Headaches | Headache NewsBlog

Terrorism and headaches

By: Dr. Mauskop

22-01-2018

Chronic migraine, Headaches, Headaches in children, Psychology of headaches

Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer from tension-type headaches, according to a study just published in Neurology. The researchers evaluated 213 of 358 adolescent survivors of the 2011 massacre at a summer camp in Norway that resulted in deaths of 69 people. These survivors were compared to over 1,700 adolescents of the same sex and age who were not exposed to terrorism. The survivors were not only much more likely to suffer from migraines and tension-type headaches, but were also much more likely to have daily or weekly attacks.

Many previous studies have shown that physical, sexual, and emotional abuse in childhood and posttraumatic stress disorder (PTSD) are strong risk factors for the development of migraines and chronic pain in many previous studies. Having a family history of migraines further increases this risk, as does head trauma, and having other painful or psychological disorders. Headache is also one of the first symptoms reported by adolescent girls and women who were raped.

The authors of the current report cite evidence that “Childhood maltreatment during periods of high developmental plasticity seems to trigger modifications in genetic expression, neural circuits, immunologic functioning, and related physiologic stress responses. It is plausible that exposure to interpersonal violence could induce functional, neuroendoimmunologic alterations, affecting central sensitization and pain modulation and perception. Central sensitization, expressed as hypersensitivity to visual, auditory, olfactory, and somatosensory stimuli, has long been thought to play a key role in the pathogenesis and chronification of migraine.”

It is likely that early intervention after a traumatic event will result not only in better psychological outcomes, but also in fewer and milder headaches. One such intervention is cognitive-behavioral therapy. However, there are several different types of such therapy and a study just published in JAMA Psychiatry compared 12 sessions of cognitive processing therapy (CPT) with 5 sessions of written exposure therapy (WET) for the treatment of posttraumatic stress disorder. WET was shown to be at least as good as CPT with fewer treatment sessions required. This makes WET more efficient and affordable and patients are more likely to complete it.

My previous blog posts mention online self-administered courses of cognitive-behavioral therapy for PTSD, anxiety, depression, OCD, insomnia, chronic pain, and other conditions. The site is ThisWayUp.org.au and the researchers behind it have published scientific data indicating that their approach is very effective. It is also very inexpensive – some courses are free and some cost about $50.

Gut bacteria can cause big holes in the brain

By: Dr. Mauskop

16-10-2017

Alternative Therapies, Chronic migraine, Headaches, Migraine

Biome, or the collection of bacteria living in our bodies has been receiving belated and well deserved attention. The discovery that bacteria living in our intestines can cause cerebral cavernous malformations or CCM (see photo) is quite dramatic. But there is no need to panic since this is a rare condition. However, it does indicate that gut bacteria can have a major impact on our brains.

It was a serendipitous discovery by Dr. Mark Kahn, professor of medicine at U. Penn, who studied mice with CCM. He noticed that mutant mice prone to CCM stopped developing holes in their brains after being moved to a new building. The exception was mice who developed an abscess after having their intestines accidentally stuck with a needle during a routine injection. Dr. Kahn and his colleagues identified a specific bacterium, Bacteroides fragilis, which was responsible for the development of brain caverns.

This finding may explain why there is such a wide variety of presentations in people who have the familial form of CCM. Some have no lesions even when they are 70, while others have hundreds of them at age 10. Just like mutant mice, humans seem to need an additional trigger to start developing CCMs. This finding provides a clear path to developing an effective treatment and perhaps, just a simple probiotic could keep such patients healthy.

In fact, a probiotic containing 14 different strains of bacteria (Bio-Kult, made in UK) is effective in preventing migraine headaches, according to a study presented by Iranian doctors at the recent International Headache Congress in Vancouver. Fifty patients were recruited into this study with half taking the probiotic and the other half, placebo. After 8 weeks, patients on the probiotic had fewer days with migraine and the pain was milder when compared to those taking placebo.

The big question is, what other brain disorders are triggered or worsened by our gut bacteria. We have more bacterial cells living in our bodies (about 39 trillion) than we have of our own cells (about 30 trillion) and scientists are finally beginning to study them. I Contain Multitudes: The Microbes Within Us and a Grander View of Life, is a fascinating and well-written book by Ed Yong on this subject.

Two different types of exercise prevent migraines

By: Dr. Mauskop

11-10-2017

Alternative Therapies, Headaches

A new study by Swiss researchers compared the effect of high intensity interval training (HIT) with moderate intensity continuous training (MCT) and with no exercise at all on the number of migraine headache days.

The results were presented at the International Headache Congress held in Vancouver last month. Not surprisingly, both types of exercise reduced the number of migraine headache days, but HIT was more effective. In the study, patients in HIT group did 4 periods of intensive exercise (90% of maximum intensity) each lasting 4 minutes, separated by periods of 3 minutes at 70% of maximum. The moderate intensity exercise was done at 70% for 45 minutes. Both groups performed these exercise twice a week.

A previous study has established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate however has many potential side effects, including some serious ones. A Swedish study of 46,648 people established a strong inverse correlation between physical activity and the frequency of headaches.

HIT has been gaining in popularity since the 1980’s because it provides all of the benefits of exercise in a shorter period of time.

Telemedicine is effective to treat headache patients

By: Dr. Mauskop

19-07-2017

Headaches

We often get requests for a telephone consultation from patients who live too far to come in for a visit. Unfortunately, insurance companies do not cover telephone or video-link consultations. An additional obstacle in the US is that doctors cannot treat patients outside the state where they are licensed because each state licenses their own doctors. If patients can afford to pay, we do offer follow-up telephone consultations to patients who live out of state or abroad and who were first seen in our office.

A group of Norwegian researchers examined how safe and effective it is to treat patients without seeing them in person by using a video link. The results of their study was published in a recent issue of the journal Neurology. They compared 3 and 12 month outcomes after a single consultation in 200 patients using telemedicine with 202 patients seen in the office. All patients were referred by their primary care doctor. They included only patients with non-acute headaches, that is those whose headaches started gradually more than 4 weeks prior to the visit and showed no clinical or MRI abnormalities. Doctors ordered about the same number of MRI scans in both group (58 and 62). Over the subsequent year a serious underlying cause was found in one patient in each group. Treatment outcomes after 1 year were the same in both group, although in both groups the improvement in headache severity and its impact on the daily life was modest. There was a high level of satisfaction with the consultation in both groups.

The main shortcoming of the study is that every patient completed a variety of questionnaires and had a much more detailed evaluation than you’d expect in a non-study setting. The study suggests that a single consultation may not be sufficient to provide an optimal outcome. Also, while over 40% of patients had chronic migraines, obviously none could be treated with Botox, which is the only FDA-approved treatment for chronic migraines.

In conclusion, consultation via telemedicine is a viable option for patients in areas without headache specialists.

A new book for migraine sufferers and their families

By: Dr. Mauskop

14-06-2017

Alternative Therapies, Botox, Headache medications, Headaches

Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the latest book on migraines, Understanding Your Migraines, the answer is a definite yes.

The book is written by two colleagues who for many years co-directed the Dartmouth Headache Clinic. Dr. Morris Levin is now the Director of the Headache Center and a Professor of Neurology at UCSF, while Dr. Thomas Ward is Professor of Neurology Emeritus at the Geiser School of Medicine at Dartmouth and the editor of the journal Headache. They are clearly highly qualified to write such a book, but qualifications are not enough – you need to be a good writer as well. And in fact, excellent writing style and case-based discussion are two of the major strengths of the book.

The book consists of 17 chapters, which cover diagnosis and our understanding of the underlying causes of this condition. What the readers will find most useful is the treatment approaches. Drs. Levin and Ward go into great detail about various non-drug options, including nutrition, exercise, meditation, acupressure, herbal products, vitamins and minerals. They also present pros and cons of various medications, nerve blocks and describe in detail the most effective and the safest preventive treatment for chronic migraines, Botox injections.

One chapter is devoted to specifics of migraines in pregnancy and another one to children and adolescents. The book also includes individual chapters on tension-type headaches, cluster and other less common headache types, and postconcussion headaches.

The authors also mention an exciting new treatment option, which we expect to be approved by the end of 2018. Four companies are racing to bring to the market CGRP monoclonal antibodies, which act like vaccines against migraines. A single injection will provide 1 to 3 months of relief with very few side effects. It is likely that this treatment will help about 60% of patients with both episodic and chronic migraines. Cluster headache patients might also benefit from these biologic drugs.

Reading so much information can make it difficult to understand how to actually use it and how to talk to your doctor about all these options. The authors successfully tackle this problem by providing many real-life cases and by including a chapter, How to Communicate with Your Medical Team.

I am sure that this book will help many migraine sufferers find relief. You can buy it on Amazon.

A new drug is approved for temporal arteritis, cause of headaches in those over 50

By: Dr. Mauskop

31-05-2017

Headache medications, Headaches, New treatments

Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected. It is not common below the age of 60 and becomes more prevalent with the advancing age. Temporal arteritis is also known as giant cell arteritis because it causes inflammation of arteries with giant cells seen under the microscope.

Headache is often the first symptom and it is typically localized to one temple, but it can involve other parts of the head and occur on both sides. If left undiagnosed and untreated temporal arteritis can cause a stroke and blindness, which can affect both eyes.

Besides headaches, temporal arteritis can cause neck and jaw pain, weakness, muscle aches, and a mild fever. The preliminary diagnosis is made by blood tests (ESR and CRP) and it is confirmed by a biopsy of the temporal artery. Polymyalgia rheumatica is a related rheumatological condition, which can occur alone or with temporal arteritis and it causes severe muscle pains.

Temporal arteritis (and polymyalgia rheumatica) are treated with steroid medications, such as prednisone. Although the initial dose is high, relatively small doses are usually effective for maintenance. Since the condition can last for years and long-term intake of prednisone can cause many potentially serious side effects it is very important to perform a temporal artery biopsy in most cases, rather than rely just on blood tests and clinical diagnosis.

Subcutaneous injection of Actemra (tocilizumab) was just approved by the FDA for the treatment of temporal arteritis. This drug has been available since 2010 for the treatment of rheumatoid and other forms of arthritis. Actemra was injected every two weeks for a year along with prednisone, but more patients were able to get off prednisone if they received Actemra rather than a placebo injection. Unfortunately Actemra also has potentially dangerous side effects, such as serious infections and it requires regular blood tests.

Because headache is one of the main symptoms of giant cell arteritis, the condition is often diagnosed by a neurologist or a primary care doctor. The treatment though is typically handled by a rheumatologist and they are already familiar with tocilizumab.

Preeclampsia can have lasting effects on the brain

By: Dr. Mauskop

27-05-2017

Alternative Therapies, Brain disorders, Headaches

Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated, they can cause strokes and kidney failure.

Fortunately, these conditions are very responsive to intravenous infusions of high doses of magnesium (5-6 grams at a time, while we give 1 gram to our migraine patients). A study recently published in Neurology suggests that even if preeclampsia is treated effectively, it can lead to persistent brain lesions. The researchers found these small white matter lesions (WMLs) in the healthy controls as well, but not as many as in women who suffered from preeclampsia 5 to 15 years prior to the study. We also see these lesions, which appear as small spots, on MRI scans of patients with migraines. The exact nature of these spots remains unclear, but the leading theory is that they are due to impaired blood flow.

The authors looked at a wide variety of factors that might have predisposed women to preeclampsia and subsequent WMLs, but did not find any. They did confirm previous findings indicating that age and high blood pressure increases the number of WMLs, but those with preeclampsia had more WMLs in the temporal lobes of the brain. They also found a decrease of the cortical volume, which means loss of brain cells on the surface of the brain.

Surprisingly, one of the factors they did not measure was magnesium levels. If preeclampsia responds so well to magnesium, it is possible that these women have chronic magnesium deficiency. Magnesium deficiency predisposes people not only to migraines, but also to heart attacks and strokes. The test that should have been done is red blood cell (RBC) magnesium since 98% of magnesium is inside the cells or in the bones. The most commonly used serum magnesium level measures the remaining 2% and is highly unreliable.

If you’ve suffered from preeclampsia or eclampsia, in addition to reducing other risk factors for vascular problems – control your blood pressure, sugar and cholesterol, stop smoking if you smoke, lose weight, and exercise, you may also want to ask your doctor to check your RBC magnesium level. If the level is low or at the bottom of normal range, take a magnesium supplement. A good starting dose is 400 mg of magnesium glycinate taken daily with food. If subsequent tests show no improvement, the dose can be increased to 400 mg twice a day and even higher.

Non-drug treatment of insomnia helps headaches

By: Dr. Mauskop

01-05-2017

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

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.

Soccer is not good for your brain, at any age and whether you head the ball or not

By: Dr. Mauskop

08-03-2017

Head trauma, Headaches, Headaches in children

With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period.

The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%.

Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive.

According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any age may be risking brain injury, mostly from heading and unintentional head injuries.

Guidelines for the use of medical marijuana

By: Dr. Mauskop

24-10-2016

Alternative Therapies, Headaches, Migraine, New treatments, Pain

Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with.

Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments:

“The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.”
Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed.

“The doctor’s office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.”
This one is easy for us.

“The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.”
I’ve never tried it.

“There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.”
I prescribe it only to our established patients.

“The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.”
All of our patients undergo a thorough evaluation.

“The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.”
We use medical marijuana only after other non-drug and drug treatments fail.

“If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.”
Yes, I do that.

“The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.”
This is a standard practice with any treatment.

“Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.”
I typically avoid prescribing medical marijuana to such patients.

Thyroid disease and headaches

By: Dr. Mauskop

08-10-2016

Headaches, Migraine

Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as Synthroid or Armour Thyroid often improves headaches.

Researchers at the University of Cincinnati College of Medicine tried to determine if having headaches made one more prone to developing hypothyroidism. They examined 8,412 healthy people and checked their thyroid function every 3 years over a 20 year period. They excluded from the group people with past thyroid disease or abnormal thyroid function tests at the first office visit. The diagnosis of a headache disorder was established based on person’s report of “frequent headaches,” by the use of any headache-specific medication, or a physician’s diagnosis of a headache disorder. They also recorded age, sex, body mass index, income, smoking, narcotic use, and medicines that could cause thyroid dysfunction.

Headache disorders were present in about 26% of the population and new onset hypothyroidism developed in 7%. Those who had a headache disorder had a slightly higher risk (1.2 times) of developing hypothyroidism. The researchers concluded that headache disorders may be associated with increased risk for the development of new onset hypothyroidism. These results were published in Headache.

One of my colleagues tells an embarrassing story of his wife’s headaches. She developed them after giving birth to their child, so he attributed them to stress and lack of sleep. When headaches persisted she went to her primary care doctor who discovered that she had an underactive thyroid. The headaches promptly went away with thyroid medicine.

Besides headaches, low thyroid function can cause weight gain, fatigue, constipation, muscle cramps, intolerance of cold, dryness of the skin, memory and concentration difficulties. Many of these symptoms also occur with magnesium deficiency, so both RBC magnesium and thyroid function tests (along with vitamin B12, vitamin D, and routine tests) need to be checked when headaches worsen or new ones develop.

Common avoidable problems with Botox injections

By: Dr. Mauskop

28-09-2016

Botox, Headaches, Migraine, Pain, TMJ

One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man.

Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding the remaining 45 units, we usually give additional injections into the areas of pain that may not be included in the standard protocol.

Giving injections every 3 months or even every 12 weeks works well for many patients. However, about a quarter of my migraine patients find that the effect of Botox lasts only 10 weeks and in a small number , even less than 10 weeks. Fortunately, some insurance companies allow Botox to be administered every 10 weeks, but many do not. Some even limit injections to every 3 months, and not a day earlier, even though the clinical trials that led to the FDA approval involved giving injections every 12 weeks. Having a week or two of worsening migraines can eliminate the cumulative effect we see with repeated treatments. That is, each subsequent Botox treatment provides better relief than the previous one. This may not the case if headaches worsen before the next treatment is given.

Cosmetic concerns are not trivial since Botox injections can make you look strange – as if you are always surprised or look sinister with the ends of your eyebrows always lifted. This can be easily avoided by injecting a very small amount of Botox into the appropriate muscles above the ends of the eyebrows or a little beyond them. In some patients this can be predicted before the first treatment by looking at the lines seen with lifting of the eyebrows. In others, it becomes apparent only after the first treatment. If the appearance is very unappealing, we ask the patient to return to get two small additional injections for which we do not charge.

To minimize bruising and pain we use very thin needles. A 30-gauge needle is used most often, however an even thinner, 33-gauge needle is also available, but is rarely used (higher number indicates a thinner needle). We recommend using a 33-gauge needles, at least for the forehead, where injections tend to be more painful and where bruising, if it happens, is very visible.

Many dermatologists and plastic surgeons tell their patients not to bend down or do anything strenuous to avoid movement of Botox which may lead to drooping of the eyelids. There is no theoretical or practical evidence for this restriction. Once injected, Botox does not move around freely but stays in the injected area. In my 22 years of injecting Botox, I’ve treated thousands of headache sufferers and fewer than 1% of patients developed drooping eyelids and none were related to bending or any other activities. Drooping is more common in older patients, is always reversible within days or weeks, and sometimes can be relieved by eye drops (aproclonidine).