Headaches | Headache NewsBlog

New Daily Persistent Headache is very treatable

By: Dr. Mauskop

09-10-2023

Alternative Therapies, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments, Psychology of headaches, Science of Migraine

New daily persistent headache (NDPH) is condition that is defined solely by the fact that the headache begins suddenly one day and does not go away. There are no scientific studies to suggest possible underlying mechanisms or treatments. Some patients develop it after a viral infection while others, after a period of stress and many with no apparent trigger.

In my latest book, I mentioned how a seemingly benign idea of classifying medical conditions can cause harm. In case of NDPH, many anecdotal reports in medical journals indicate that this condition is not responsive to treatment. However, there are no controlled double-blind studies, only anecdotal reports. Many patients with this condition will look up this literature and conclude that there is no hope of getting better. I have seen many such devastated people. But this bleak picture is clearly wrong.

I have seen many patients with NDPH who responded to various treatments. In my 30 years of using Botox, I have found it to be one of the safest and most effective treatments for NDPH as well as migraine and other types of headaches.

At the recent meeting of the International Headache Society held in Seoul, two presentations described good responses of NDPH to Botox injections.

The first report was by S. Cheema and colleagues of Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK. They compared patients with NDPH (58) and those with chronic migraine (CM) with daily attacks (153) and chronic migraines without daily attacks (85). There was a 30% reduction in mean moderate and severe headache days in 33% of patients with NDPH, 43% with daily CM and 55% with non-daily CM.

The second report was by Shuu-Jiun Wang and colleagues of the Neurological Institute, Taipei Veterans General Hospital. They looked at the response of patients with NDPH who had predominately migraine features and those who had predominantly features of tension-type headaches. Of 228 patients diagnosed with NDPH, 199 patients (87%) had migrainous features and 29 patients (13%) had tension-type features. Their conclusion: “Through a mean follow-up duration of 2.5 years, around 40% patients with NDPH showed a favorable outcome at our headache center. Our results suggest NDPH might not be as grave as previously reported.”

Yes, these were also anecdotal reports rather than controlled trials, but they clearly show what I have also observed in my practice – NDPH is a very treatable condition. Hopefully, the next, fourth edition of the International Classification of Headache Disorders will no longer list NDPH as a diagnosis since it has no scientific basis.

Gut bacteria and migraine

By: Dr. Mauskop

18-09-2023

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

Most people have heard about the gut-brain connection. Research published in The Journal of Headache and Pain examined this connection in relation to migraine headaches. The researchers looked at whether the collection of microorganisms living in our guts (called the gut microbiome) could be linked to the development of migraine headaches and its different types – migraine with and without aura.

To do this, the scientists used information from a big genetic study that looked at the genes related to the gut microbiome. They also used data from studies that explored the genetics of migraine headaches. They employed sophisticated methods to analyze this data, and they also checked for other factors that could affect the results.

In the analysis, they found that certain types of bacteria in the gut were connected to migraine headaches, including ones with and without aura. They also found that some specific types of bacteria were more likely to be associated with certain types of migraines. Even after doing some statistical adjustments, these connections still held up.

So, this study suggests that the mix of bacteria in our guts might actually influence whether we get migraines and what kind they are. It shows that there might be a link between our gut and our brain when it comes to migraines.

They found that while some bacteria seemed to contribute to migraines, one type appeared to be protective. This protective effect was linked to the Bifidobacterium family. You can find Bifidobacterium in many probiotics, including a well-known brand called Align. Additionally, various fermented foods like milk kefir, sourdough bread, sauerkraut, kimchi, and other fermented vegetables contain Bifidobacterium.

However, it’s important to note that this research doesn’t mean other types of bacteria aren’t helpful too. A healthy human gut microbiome consists of many different types of bacteria. When there is an imbalance of these healthy bacteria, it can lead to various health problems, not just migraines. This imbalance can come in many different forms and may require different probiotics to correct it. That is why I recommend that patients try different types of probiotics for a few months at a time. Besides Bifidobacteria, some patients respond well to Saccharomyces, Lactobacillus, or other types, or even a combination of several.

Anxiety may facilitate transformation of pain from acute to chronic

By: Dr. Mauskop

07-09-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Psychology of headaches, Science of Migraine

Our thoughts and emotions can impact the development of chronic pain. However, there haven’t been many studies exploring what causes pain to transition from being short-term (acute) to long-lasting (chronic).

Australian researchers conducted a study to investigate how our thought patterns, anxiety related to pain, and the tendency to avoid pain affect both acute and chronic pain. They conducted two studies for this purpose. In the first study, they interviewed 85 individuals experiencing long-term pain to understand their thoughts and emotions. In the second study, they observed 254 individuals who had recently started experiencing acute pain and followed up with them three months later.

In both studies, they examined interpretation bias using a word association task and assessed pain-related anxiety, pain avoidance, pain intensity, and how pain interfered with daily life. In both cases, they discovered that the way people think about pain was linked to how much it disrupted their daily lives. In the second study, they also found that people’s thought patterns about pain were connected to increased anxiety about pain. This heightened anxiety, in turn, made the pain more severe and disruptive after three months. While anxiety about pain also led people to try to avoid it, this avoidance behavior didn’t seem to affect the level of pain they experienced later on.

This research provides valuable insights into how pain can transition from acute to chronic. It suggests that our initial thoughts about pain might trigger anxiety related to pain, which can contribute to the pain persisting and becoming more troublesome over time. This finding could be crucial in developing strategies to prevent chronification of pain by addressing how people perceive and manage their anxiety about pain during its early stages. Cognitive-behavioral therapy, meditation, and other mind-body techniques could be some of such strategies.

The role of a physical therapist in treating migraines

By: Dr. Mauskop

14-08-2023

Alternative Therapies, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their contribution can be profoundly impactful, provided they have a keen interest in the nuances of migraine care.

One such physical therapist to whom I refer patients, Pete Schultz, just co-wrote an article, A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist’s Perspective.

This article shows how experienced physical therapists approach migraine patients. They usually perform a very thorough examination and they can sometimes detect a serious problem that was missed by a physician.

The physical therapist often discovers general weakness, muscle tension, poor posture, diminished endurance, neck pain, teeth clenching, visual symptoms, dizziness, poor balance and coordination and high stress levels.

The interventions may include exercise directed at strengthening neck and upper back muscles, manual therapy, general conditioning exercise, biofeedback and mindfulness techniques, and vestibular therapy.

There is a wealth of data on the therapeutic effect of exercise in migraine patients. Interestingly, weight training seems to be more effective in the prevention of migraines than aerobic exercise.

Vestibular symptoms, such as dizziness and unsteadiness, are very common and are highly responsive to vestibular therapy.

Biofeedback is typically done by mental health professionals, but also by physical therapists. Over 100 clinical trials have been performed utilizing biofeedback in the treatment of headaches. The consensus is that this is a very effective technique.

An additional benefit that physical therapists can provide is what psychologist call a shift in locus of control, from internal to external. This means that instead of feeling like a victim of external uncontrollable circumstances, people acquire agency and cam actively do things to help themselves. This shift has been consistently shown to increase the efficacy of headache and pain treatment.

Botox in pregnancy

By: Dr. Mauskop

24-07-2023

Alternative Therapies, Botox, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant women receiving Botox for various medical and cosmetic reasons, and no evidence suggests that the fetus gets harmed during this treatment. The botulinum toxin molecule is too large to cross the placenta and enter the circulation of the fetus, which further supports its safety during pregnancy.

An analysis of pregnancy outcomes after onabotulinumtoxinA exposure over a 29-year period was conducted to gain more insights into the safety of the treatment during pregnancy. The researchers examined data from the Allergan Global Safety Database from 1990 to 2018, focusing on pregnant women or those who became pregnant within three months of receiving onabotulinumtoxinA treatment. They analyzed the outcomes of these pregnancies to estimate the prevalence of birth defects in live births.

Out of 913 pregnancies, the study considered 397 with known outcomes. The majority of the mothers were 35 years or older, and most of the onabotulinumtoxinA exposures occurred before conception or during the first trimester of pregnancy. Among the 197 fetuses from 195 pregnancies, there were 152 live births and 45 fetal losses (including spontaneous and elective abortions). Four of the 152 live births had abnormal outcomes, with one major birth defect, two minor fetal defects, and one birth complication. The overall prevalence of fetal defects in live births was 2.6%, with a prevalence of 0.7% for major defects, similar to the rates seen in the general population. Among the cases with known exposure times, one birth defect occurred with preconception exposure and two with first-trimester exposure.

While the study has some limitations due to the nature of the data collected, the results indicate that the rate of major birth defects in live births exposed to onabotulinumtoxinA is consistent with the rates seen in the general population. However, it is important to note that there is limited data available for exposure during the second and third trimesters of pregnancy. Nevertheless, this updated and expanded analysis provides valuable real-world evidence for healthcare providers and their patients when considering Botox treatment during pregnancy.

I’ve treated more than a dozen pregnant women in my 30 years of using Botox for migraines. Some of them received Botox during more than one pregnancy. Some pregnant women sought Botox treatment specifically because they preferred to avoid taking any medications during pregnancy. Their decision was justified. When it comes to migraine drugs, including over-the-counter pain medications, they carry a higher likelihood of causing harm during pregnancy.

Controlled trial of meditation for migraines

By: Dr. Mauskop

17-07-2023

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

Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to 45 minutes. I have found that sumatriptan has always been very effective and migraines have never disrupted my daily life, even when I experienced prolonged periods of daily headaches. Because of meditation I hardly ever need to take sumatriptan. My personal experience and that of many of my patients align with the viewpoint of a small group of headache specialists who believe that triptans do not cause medication overuse headaches.

Mindfulness has been gaining a lot of attention as a potential way to manage migraines, but there haven’t been many scientific studies to support this. A group of Italian researchers investigated whether a specific mindfulness-based treatment, consisting of six sessions of mindfulness practice and daily self-practice, would be effective when added to the usual treatment for patients with chronic migraine and medication overuse headaches.

They conducted a study with 177 patients. Half of the participants received the usual treatment alone, which included withdrawing from overused medications, education on proper medication use and lifestyle, and tailored prevention. The other half received the usual treatment plus the mindfulness-based intervention.

They looked at various factors to assess the effectiveness of the mindfulness-based treatment, including headache frequency, medication intake, quality of life, disability, depression and anxiety, sensitivity to touch, awareness of inner states, work-related difficulties, and disease-related costs.

After analyzing the data, they found that the patients who received the mindfulness-based treatment in addition to the usual treatment had better outcomes. They were more likely to achieve a significant reduction in headache frequency compared to their baseline (at least 50% reduction), and they also showed improvements in other areas such as quality of life, disability, headache impact, productivity loss due to headaches, medication intake, and healthcare costs.

They concluded that adding a six-session mindfulness-based treatment, along with daily self-practice, to the usual treatment is more effective than the usual treatment alone for patients with chronic migraine and medication overuse headaches.

PTSD biomarkers

By: Dr. Mauskop

12-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, post-traumatic headache, Psychology of headaches

Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder (PTSD). These biomarkers could lead to more accurate methods of screening for PTSD, allowing for early intervention and prevention strategies. Additionally, they could help monitor treatment progress, identify different subtypes of PTSD, and enhance our understanding of the underlying mechanisms of the disorder.

The study was conducted by the PTSD Systems Biology Consortium, initiated by the Department of Defense, and involved approximately 45 researchers. The team analyzed blood samples from 1,000 active-duty Army personnel from the Fort Campbell Cohort (FCC), who were assessed before and after deployment to Afghanistan in 2014.

The researchers focused on four biomarkers: glycolytic ratio, arginine, serotonin, and glutamate. They categorized the participants into four groups based on their PTSD symptoms, resilience levels, and clinical assessments. The findings revealed that individuals with PTSD or subthreshold PTSD had higher glycolytic ratios and lower arginine levels compared to those with high resilience. Additionally, participants with PTSD exhibited lower serotonin and higher glutamate levels. These associations were independent of factors such as age, gender, body mass index, smoking, and caffeine consumption.

The study results require further validation. The researchers also aim to determine the optimal time to screen soldiers for PTSD, considering the psychological challenges that arise around 2 to 3 months post-deployment. Moreover, they recognize the need for gender-specific biomarkers to improve the clinical assessment of female soldiers, given the increasing number of women serving in combat roles.

Ultimately, these findings may apply to the civilian population experiencing PTSD.

Weather and headaches – AI confirms the connection

By: Dr. Mauskop

05-06-2023

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

The fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have investigated this relationship, but the findings have been inconsistent. The reported weather triggers range from humidity and strong winds to heat, cold, and barometric pressure changes.

In a recent study, Japanese researchers analyzed data collected from a smartphone app used by 4,375 individuals who experience headaches. By employing statistical and deep learning models, they aimed to predict the occurrence of headaches based on weather factors. The results of their study have been published in Headache, the journal of the American Headache Society.

The research confirms that headaches are more likely to occur under specific weather conditions. Low barometric pressure, barometric pressure changes, higher humidity, and rainfall were identified as factors associated with a higher occurrence of headaches.

This finding is not just a matter of curiosity; it has practical implications. There are several options besides moving to a place with a consistently mild climate, such as Southern California. For instance, low barometric pressure headaches can sometimes be prevented with the use of acetazolamide (Diamox), a medication commonly prescribed for mountain sickness. Setting up a Google Alert or using an app like WeatherX can provide warnings when barometric pressure drops. This allows individuals to take preemptive measures such as taking acetazolamide to prevent a headache the following day. Adopting general measures such as regular exercise, meditation, a healthy diet, and sufficient sleep can also help mitigate the effects of weather-related headaches.

Structural brain connectivity predicts pain

By: Dr. Mauskop

29-05-2023

Head trauma, Headaches, Migraine, Pain, Pain Research, post-traumatic headache

In a recent post, I mentioned a study in which researchers using functional MRI (fMRI) were able to link functional connectivity within the default mode network (DMN) and between DMN and executive control network (ECN) with the degree of disability in migraine patients.

In a new study published in the journal Pain, researchers examined the brains of patients with mild traumatic brain injury (mTBI) using fMRI imaging to understand the brain networks associated with early acute pain following a motor vehicle collision. Here are some key findings:

The properties of the brain’s white matter explained a significant portion of the variation in pain experienced after mTBI. This suggests that certain brain features make patients more likely to report higher levels of pain after the injury.
These white matter connections are associated with physiological and psychological characteristics related to pain sensitivity. The interactions between these connections and parameters of sensory testing and pain sensitivity can explain about one-third of the variability in pain.
The connectivity patterns in the brain’s white matter do not change over time, as observed up to a year after the injury. The same connectivity measures collected shortly after the injury and at six months post-injury can predict the level of pain reported by patients at the six-month mark.
The study further indicates that the strength of white matter connections in the sensorimotor, thalamic-cortical, and default-mode networks is associated with pain severity. These findings highlight the involvement of these brain networks in pain perception and suggest that connections within these networks can influence the experience of pain.

Over the past decade, scientists have been increasingly interested in functional connectivity, which is a way of finding networks in the brain that are related to particular activities, including resting. One of the most prominent networks is the default mode network.

The DMN is most active when the brain is at rest. When the brain is directed towards a task or goal, the default network deactivates. The DMN involves low-frequency oscillations of about one fluctuation per second.

The DMN is thought to be involved in a variety of cognitive functions, including self-awareness, social cognition, memory, thinking about the future, and daydreaming. The DMN is also thought to be involved in some psychiatric disorders, such as depression, post-traumatic stress disorder, obsessive-compulsive disorder, schizophrenia, and others.

The findings of this study suggest that the brain’s white matter networks plays an important role in pain perception, and that understanding these brain-pain relationships may lead to new treatments for pain in individuals with mTBI.

These brain networks are not fixed and we already have tools to improve their function. Meditation is one of the most effective and accessible such tools. Meditation has been shown to increase connectivity between different brain regions, including those involved in pain perception. It has also been shown to reduce the activity of pain-related brain regions. In addition to meditation, other things that people can do to improve the function of their brain networks and reduce pain include exercise and sleep.

Migraine, strokes, and oral contraceptives

By: Dr. Mauskop

22-05-2023

Brain disorders, Headaches, Migraine, Migraine in pregnancy

Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for individuals with migraines. The results of their study were recently published in the journal of the American Headache Society, Headache.

The overall stroke risk among OCP users in this study was low. Out of the 203,853 women aged 18-55 who used OCPs, 127 were confirmed to have had a stroke. The case group had a higher proportion of individuals diagnosed with migraines (34/127, 26.8%) compared to a control group of 635 women (109/635, 17.2%; p = 0.011). The risk of stroke was higher among those using OCPs with 30 mcg or more of estrogen compared to those using OCPs with less than 30 mcg. Having a personal history of migraines increased the likelihood of stroke compared to those without migraines. There was no significant increase in stroke risk among those with migraine with aura, but migraine without aura did increase the risk.

Interestingly, previous studies have suggested the opposite—that migraine with aura carries a higher stroke risk compared to migraine without aura. The researchers speculate that this discrepancy could be because patients with migraine with aura are rarely prescribed OCPs, and the number of such patients in this study was small.

Traditionally, young and healthy women diagnosed with migraine with aura have been advised against using estrogen contraceptives due to concerns about increased stroke risk compared to those without aura. However, the risk of unintended pregnancies should be weighed against the risk of a stroke. The authors emphasize the need for proper patient education and shared decision-making when it comes to starting contraceptives in women with a history of migraines, including those without aura. OCP formulations with less than 30 mcg of estrogen are preferred to minimize the risk of stroke.

Avoid screen time after a concussion

By: Dr. Mauskop

15-05-2023

Brain disorders, Head trauma, Headaches, Headaches in children, Migraine

A new study published in JAMA Pediatrics found that engaging in screen time within the first 48 hours after concussion may prolong recovery time. The study was conducted by researchers at UCSF. They looked at data from 125 patients aged 12 to 25 who had recently been diagnosed with a concussion. The participants were divided into two groups: one group was allowed to use screens, and the other group was asked to abstain from screen time.

The study found that the group permitted to use screens had a significantly longer median recovery time of 8.0 days compared to 3.5 days in the group that abstained from screens. Additionally, individuals who used screens reported experiencing more symptoms such as headaches, dizziness, and fatigue. The screen time permitted group reported a median screen time of 630 minutes during the intervention period, while the screen time abstinent group reported 130 minutes.

The study’s authors concluded that avoiding screen time in the first 48 hours after concussion may help to shorten the duration of symptoms. However, this was a relatively small study and more research is needed to confirm these findings.

In a recent post, I mentioned a large Canadian study that showed that early return to school after a concussion was associated with better outcomes. These two reports are not contradictory. Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations. Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental.

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.