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We now offer transcranial magnetic stimulation (TMS) for migraines and other neurological conditions

By: Dr. Mauskop

20-01-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Neurologists frequently find themselves managing patients resistant to standard treatments due to limited proven therapies for many neurological conditions. Some patients cannot tolerate or have contraindications to medications, particularly for such common disabling conditions like migraine and chronic pain.

One promising treatment is transcranial magnetic stimulation (TMS). It is a proven procedure for anxiety, depression, obsessive-compulsive disorder (OCD), smoking cessation, and acute migraines. TMS utilizes magnetic fields to stimulate nerve cells in the brain that are underactive or reduce the excitability of overactive cells. TMS can change the flow of information between different parts of the brain in various neurological conditions. Published reports show the potential benefit of TMS in fibromyalgia, neuropathic pain, cluster headaches, facial pain, trigeminal and other neuralgias, back pain, insomnia, memory disorders, tinnitus, post-concussion syndrome, post-traumatic stress disorder (PTSD), restless leg syndrome, and long COVID. The evidence for the efficacy of TMS for these neurological disorders, however, is still limited.

Single-pulse TMS is approved by the FDA for the acute treatment of migraines with aura. The patient uses a portable device during the aura phase to self-administer a single pulse of TMS to the back of the head. This can abort the attack. Repetitive TMS (rTMS) has been studied for the prevention of migraines and other types of pain. It appears effective, but compared to depression trials, migraine studies were relatively small and the FDA has not cleared rTMS for the treatment of migraines. This means that insurance companies are not likely to pay for this “off-label” use of TMS.

rTMS is generally considered safe and well-tolerated, with side effects typically mild and temporary, including scalp discomfort, headaches, and facial twitching. More serious side effects like seizures and mania are very rare.

Before starting TMS, patients undergo a physical and mental health evaluation. The coil placement and dose are determined in the first session. During a TMS session, patients sit in a comfortable chair with earplugs. An electromagnetic coil is positioned near the scalp, delivering short magnetic pulses to specific brain regions involved in processing pain and other information. Patients feel and hear rapid tapping on their scalp that continues, on and off. Patients are awake and alert during the entire procedure. There are no limitations to activities before or after the treatment.

Treatment length varies from 20 to 45 minutes, depending on the stimulation pattern and number of sites stimulated. The frequency of treatments also varies – anywhere from daily for several weeks, to once a week. After the initial period of more frequent sessions, some patients require weekly or monthly sessions to maintain the effect. It may take a few weeks to see noticeable effects.

TMS is a good choice for people who have not responded to multiple standard therapies, people who do not want to take drugs, those who also suffer from depression and anxiety, and pregnant women. Sufficient evidence suggests that TMS is as safe in children as it is in adults, with studies indicating its effectiveness in treating depression in adolescents.

More on the dangers of PPIs such as Prilosec, Nexium, Dexilant, et al.

By: Dr. Mauskop

14-01-2024

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

Proton Pump Inhibitors (PPIs) are a class of medications commonly used to treat conditions such as acid reflux, ulcers, and heartburn. They include omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), Dexlansoprazole (Dexilant), and pantoprazole (Protonix). Several of these are available without a prescription.

While PPIs are generally considered safe and effective, several studies have suggested a potential association between PPI use and several medical and neurological problems. These include osteoporosis, kidney problems, impaired hearing, vision, memory, and an increased risk of conditions such as migraines, dementia, peripheral neuropathies, and seizures. The evidence is circumstantial and not definitive. However, considering the large number of studies and a large number of conditions, PPIs are probably not safe for long-term use.

In the case of migraines, one study found that past and current use of PPI increased the odds of migraine by 2.56-fold and 4.66-fold, respectively. The exact reason for this link is still a mystery, but researchers are exploring several possibilities:

Nutrient deficiencies: PPIs can interfere with the absorption of important nutrients like vitamin B12, other B vitamins, and magnesium, which can contribute to headaches.

Gut microbiome changes: PPIs can alter the gut microbiome, which may indirectly impact brain function and migraine susceptibility.

Inflammation: Some studies suggest PPIs might trigger low-grade inflammation, a potential factor in migraine development.

This post was prompted by a recent study showing an association between PPI intake and the risk of dementia. Those who used PPIs for a cumulative four and a half years or longer had a 33% higher risk of developing dementia.

Stopping a PPI can cause severe rebound acidity. This is why people get stuck taking them for years. The way to try is by replacing the PPI with an H2 blocker such as famotidine (Pepcid, Zantac 360) along with an antacid such as Rolaids (it’s better than Tums because it contains not only calcium but also magnesium) or Gaviscon. After a few weeks, people can often stop famotidine and after another few weeks, stop the antacid. Famotidine does not cause problems associated with PPIs.

If you cannot stop or have a condition that requires long-term intake of a PPI (e.g. Barrett’s esophagitis), make sure to take a variety of vitamins and minerals. However, the lack of acidity can prevent the absorption of supplements. We usually do a blood test to check vitamin B12, RBC magnesium, vitamin D, and others. Some of our patients come in for monthly infusions of magnesium and other nutrients they are deficient in.

Attend the Diamond Research & Educational Foundation’s course

By: Dr. Mauskop

06-01-2024

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, New treatments, Science of Migraine

The annual course, “The Shifting Migraine Paradigm 2024” will be held February 15-17, 2024 at the Plaza San Antonio Hotel & Spa. This three-day conference offers an excellent update on the treatment of migraine and other headaches.

It is always an honor to be invited to speak at this event. The topic of my presentation is Supplements and Medical Foods.

Why sleep regularity is important

By: Dr. Mauskop

25-12-2023

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

Lack of sleep is a common migraine trigger. A less common trigger is getting too much sleep. I always recommend that patients try to go to sleep at the same time and get up at the same time. Even on weekends. Instead of sleeping in on the weekend, take a 30-minute nap in the afternoon.

A new study by Australian researchers published in Neurology reports another important reason for sleep regularity. This was a large and rigorous study involving 88,094 UK subjects. All subjects wore an accelerometer that detected their sleep patterns. The researchers controlled for variables that are known to predispose to dementia – age, sex, ethnicity, material deprivation, retirement status, current shift work status, household income, highest level of education, smoking status, use of sedative, antidepressant, or antipsychotic medication, and genetics (APOE ?4 carrier status).

They “identified a nonlinear relationship between day-to-day sleep regularity and dementia risk such that dementia rates were highest in those with the most irregular sleep, dipped as sleep regularity approached the median, and then marginally increased at the highest estimates of sleep regularity.” In subjects who underwent brain MRI (n = 15,263), gray matter and hippocampal volume (area of the brain critical to memory) similarly tended to be lowest at the extremes of the sleep regularity index. This was surprising – subjects whose sleep patterns were extremely chaotic did slightly better than those with moderately irregular sleep.

Other sleep disorders that can contribute to migraines and increase the risk of dementia are restless leg syndrome, sleep apnea, and sleeping too much or not enough.

Migraine and thyroid disease

By: Dr. Mauskop

11-12-2023

Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Science of Migraine

The thyroid function test is in the initial battery of blood tests we order on all our headache patients (along with RBC magnesium, vitamins D, B12, folate, and others). Having either an overactive or underactive thyroid is known to worsen migraine headaches.

A new study published by Indian researchers confirmed that treating an underactive thyroid improves headaches. The researchers studied 87 headache patients with a mild decrease in thyroid function. Half of them were prescribed thyroid medicine and the other half received a placebo. Correcting thyroid deficiency improved headache frequency, severity, and disability (MIDAS score) at three months of follow-up in the treatment group compared to the placebo group.

The conclusion was that it is logical to check thyroid function status in patients presenting with migraine headaches.

Thyroid function can sometimes decline precipitously and cause worsening of headaches without any other symptoms. This can happen after delivering a baby and the cause is often misinterpreted. Lack of sleep, stress, hormonal changes (female hormones, not thyroid hormone), occlusion of veins inside the head, and even stroke are suspected. All those conditions can cause headaches after the delivery. But we should not forget to check the thyroid.

fMRI scan can establish the diagnosis of migraine

By: Dr. Mauskop

02-12-2023

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

Neurologists diagnose migraine by the description of symptoms provided by the patient. We have not had an objective test to confirm that a person suffers from migraines.

A group of researchers led by Dr. Yiheng Tu in the department of psychiatry at Harvard Medical School developed an AI program that can diagnose migraine using fMRI (functional MRI) scanning. The AI program was first fed information on fMRIs of 116 individuals with migraines and then had this data compared to healthy controls.

The AI program had 93% sensitivity and 89% specificity. This means that it missed the diagnosis of migraine in only 7 out of 1oo patients and diagnosed migraine in 11% of patients who did not have it. These are very good numbers, but clearly, the method is not error-proof.

When they compared people with migraines to those with other types of pain, the sensitivity dropped to 78% and specificity, to 76%. This can be explained by the fact that similar functional changes in the brain probably occur with any type of pain.

A major obstacle to the wide use of fMRI scans is the cost. They are more expensive to perform than a regular MRI. Insurance companies are not likely to cover it since this is an experimental procedure. Another potential difficulty is that fMRI takes much longer to do than a regular MRI – an hour vs 20 minutes. During this time you have to lie inside a tube while trying not to move and hearing loud banging noises.

Combining supplements

By: Dr. Mauskop

20-11-2023

Alternative Therapies, Chronic migraine, Headaches, Migraine

Every patient visiting our clinic undergoes a routine blood test, which includes an assessment for magnesium and vitamin deficiencies. We know that close to 50% of patients with migraines are deficient in magnesium and many are deficient in riboflavin and other nutrients.

In addition to vitamins and magnesium, we often recommend herbal supplements. One of the herbal remedies that has been used for centuries, is feverfew. It is helpful not only for migraines but also for fever, arthritis, and other conditions. Often referred to as “medieval aspirin”. Most importantly, it has proven to be safe, that is if it is manufactured by a reputable company or you grow your own.

Many patients find it daunting to have to take multiple tablets every day. There are several products on the market that combine various supplements in one tablet. One such supplement that has been on the market the longest, includes magnesium, riboflavin (vitamin B2), and feverfew. I’ve helped develop and promote this combination, so I may be biased. However, it has high-quality ingredients and the same experienced and knowledgeable team that developed it still stands behind it.

Some products also include CoQ10. One-third of migraine sufferers are deficient in this supplement. Because CoQ10 is relatively expensive, many combination products contain insufficient amounts of it. I usually check CoQ10 levels in the blood and if a patient is deficient, I recommend that she takes it separately, 200-300 mg a day.

An important consideration is that you may have a vitamin or RBC magnesium level within the normal range, but if your level is at the bottom of this range, you are likely to be deficient. RBC magnesium level should be above 5, CoQ10 level, above 0.7, vitamin D level, above 45, and vitamin B12 level, above 500.

Shingles vaccine for the prevention of cluster headaches

By: Dr. Mauskop

12-11-2023

Alternative Therapies, Cluster headaches, Headache medications, Headaches, New treatments

Cluster headaches arguably cause the worst imaginable pain, hence the moniker, suicide headaches. Fortunately, there are many treatments for this condition, including two FDA-approved drugs. One is sumatriptan injections taken as needed to stop an attack. The other is a preventive monthly injection of galcanezumab (Emgality). We also use Botox injections, oxygen and a variety of medications. Nevertheless, some people do not respond to these treatments.

A report by Japanese neurologists from Tokyo suggests a new treatment. One theory of the origin of cluster headaches is the reactivation of the varicella-zoster virus that causes chickenpox and shingles.

The study included over 160 patients with episodic cluster headaches who received a shingles vaccine. The response to the vaccine was measured by the amount of antibodies in the blood. Those patients who had more antibodies had a longer delay to the next cluster episode than those with low antibody counts. They also found that those who had a COVID infection and received multiple COVID vaccines, tended to do worse.

It is premature to recommend shingles vaccine to patients with cluster headaches unless they are over 50, the age when everyone is advised to get it.

More research on vitamin D and migraine

By: Dr. Mauskop

06-11-2023

Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments

There is growing evidence that vitamin D is important in the development and treatment of migraines. In the past 15 years, I have written a dozen posts on the role of vitamin D in migraines.

At the last meeting of the International Headache Society, Maria Papasavva and her Greek colleagues presented a study entitled, Genetic variability in vitamin D receptor and migraine susceptibility: a case-control study.

Their study aimed to investigate an association of three genetic variants of vitamin D receptor with the susceptibility to develop migraine. DNA sample was collected and extracted from 191 patients diagnosed with migraine and 265 headache-free subjects. According to their statistical analysis, a significant association between migraine susceptibility and abnormal variants of vitamin D receptors was found. They also showed a significant association of two variants with migraine without aura. Their conclusion was that there is a clear association between migraine susceptibility and two vitamin D receptor variants. This further supports the role of vitamin D and its receptor in migraine.

Vitamin D is important not only for migraines but also for your immune system. Vitamin D deficiency increases the risk of COVID and other viral infections. Lower levels of vitamin D are associated with a higher risk of attacks of multiple sclerosis even if the level is still within normal range. There are many other reasons to maintain your blood vitamin D level at least in the middle of the normal range. The normal range is 30 to 100, so keep it well above 40. If your doctor tells you that your level is normal, ask for the actual number.

A double-blind study of cannabis for the acute treatment of migraine

By: Dr. Mauskop

30-10-2023

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, New treatments

Since the legalization of medical marijuana in New York in 2014, I have prescribed it to several hundred patients. My experience suggests that approximately one-third of my patients benefit from its use and continue to rely on it for their medical needs. Some have reported relief from symptoms such as nausea and anxiety, often associated with migraines, while others find it highly effective in aiding sleep. Additionally, there are patients who have reported significant pain relief.

It is possible that the relatively low response rate I see in my patients is due to the fact that I reserve medical marijuana for those patients who do not respond to multiple drugs.

At the recent meeting of the International Headache Society, Dr. Nathaniel Schuster and his colleagues presented a study titled “Vaporized cannabis versus placebo for the acute treatment of migraine: a randomized, double-blind, placebo-controlled, crossover trial.” This study aimed to investigate the potential of medical marijuana in alleviating pain and associated migraine symptoms.

In this study, participants were instructed to treat moderate-to-severe migraine attacks within four hours of onset using vaporized cannabis flower. They were asked to treat up to four separate migraine attacks, using vaporized cannabis with different compositions: 1) THC-dominant (6% THC), 2) CBD-dominant (11% CBD), 3) THC/CBD mix (6% THC/11% CBD), and 4) placebo cannabis, with the order randomized and double-blinded.

Out of the 92 participants enrolled, 71 treated at least one migraine attack. Two hours after vaporization, the THC/CBD mix outperformed the placebo in achieving pain relief (69% vs. 48%), pain freedom (36% vs. 16%), and freedom from the most bothersome symptoms, such as nausea, photophobia, or phonophobia (62% vs. 36%). The THC-dominant option was superior to the placebo for pain relief at 2 hours (71% vs. 48%) but was not significantly different from the placebo regarding pain freedom or freedom from the most bothersome symptoms. The CBD-dominant option did not significantly differ from the placebo in terms of pain relief, pain freedom, or freedom from the most bothersome symptoms. The most common side effects reported were sleepiness, followed by euphoria, with no serious adverse events observed.

In conclusion, the authors of the study found that the acute treatment of migraine with a vaporized THC/CBD mix (6% THC/11% CBD) was superior to the placebo in terms of pain relief, pain freedom, and freedom from the most bothersome symptoms at the 2-hour mark.

This study has significant practical implications. In the past, I would leave the choice of products to the licensed pharmacist at the dispensary, while advising patients that finding the right combination is often a trial-and-error process. However, now, I will be better equipped to advise my patients on the most suitable type of medical marijuana for their specific needs based on the findings of this study.

Another report on triptan safety

By: Dr. Mauskop

22-10-2023

Chronic migraine, Headache medications, Headaches, Migraine

A presentation by Jing Jie Yu, Joshua E. Levine, and others from U. of Florida at the last meeting of the International Headache Society described their analysis of the potential risks of triptans.

Triptans are drugs that were first approved in 1992 and include sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova). Because triptans have the potential to constrict blood vessels they are contraindicated in patients who have coronary artery disease (CAD) or cerebrovascular disease (CVD).

The study was entitled, Association between Triptan Use and Cardiovascular Disease and All-Cause Mortality among Patients with Migraine: A Systematic Review and Meta-analysis

This meta-analysis of several studies showed that triptan use was not associated with increased risk of stroke, TIA, or all-cause death risk but with a decreased CAD risk in migraine patients.

A report presented in 2022 showed not only that triptans are safe in people without CVD, but are relatively safe even in those who have CVD. The risk of major adverse cardiovascular events with triptans was 1% while with NSAIDs, such as ibuprofen and naproxen, it was 3.8%.

Magnificent Magnesium and Movement Disorders

By: Dr. Mauskop

15-10-2023

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

Magnificent Magnesium is the title of a book my colleague and friend, cardiologist Dr. Dennis Goodman wrote about this underappreciated mineral. Magnesium produces magical results, albeit only in those who are deficient. And millions of Americans are deficient. Our research has shown that close to half of migraine sufferers are. Magnesium saves lives in cardiac care units by reducing the risk of arrhythmias. It is given intravenously for acute asthma attacks and treats eclampsia and pre-eclampsia in pregnancy. The list goes on.

A report by Canadian neurologists just published in a leading neurology journal, Neurology, describes magnesium’s role in the treatment of movement disorders. Sixty patients with low magnesium levels who had a movement disorder were identified in medical journals. Movement disorders observed were postural tremor (14 patients), resting tremor (5), intention tremor (6), ataxia involving the trunk (29) or limbs (15) and dysarthria (13), athetosis (5), myoclonus (4), and chorea (1). Some patients also had downbeat nystagmus, tetany (muscle cramping), drowsiness, vertigo, and proximal muscle weakness.

The most common culprit in these patients was a class of drugs called proton pump inhibitors (PPIs). These are drugs like omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and dexlansoprazole (Dexilant). They are known to interfere with the absorption of not only magnesium but also other vitamins. Long-term users of these drugs are at a higher risk of dementia, most likely because they prevent absorption of vitamin B12. I try to get all of my patients off PPIs. This is not easy because stopping the drug causes a rebound in acid production. Some people have worse heartburn than when they started the PPI. One strategy is to replace these drugs with famotidine (Pepcid) and Rolaids (better than Tums since Rolaids have calcium and magnesium while Tums have only calcium). After a period of time, patients are able to stop famotidine and take only Rolaids and then, stop Rolaids as well. A healthy low-acid diet, stress management, weight loss, and sleeping on the left side can also help.

#magnesium #migraine #ataxia #dysarthria #tremor #PPIs

We now offer transcranial magnetic stimulation (TMS) for migraines and other neurological conditions

More on the dangers of PPIs such as Prilosec, Nexium, Dexilant, et al.

Attend the Diamond Research & Educational Foundation’s course

Why sleep regularity is important

Migraine and thyroid disease

fMRI scan can establish the diagnosis of migraine

Combining supplements

Shingles vaccine for the prevention of cluster headaches

More research on vitamin D and migraine

A double-blind study of cannabis for the acute treatment of migraine

Another report on triptan safety

Magnificent Magnesium and Movement Disorders

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