Headaches | Headache NewsBlog

Temporal arteritis may be due to shingles virus

By: Dr. Mauskop

25-01-2016

Headache is usually the main presenting symptom of temporal arteritis (also known as giant cell arteritis, or GCA), which is caused by inflammation of blood vessels. This condition happens almost exclusively in the elderly. It presents with a severe headache, which is often one-sided. Some, but not all patients have swelling and tenderness of their temporal artery at the temple. This is a serious condition because it damages blood vessels and can cause strokes, loss of vision, and other complications. The diagnosis is made by blood tests (C-reactive protein, or CRP and erythrocyte sedimentation rate, or ESR) and temporal artery biopsy. However, even the biopsy sometimes does not show the inflammation. The treatment consists of steroid medications, such as prednisone. Prednisone is usually very effective. Unfortunately, prednisone needs to be taken for years if not for the rest of the person’s life and when it is used for long periods, it has many potentially dangerous side effects.

A recent study published in JAMA Neurology showed that many patients with biopsy-proven giant cell arteritis have an infection with varicella-zoster virus. This virus is also responsible for shingles and chickenpox

The researchers reviewed samples of temporal arteries for the presence of varicella-zoster virus. It was found in 68 of 93 (73%) of temporal arteries of patients with the disease, compared with 11 of 49 (22%) normals.

The authors concluded that in patients with clinically suspected GCA, prevalence of the virus in their temporal arteries is similar independent of whether biopsy results are negative or positive. They also felt that “Antiviral treatment may confer additional benefit to patients with biopsy-negative GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined”, and that “Considering that antiviral medications such as Acyclovir are very safe, it is reasonable to give them to all patients with temporal arteritis.”

PMS, high blood pressure and magnesium

By: Dr. Mauskop

20-12-2015

Alternative Therapies, Headache medications, Headaches, Migraine

Magnesium deficiency is a regular topic on this blog. Up to half of migraine sufferers are deficient in magnesium, but magnesium levels are rarely checked by doctors. Even when magnesium level is checked, it is usually the serum level, which is totally unreliable. The more accurate test is RBC magnesium or red blood cell magnesium because 98% of body’s magnesium resides inside cells or in bones. At the New York Headache Center we often don’t bother checking even the RBC magnesium level, especially if other signs of magnesium deficiency besides migraines are present. These include coldness of hands and feet or just always feeling cold, leg muscle cramps, palpitations, anxiety, brain fog, and in women, premenstrual syndrome or PMS (bloating, breast tenderness, irritability). For these patients we recommend daily magnesium supplementation and sometimes monthly magnesium infusions.

About 20 to 30 million women suffer from moderate or severe PMS, and a recent study published in the American Journal of Epidemiology indicates that having PMS increases the risk for hypertension (high blood pressure) later in life.

This study was done at the University of Massachusetts, Amherst and it involved 1,260 women who suffered from moderate or severe PMS as well as more than 2,400 women with mild or no PMS. Women with moderate or severe PMS were 40 percent more likely to develop high blood pressure than those with mild or no PMS symptoms. The researchers adjusted the risk for other risk for hypertension, such as being overweight, smoking, drinking, inactivity, use of birth control pills, postmenopausal hormone use, and family history of high blood pressure.

The association between moderate or severe PMS and high blood pressure was most pronounced among women younger than 40, who were three times more likely to develop hypertension.

Interestingly, the risk of high blood pressure was not increased in women with moderate or severe PMS who were taking thiamine (vitamin B1) and riboflavin (vitamin B2). Other researchers found that women who consumed high levels of those vitamins were 25 to 35 percent less likely to develop PMS.

Unfortunately, the researchers did not look at magnesium levels or magnesium consumption in these women. A strong association exists between magnesium deficiency and high blood pressure. There is also an association between an increased magnesium (and potassium) intake and reduced risk of strokes. Supplementation with magnesium during pregnancy decreases the risk of hypertension during pregnancy. There is also a strong association between magnesium and depression.

There are literally hundreds of scientific articles on beneficial effects of magnesium, but unfortunately magnesium remains ignored by mainstream physicians. However, consumers are ahead of most doctors and many do take magnesium supplements. This is helped by many print and online articles and many books. Some of these books include Magnificent Magnesium, Magnesium Miracle, Magnesium – The Miraculous Mineral of Calm, and my two books – The Headache Alternative: A Neurologist’s Guide to Drug-Free Relief and What Your Doctor May Not Tell You About Migraines.

Migralex is a product I patented and developed for the treatment of headaches. It contains an extra-strength dose of aspirin and magnesium. Magnesium in Migralex acts as a buffering agent and reduces the risk of stomach irritation by aspirin. Migralex is available at CVS stores, Amazon.com, and Migralex.com.

Headaches in pregnancy – when to worry

By: Dr. Mauskop

23-08-2015

Headaches, Migraine

New onset of headaches is always worrisome, but even more so in a pregnant woman. Neurologists at the Montefiore Headache clinic in the Bronx conducted a 5-year retrospective study of pregnant women who presented with an acute headache, were hospitalized, and received a neurologic consultation. The study was published in Neurology.

The researchers identified 140 women with a mean age of 29 years. About 56% of these women presented in the third trimester. Primary headaches was present in 65% and secondary (due to an underlying disease) was found in 35% of women. The most common primary headache disorder was migraine and it was found in 91%, while the most common secondary headache disorder present in 51% was high blood pressure.

Primary headaches included migraine without aura, seen in 37%, migraine with aura, in 24%, chronic migraine, in 6%, episodic tension-type headache, in 3%, chronic tension-type headache, in 1%, and primary stabbing headache, in 2% (this adds up to more than 65% because some had more than one type of headaches). Besides hypertensive disorders such as preeclampsia and eclampsia (18%), secondary headache diagnoses included pituitary adenoma or apoplexy in 4%, infections in 2%, stroke in 3%. Pregnant women with secondary headaches were less likely to have had headaches in the past (37% in secondary vs 13% in primary) and were more likely to have seizures (12% vs 0%), elevated blood pressure (55% vs 9%), fever (8% vs 0%), and an abnormal neurologic examination (35% vs 17%). Psychiatric comorbidity (presence of depression, anxiety, bipolar, etc) and phonophobia (sensitivity to light) were less likely with secondary headache.

The authors concluded that among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache. Doctors should be particularly vigilant in the absence of a headache history and if seizures, hypertension, or fever are present. On the other hand, specific headache features such as location of the pain, throbbing character, sensitivity to light and noise are less helpful in distinguish primary vs secondary headaches. The neurologists who conducted this review recommend low thresholds for neuroimaging (CT or MRI scan) and monitoring for preeclampsia and eclampsia. Preeclampsia and eclampsia are complications of pregnancy with elevated blood pressure, sometimes seizures, and kidney problems, which can be life-threatening and which are treated with intravenous infusions of magnesium.

Headaches are common in Ehlers-Danlos syndrome (lax ligaments, loose joints, etc)

By: Dr. Mauskop

02-08-2015

Headaches, Migraine, Science of Migraine

Ehlers-Danlos syndrome is a group of inherited disorders that are notable for excessive joint mobility with some people also having lax or stretchy skin, at times heart problems, and other symptoms. Headaches appear to be also very common.

We see Ehlers-Danlos syndrome in many of our migraine patients and most of our headache specialist colleagues also notice this association. However, there are very few studies that confirm this observation. One such study was recently presented at the annual scientific meeting of the American Headache Society in Washington, DC. The research was performed at a cardiology clinic in Texas. They looked at the records of 139 patients who were referred to this clinic in a period of one year. Of these 139 patients with Ehlers-Danlos syndrome, 90% were women and the average age was 32. Out of 139 patients, 70% suffered from headaches – 32% had tension-type, 26% had migraines, 9% had chronic migraines and 2% had sinus headaches. These numbers are much higher than what is seen in the general population, confirming clinical observations by headache specialists.

One form of Ehlers-Danlos syndrome affects not only joints and ligaments, but also the heart. So, when see a migraine patients who also appears to have Ehlers-Danlos syndrome, we also ask about symptoms related to the heart and if they are present refer such patients to a cardiologist.

Another presentation at the same meeting described a 23-year-old woman with Ehlers-Danlos syndrome who suddenly developed headaches that would worsen on standing up and improve on lying down. This is typical of headaches due to low cerebrospinal fluid (CSF) pressure, which was confirmed by a spinal tap. The most common causes of low CSF pressure are a leak caused by a spinal tap done to diagnose a neurological disease or caused by a complication of epidural anesthesia. Spontaneous unprovoked leaks have also been reported. In this patient with Ehlers-Danlos syndrome the leak probably occurred because of the lax ligaments that surround the spinal canal and contain the CSF. The report describes the most accurate test to document such leaks, which is an MRI myelogram.

The treatment of CSF leaks begins with a blood patch procedure, but if it is ineffective, surgery is sometimes done to repair the leak. A recent report suggested that Botox could be effective for low spinal fluid pressure headaches.

Neck weakness and tension-type headaches

By: Dr. Mauskop

13-05-2015

Alternative Therapies, Botox, Headaches

Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

Opiates (narcotics) increase ER stay in patients with headaches

By: Dr. Mauskop

25-03-2015

Headaches, injections, Migraine

Narcotics are not only ineffective for the treatment of headaches, but they can also make headaches worse and transform an episodic migraine into chronic. A study mentioned in a previous post showed that more than half of migraine sufferers who went to an ER were given a narcotic.

A new study recently published in the journal of the International Headache Society, Cephalalgia showed that if patients presenting with a headache to an ER are treated with an injection of opiates (narcotics) they will stay in the hospital longer than if no narcotics are given. This treatment also leads to an increased risk of return visits to the emergency department within seven days.

The study was conducted by two neurologists, Dr. McCarthy at Puget Sound VA Healthcare System in Seattle and Dr. Cowan at Stanford University in California. They examined charts of 574 people and discovered that 23% received a narcotic when they were seen at an emergency department. Only 53% were given an injection of a drug recommended by a published consensus of headache experts. These include sumatriptan (Imitrex, the only injectable triptan), prochlorperazine (Compazine), metoclopramide (Reglan), chlorpromazine (Thorazine), ketorolac (Toradol), aspirin, acetaminophen, and dihydroergotamine. The remaining 24% were given an injection of another non-narcotic drug.

Patients who were given opiates were 4 times more likely to have a long stay, compared with patients given first-line recommended medications. 69 participants had at least one readmission for headache, of whom 20 returned to the emergency department within seven days. Interestingly, patients who had a CAT or an MRI scan of the brain had a significantly higher rate of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended drugs.

Dr. McCarthy was quoted saying that “Opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications”. He added that regardless of whether the acute headache was diagnosed as a migraine or a tension-type headache, it is likely to respond to most non-narcotic injectable treatments.

An editorial accompanying this article concluded that “The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department”.

Stabbing headaches as a sign of MS

By: Dr. Mauskop

22-09-2014

Headaches

Stabbing headaches can be a sign of acute multiple sclerosis, according to a report by German doctors in the journal Headache. Stabbing headache is a rare type of headache, although patients with migraines often report having occasional “ice pick” headaches. Some call these headaches “jabs and jolts”. In some people, stabbing headaches can be quite disabling. The pain lasts only a couple of seconds but can occur up to 100 times a day. Treatment usually involves indomethacin or another non-steroidal anti-inflammatory medication in the aspirin family (including our own Migralex). However, in this case where stabbing headaches were associated with MS, treating MS relieved headaches as well.

In a prior report in Clinical Neurology and Neurosurgery Italian physicians also found that of 26 patients with stabbing headaches they had seen over 10 years, more than half had autoimmune disorders, including multiple sclerosis, Sjögren’s disease, lupus, Behçet’s disease, autoimmune vasculitis, and antiphospholipid antibody syndrome. The authors speculated that stabbing headache may develop as a result of inflammation in the brain with loss of myelin around the nerve fibers, which is seen with MS and other auto-immune disorders.

Botox relieves new daily persistent headaches.

By: Dr. Mauskop

15-08-2014

Botox, Chronic migraine, Headaches

A report from the Cleveland Clinic and Case Western Reserve describes 22 patients with new daily persistent headaches (NDPH) who were treated with Botox injections.

NDPH is a condition in which the headache begins suddenly without an obvious trigger and persists continuously without a break. Because NDPH is relatively uncommon, there have been no large studies of this condition. Patients with NDPH usually do not exhibit symptoms of migraine, such as throbbing pain, nausea, sensitivity to light, noise or physical activity. Because of its sudden onset, we suspect that these headaches may be the result of a viral or another type of infection. There are no treatments that consistently relieve these headaches, but we usually try all of the drugs and approaches we use in migraines.

A group of doctors from Cleveland, Ohio discovered that while Botox seems to help, only 32% of patients with NDPH showed improvement, confirming the refractory nature of this type of headaches. Twenty one of the 22 patients underwent more than one treatment with Botox and most were given a standard migraine treatment protocol with 155 units injected into 31 sites. The improvement was modest but it did result in headache-free days, which were not observed prior to this treatment. The disability improved slightly and when the improvement did occur, it lasted about 8 weeks. Some of our chronic migraine patients also require Botox injections every 8 to 10 weeks, instead of the usual 12. Considering that we do not have any better treatments, Botox should be offered to patients with NDPH.

Botox helps post-traumatic headaches.

By: Dr. Mauskop

04-08-2014

Botox, Headaches

Botox is FDA-approved only for chronic migraine headaches, however, it is being used “off-label” for other types of headaches as well. We find that frequent episodic migraines, cluster headaches, numular, and cervicogenic (neck-related) headaches improve with Botox. In our practice, post-traumatic headaches also seem to respond to Botox.

A report by neurologists from Stony Brook University describes five patients suffering from post-traumatic headaches, who responded to Botox. These patients sustained a traumatic brain injury and had suffered from post-traumatic headaches for years, despite trials of various prophylactic medications. After treatment with Botox, all of their five patients had greater than 50% improvement of their disability as measured by the MIDAS (MIgraine Disability Assessment Scale) questionnaire.

This is not a surprising observation because in many patients with a traumatic brain injury headaches have migraine features, suggesting similar underlying mechanisms. People with a family history of migraines who sustain a head injury seem to be more likely to develop post-traumatic headaches than those without such family history, which also suggests a link with migraines. Some patients with post-traumatic headaches and especially those with overt whiplash injury (almost all head injuries, to a varying degree, involve a whiplash neck injury) may respond to Botox because Botox relaxes tight muscles. We no longer think that this is the reason Botox helps migraines because there is evidence that in migraines Botox works by blocking sensory nerve endings rather than by relaxing muscles.

Because of the cost, insurance companies are often unwilling to pay for Botox to treat anything but chronic migraines. However, headaches that begin after a head injury and are accompanied by some migraine features can be correctly classified as post-traumatic chronic migraines, thus avoiding difficulties with the insurance companies.

Narcotics (opioids) are still overused in ERs for migraines

By: Dr. Mauskop

11-05-2014

Headaches, New treatments

Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers.

In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn’t changed.

Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx.

In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients.

Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not cause addiction and rebound (medication overuse) headaches, which narcotics do.

Dr. Friedman and his colleagues looked at the national data for 2010 and found that there were 1.2 million visits to the emergency departments for the treatment of migraine. Migraine was the 5th most common reason people come to the emergency room.

They also discovered that people who were given a triptan in the emergency department had an average length of stay in the ER of 90 minutes, while those given Dilaudid (hydromorphone) – the most popular narcotic, stayed in the ER for an average of 178 minutes.

Opioids should be used only occasionally – when triptans, ketorolac, and metoclopramide are ineffective or are contraindicated. This should be the case in maybe 5% of these patients, according to Dr. Friedman

One possible reason why ER doctors do not follow recommended treatments and use narcotics instead, is that they do not recognize a severe headache as migraine and misdiagnose it as sinus, tension-type or just as a “severe headache”. Many doctors still believe that migraine has to be a one-sided headache, or a visual aura must precede a migraine, or that the pain has to be throbbing. It is well established that none of these features are required for the diagnosis of migraine.

Another possible reason for the widespread use of opioid drugs in the ER is that doctors are very accustomed to using them, while triptans may be unfamiliar and require thinking about potential contraindications, what dose to give, what side effects to expect, etc.

In summary, if you or someone you know has to go to an ER with a severe migraine, ask for injectable sumatriptan (which you should have at home to avoid such visits to the ER) or ketorolac.

What to ask for if your migraine lands you in the emergency room.

By: Dr. Mauskop

19-03-2014

Headache medications, Headaches, New treatments

A severe migraine attack can sometimes land you in an emergency room. With its bright lights, noise, and long waits, it is the last place you want to be in. To add insult to the injury, some doctors will think that you are looking for narcotic drugs and treat you with suspicion, while others will offer ibuprofen tablets. It is hard to think clearly when you are in the throes of a migraine, so you need to be prepared and have a list of treatments you may want to ask for, just in case the ER doctor is not good at treating migraines.

If you are vomiting, first ask for intravenous hydration and insist on having at least 1 gram of magnesium added to the intravenous fluids. Everyone with severe migraines should have sumatriptan (Imitrex) injection at home since it often eliminates the need to go to an ER in the first place. If you haven’t taken a shot at home, ask for one in the ER. The next best drug is a non-narcotic pain medicine, ketorolac (Toradol) and if you are nauseous, metoclopramide (Reglan). Do not let the doctor start your treatment with divalproex sodium (Depakene, drug similar to an oral drug for migraine prophylaxis, Depakote) or opioid (narcotic drugs) such as demerol, morphine, hydromorphone and other.

This post was prompted by an article just published in the journal Neurology by emergency room doctors at the Montefiore Hospital in the Bronx. It was a double-blind trial which compared intravenous infusion of 1,000 mg of sodium valproate with 10 mg metoclopramide, and with 30 mg ketorolac. They looked at relief of headache by 1 hour, measured on a verbal 0 to 10 scale. They also recorded how many patients needed another rescue medication and how many had sustained headache freedom.

Three hundred thirty patients were enrolled in the study. Those on divalproex improved by a mean of 2.8 points, those receiving IV metoclopramide improved by 4.7 points, and those receiving IV ketorolac improved by 3.9 points. 69% of those given valproate required rescue medication, compared with 33% of metoclopramide patients and 52% of those assigned to ketorolac. Sustained headache freedom was achieved in 4% of those randomized to valproate, 11% of metoclopramide patients, and 16% receiving ketorolac. In the metoclopramide arm, 6% of patients reported feeling “very restless”, which can be a very unpleasant side effect of this drug.

The authors concluded that the valproate was less efficacious than either metoclopramide or ketorolac. Metoclopramide was somewhat better than ketorolac but it also had more side effects.

To summarize, ask the doctor to start with hydration and magnesium, then sumatriptan injection, followed by metoclopramide and ketorolac, if needed. If the above treatments do not help, we also give dexamethasone (Decadron, a steroid medication) and DHE-45 (dihydroergotamine). All these medications can be administered in the office and we always tell our patients not to go to an ER and to come into the office if the attack occurs during our office hours.

Cefaly is approved by the FDA for sale in the US.

By: Dr. Mauskop

11-03-2014

Alternative Therapies, Headaches

Cefaly, a TENS unit specifically developed for the treatment of migraine headaches, was cleared for sale in the US. It was available last year for a short time on Amazon.com, but because it was not yet approved, it was taken off the market. I mentioned in my previous post that TENS units have been in use for muscle and nerve pain for decades. TENS has good proof of efficacy in musculo-skeletal pain, but studies in migraines have been relatively small. Even Cefaly was tested in only 67 migraine patients. So, while it is not definitely proven effective, TENS is safe and is worth a try if usual treatments do not help. Cefaly is easy to use but it is expected to cost around $300. The old-fashioned TENS units are not as convenient to use, but sell for as little as $50. Both Cefaly and regular TENS units require doctor’s prescription, although many websites sell TENS units without one. These devices are usually powered by a 9 volt battery and, unless you have a pacemaker or another electrical device in your body, the risk of side effects is low.