PFO.

In the study presented in Dublin by two Chinese doctors PFO was found in 151 out of 266 (57%) of all migraine patients, of whom 65 the opening was large. PFO was found in 59 out of 84 (70%) of all migraine with aura and 36 patients had a large opening. 27 migraine patients who did not respond to standard medical therapy were given clopidogrel, 75 mg a day for 3 months. 22 patients completed this study. Headache frequency, severity and duration were significantly decreased by addition of this drug. Migraine-related disability was also reduced.

Aspirin, clopidogrel as well as prasugrel (Effient) and ticagrelor (Brilinta) are drugs that inhibit the function of platelets, small blood particles that are involved in blood clotting. Platelet dysfunction and other blood clotting problems have been suspected to play a role in triggering migraines, but the scientific evidence has been lacking.

A report by a cardiologist Dr. Robert Sommer and his colleagues at the Columbia University Medical Center suggests that platelets do contribute to migraines in some patients. They reviewed records of their 136 patients (86% female, mean age 38 years, with an average of 15 headache days a month). Migraines improved on clopidogrel in 80 (59%). The clopidogrel was equally beneficial in patients with episodic and chronic migraines, with and without aura. When the researchers tested platelets in non-responders, 19 of 45 (40%) did not have their platelets inhibited by clopidogrel. Sixteen of those patients were switched to prasugrel, which adequately inhibited platelets and 10 of 16 (62%) had improvement in their migraines. 56 of 90 responders had their PFO closed and the drug stopped after 3 months, which is typically done after a PFO closure. Ninety-four percent had ongoing migraine relief. All 8 of 8 responders who stopped their medication without PFO closure had worsening of their migraines.

This was not a blinded study, so it is premature to recommend PFO closure to migraine patients. However, it can be argued that patients whose migraines do not respond to several drugs, Botox, and monoclonal antibodies should have an echocardiogram to look for a PFO and if one is found, at least given a trial of an antiplatelet medication.

Cove, a telemedicine startup for migraine sufferers

By: Dr. Mauskop

30-10-2019

Alternative Therapies, Headache medications, Headaches, Migraine, New treatments

Cove, a telemedicine startup provides medical care to people suffering from migraines. There are 40 million migraine sufferers in the US, only half of whom seek medical care. The other half may have mild migraines, not have access to medical care, or are under the impression that nothing can be done about their headaches. Only half of the half that go to a doctor receive a correct diagnosis of migraine. The other half, or about 10 million, are misdiagnosed as sinus, tension, or stress headaches and never receive effective treatment.

Withcove.com is website where migraine sufferers can have a neurologist evaluate their symptoms and provide an accurate diagnosis and prescribe individualized treatment. It may seem that not seeing a doctor in person would be a major obstacle, but it is not. The patient completes a questionnaire and video is used for neurological examination. The doctor evaluates the information and prescribes migraine drugs, both for the acute treatment of an attack, as well for prevention. You don’t even need to go to a pharmacy – the medicine is shipped to you. Cove also offers a variety of supplements, such as magnesium and CoQ10, which can be more effective and safer for the prevention of migraines than drugs.

My colleague at the NY Headache Center, Dr. Sara Crystal and I are helping Cove with the design of proper evaluation tools, treatment algorithms, and other aspects of care.

In addition to providing direct care, Cove is conducting some research as well. In a survey of nearly 1,000 people, a combination of Cove customers and other migraine sufferers, Cove looked at the impact of migraine on careers, to identify coping strategies, and to provide tools that make it easier to get ahead. You can read the full report, “When Migraine Gets In the Way of Careers”.

Here is a sample of the survey findings:
47% of migraine sufferers who are employed feel that migraines have held them back from advancing in their career.
30% of employed migraine sufferers said that they’ve needed to quit a job, turn down responsibilities at their current job, and/or not accept a new job because of their migraines.
38% of employed migraine sufferers have missed 5+ days of work in the past 12 months due to their migraines.

These are shocking numbers, but in line with the data known to headache specialists. Migraine is ranked globally as the seventh most disabling disease among all diseases and is the leading cause of disability among all neurological disorders. Unfortunately, research into migraines does not receive appropriate attention from the National Institutes of Health and other funding sources.

Caffeine and migraine headaches

By: Dr. Mauskop

01-10-2019

Alternative Therapies, Headaches, Migraine

Medication overuse headache (MOH) is not proven to occur from the frequent intake of triptans (Imitrex, or sumatriptan and other) or NSAIDs (ibuprofen, naproxen, and other). However, there is good evidence that caffeine (and opioid analgesics) which can help relieve an occasional migraine, can definitely make them worse if taken frequently. Caffeine withdrawal is a proven trigger of headaches, including migraines.

While we know that caffeine withdrawal causes headaches, a study just published by Harvard researchers in The American Journal of Medicine addressed an unexamined question – does drinking coffee directly triggers a migraine?

This was a rigorous prospective study of 98 adults with episodic migraine who completed electronic diaries every morning and evening for a minimum of 6 weeks. 86 participants were women and 12 were men, with mean age of 35 and the average age of onset of headaches of 16. Every day, participants reported caffeinated beverage intake, other lifestyle factors, and the timing and characteristics of each migraine headache. The researchers compared incidence of migraines on days with caffeinated beverage intake to the incidence of migraines by the same individual on days with no intake. In total, the participants reported 825 migraines during 4467 days of observation.

There was a significant association between the number of caffeinated beverages and the odds of migraine headache occurrence on that day. This association was stronger in those who normally drank 1-2 cups of coffee daily – they were more likely to get a migraine on days when they drank 3 or more cups.

Even after accounting for daily alcohol intake, stress, sleep, activity, and menstrual bleeding, 1-2 servings of caffeinated beverages were not associated with headaches on that day, but 3 or more servings were associated with higher odds of headaches, even after accounting for daily alcohol intake, stress, sleep, activity, and menstrual bleeding. The researchers also considered the possibility of reverse causation, meaning that people might have drank coffee to treat a headache, but this was also not the case.

My advice to migraine sufferers is to drink not more than 1 cup of coffee a day, and I don’t mean a Venti (24 oz) cup from Starbucks, but an 8-ounce cup of regular strength coffee. During a migraine attack having an extra cup along with your usual medication may provide additional relief.

A case against migraine headache diary

By: Dr. Mauskop

02-06-2019

Headaches, Migraine, Psychology of headaches

Keeping a diary of symptoms has long been considered a part of a successful approach to managing migraine headaches. The diary can help identify potential migraine triggers and contributing factors and a description of specific symptoms can help tailor individual therapy.

An article just published in Wired magazine Why tracking your symptoms can make you feel worse, challenges this assumption.

In my early years of practicing headache medicine (yes, “headache medicine” is a formal subspecialty of neurology) I would urge my patients to keep a diary, but they would have all kinds of excuses why they did not. I even developed a phone app, which was easy to use and was loaded with features and educational materials. Everyone always has their phone nearby, so unlike with a paper diary, they would not forget it at home or need a pen, or have it eaten by their dog. Nothing doing. Maybe, one in 10 of my patients attempted to keep a diary. Then, since I also have migraines, I tried using the app and I also failed miserably. My excuses? Forgot, too busy, I know all about my migraines, so what’s the point?

The article in Wired quotes research that suggests that keeping a diary of symptoms can make you feel worse. This seems to be true across different conditions – insomnia, back pain, and also migraine. One possible explanation is that constantly paying attention to sensations in the body we can magnify them. These sensations may send an alarm to the brain, oh-oh, a migraine is starting. This in turn leads to anxiety, activation of the fight-or-flight response and soon a real migraine begins. Actually, when a patient comes in with pages and pages of notes that describe each migraine attack with possible triggers, detailed description of each attack, medications taken and their side effects, I know that this patients will be harder to help.

In case of migraine headaches we do have a very good substitute for a daily diary. It is a Migraine Disability Assessment Scale, or MIDAS, which assesses migraine-related disability over the previous three months. This is a simple 5-question scale that was validated by comparing a daily diary with patient recollection. Surprisingly, the correlation was very strong and the scale gives reliable information. We ask patients to complete MIDAS on every visit. At a glance, it tells us how disabling the migraines are and how aggressive we need to be in starting preventive therapies, such as Botox, drugs, and the new monoclonal antibodies. This score is also helpful for patients who may not remember how disabling the headaches were before they started a particular treatment. It also shows the insurance companies how well an expensive treatment such as Botox works, so that they approve continued therapy.

As far as identifying triggers, most are obvious and patients do not need a diary to tell them that alcohol, lack of sleep, skipping meals, stress, etc. are causing their attacks. Yes, for some patients a diary can identify gluten sensitivity, menstrual cycle, or another trigger that was not obvious, so I would not discourage anyone from keeping a diary. But do it for a few months and if no useful information can be gleaned from it, stop.

Exercise speeds recovery from a concussion

By: Dr. Mauskop

20-05-2019

Brain disorders, Headaches, Migraine, post-traumatic headache

Researchers at SUNY Buffalo and University of Manitoba studied the effect of exercise on recovery from a sports-related concussion in 103 adolescents. The results were published in JAMA Pediatrics.

The participants were enrolled within 10 days of a concussion. Half of the kids were given a stretching program and the other half, aerobic exercise on a treadmill. The intensity of aerobic exercise was subthreshold, or just below the level where it caused any post-concussion symptoms and was determined individually for each participant. Both stretching and aerobic exercise were performed for 20 minutes every day for a month. Those who did aerobic exercise recovered in 13 days, while those who did stretching exercise, in 17 days. There were no complications in either group.

This was the first randomized controlled trial of exercise, although prior observational studies also showed that early return to physical activity is beneficial for recovery from a concussion.

Cognitive rest is also not necessary after a concussion, but the activities should be also subthreshold and not too strenuous, which can worsen symptoms and delay recovery.

Other useful strategies include intravenous magnesium, cognitive-behavioral therapy, and Botox injections.

I decided to stop Ajovy too

By: Dr. Mauskop

14-01-2019

Headaches, Migraine, neurostimulation, New treatments

I’ve given myself an injection of Ajovy in November and December with some improvement and without constipation which I had from Aimovig. However, Ajovy did not prevent all of my migraines, especially those caused by red wine, (I received some nice red wine over the holidays) and I still had to take sumatriptan (Imitrex).

This is not at all surprising; I always tell my patients that even the most effective treatment is not 100% effective – with enough triggers migraine will still occur. It is possible that with continued use of Ajovy my migraines would progressively get better, but my headaches are quickly and completely relieved by sumatriptan. Sumatriptan has a 25 year safety record and for over 10 years has been available without a prescription in most European countries (you may want to read my post on the daily use of triptans – it is by far the most popular with over 250 comments).

My next self-experiment is to try to prevent migraines with transcranial direct current stimulation (tDCS). We are about to begin a double-blind sham-controlled study and I will describe it in in an upcoming post.

Red wine and headaches in the WSJ

By: Dr. Mauskop

03-01-2019

Headaches, Migraine, Science of Migraine

Red wine is a common trigger for migraines, although we still don’t know the cause or why red wine is worse than white. I was just interviewed for this article in the WSJ along with my friend Mo Levin of the UCSF headache clinic.

100 Migraine Drugs, A to Z: estrogen

By: Dr. Mauskop

01-01-2019

Headache medications, Headaches, Migraine

Estrogen can be an effective agent for the treatment of menstrual migraines. Many women report that their migraines tend to occur before or during their period and sometimes with ovulation. For some women menstruation is the only time they get a migraine. The attacks appear to be triggered by a drop in estrogen levels. A steady estrogen level is why 2 out of 3 women stop having migraines during pregnancy and menopause.

Most women with menstrual migraines respond well to sumatriptan (Imitrex) and other triptans. If triptan alone does not provide sufficient relief, adding a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen (Aleve) or ibuprofen (Advil) to a triptan can be very effective.

When this strategy does not work and the periods are very regular, mini prophylaxis is another approach. This means taking a preventive drug for a week, starting a day or two before the expected migraine attack. Mini prophylaxis can be tried with the usual preventive drugs such as beta blockers and also with a triptan, such as naratriptan (Amerge), which is somewhat longer acting than other triptans. Sumatriptan and other short-acting triptans also prevents migraine attacks and not only menstrual ones. Some of my patients who wake up every morning with a migraine take a triptan in the evening and avert the attack. This is somewhat surprising because the half-life of sumatriptan is only 2.5 hours.

If all these treatments fail, continuous intake (skipping the week of placebo pills) of an estrogen-containing contraceptive such as Lo Loestrin maintains a steady level of estrogen and can prevent occurrence of periods as well menstrual migraines and other period-related problems such as PMS, painful cramping, and excessive bleeding. It is very safe to suppress periods for at least a year. Several contraceptives are designed to be taken continuously for 3 months at a time. Unfortunately, in some women this strategy fails and they have breakthrough periods along with breakthrough migraines.

Exogenous estrogen (in contraceptives and for hormone replacement in menopause) should be avoided in women who have migraines with aura because of a slight increase in the risk of strokes. While this risk is very small, if a woman smokes or has other risk factors for strokes, taking estrogen-containing pills is definitely contraindicated. For contraception, such patients can take progesterone-only minipill containing norethindrone (Camila, Ortho Micronor).

100 Migraine Drugs, A to Z: caffeine

By: Dr. Mauskop

16-07-2018

Headache medications, Headaches, Migraine

Caffeine can be considered a drug since it is available in a pure form in tablets and injections. It is also included in medications, such as Excedrin, Fioricet, and Fiorinal. It is considered to be an analgesic adjuvant, meaning that it enhances the effect of other pain medicines, such as aspirin and acetaminophen, but it has been shown to relieve tension-type headaches by itself as well. However, there are no studies showing that caffeine alone taken by mouth relieves migraine headaches. It does enhance the effect of acetaminophen and aspirin in Excedrin and this combination has been proven to relieve mild and moderately severe migraines.

In a pilot open-label study of intravenous infusion of 60 mg of caffeine citrate for an acute migraine showed significant relief within an hour of infusion. The study was published in 2015 in the Journal of Caffeine Research (who knew such a journal existed).

Besides caffeine, Fioricet, Fiorinal, and Esgic contain either acetaminophen or aspirin and butalbital, which is a barbiturate. Barbiturates are used for epilepsy, anesthesia, and in the past had been used for insomnia. However, they are addictive and they are no longer widely used. However, butalbital’s use in headache products stubbornly persists despite its addictive nature and lack of proof that it relieves migraines. These products can cause not only addiction, but also medication overuse headaches, most likely due to their caffeine content.

Caffeine can cause headaches directly, but much more often the headache is due to caffeine withdrawal when it is consumed for long periods of time in large amounts. Caffeine withdrawal headaches have been proven to occur in a double-blind withdrawal study. Most people who drink a lot of coffee know this from their personal experience – skipping the morning cup or not drinking coffee on days of fasting leads to a bad headache, which is usually a migraine. Sometimes caffeine withdrawal headaches are not obvious. Someone who drinks two cups of coffee and two caffeinated sodas daily may not realize that their daily headaches are caffeine-related. They just take Excedrin, which provides temporary relief, but adds fuel to the fire.

Children who drink too much caffeinated sodas can also develop daily headaches, which are relieved by gradually reducing and then stopping caffeine intake.

Some people develop tolerance to caffeine, which means that the stimulating effect lasts shorter and shorter periods of time and such individuals have to drink more and more coffee to maintain its effect. This ends up in needing 10 cups of coffee or 10-20 tablets of Excedrin daily. My record-holder was a patient who was taking about 25-30 tablets of Fioricet daily and had to be hospitalized for detoxification.

The bottom line with caffeine is that it helps when used occasionally and worsens headaches when taken more than a few times a week.

A new book on headaches that is worth reading

By: Dr. Mauskop

25-06-2018

Alternative Therapies, Headaches

Jan Mundo, who is a Somatic and Headache Coach, and Bodyworker just wrote a book, The Headache Healer’s Handbook, which was published by the New World Library. I’ve known Jan and her wonderful work with headache patients for many years and was happy to write a foreword to her very readable and useful book. Here is the foreword:

Headaches afflict close to half of the US population with 40 million suffering from migraines, which can be very disabling. Many books have been written for the general public, including two of my own, but Jan Mundo’s Headache Healer’s Handbook brings a unique perspective to this problem.
When I treat patients in the office, they are usually reassured by the fact that I am also a migraine sufferer and so it is with Jan’s book – she knows first-hand what it feels like to have a migraine. More importantly, she has discovered ways to relieve her own attacks and those of other countless migraineurs.
Like Jan, I am a big proponent of non-drug treatments and this is what she details in her book. I also like her hands-on approach, both literally and figuratively. Psychologists have proven that active treatments, where people are doing things to improve their condition, are much more effective than passive treatments, such as massage, chiropractic, and acupuncture, where things are done to them. This leads to the transfer of external locus of control to internal locus of control or in other words, a shift from a passive and helpless victim of external circumstances, to being an active participant in the events with a significant degree of control.
Jan begins with the basics – identifying your type of headache and finding possible triggers that make headaches worse. She does recommend at least one visit to the doctor to confirm the diagnosis. This is important not because a brain tumor or an aneurysm is likely to be found since those are very rare, but a routine blood test could detect magnesium or thyroid deficiency, anemia, or another medical problem that could be contributing to headaches.
Once your diagnosis is confirmed, with Jan’s help you can take an inventory of your diet, sleeping habits, your physical environment, and posture, and try to find triggers, which can be corrected. Then Jan recommends breathing exercises which to me had echoes of the Feldenkrais method – becoming aware of how you breathe and improve not only your breathing, but also the movements of your chest, spine, and the rest of your body.
In the chapter, Being still: Mindfulness and Headaches Jan describes another powerful tool in combating not only headaches, but many other physical and mental ailments. Yes, everyone is talking about the proven benefits of meditation, but it is surprising how few people actually practice it.
Posture, Ergonomics, and Sleep is followed by a chapter on physical exercise, which is proven to not only be good for you, but to specifically reduce the frequency and the severity of headaches.
A large portion of the book is devoted to the Mundo method, Jan’s unique hands-on therapy, which she has developed to treat her own headaches and which has helped many sufferers she has worked with. The healing power of touch is scientifically proven to dramatically improve outcomes in premature babies and without a doubt, can be also harnessed to relieve a variety of headache conditions. Just follow Jan’s advice and watch your headaches go away.

Orgasmic headaches

By: Dr. Mauskop

16-06-2018

Headaches

Headaches that occur during sexual activity tend to elicit fear and embarrassment. Embarrassment is why most people are not aware that this is a fairly common condition – you would not share your experience at a party. The fear is justified – a rupture of an aneurysm in the brain is a deadly condition with 40% of patients dying before they reach the hospital. Fortunately, even though the pain is excruciating, in the vast majority of cases, the pain of an orgasmic headache is brief and the cause is benign.

Sex-induced headaches are three times more common in men. In 80% of people the pain is sudden, occurs at the time of the orgasm, and lasts 30 minutes to a couple of hours. In the remaining 20%, the pain builds up gradually during sex before the orgasm and often does not reach a crescendo if the sexual activity is aborted.

These headaches tend to be common during sex with the usual partner or less often with masturbation. Anecdotally, aneurysm rupture is more likely to occur during an extramarital affair – due to the divine punishment, or more likely, greater excitement and higher elevation of blood pressure than what would occur with the spouse.

This post was prompted by a recent patient who developed an orgasmic headache during masturbation for the first time at the age of 60. The headache had occurred the day before and had completely resolved by the following day. However, with the first orgasmic headache we usually tend to get an urgent CT scan (the CT scan is better at detecting fresh blood than the MRI) because a small leak from an aneurysm could be the underlying cause of a brief headache. My index of suspicion was low because his neurological examination was normal and he’s had some headaches in the past. But the age of onset was a bit late and aneurysms tend to enlarge with age. We both were reassured by a normal CT scan.

Orgasmic headaches can be recurrent and the pain is so severe that some patients are afraid to have sex. Sometimes the solution is simple – take 400 mg of ibuprofen or naproxen an hour before having sex. If this strategy works, after a few times of taking medicine the headaches may not return. If an over-the-counter medication does not work, a prescription migraine drug, such as sumatriptan (Imitrex) can help. Regular exercise can be helpful in preventing these headaches for people who are out of shape.

In older individuals, a common cause of sex-induced headaches is the cervical spine and neck muscles. These headache are usually not as intense. Another patient of mine, a woman in her late 60s stopped having headaches after I suggested changing her position during sex. Strengthening neck muscles, general conditioning, and taking ibuprofen can also help.