Headaches
Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the family of gepants. These drugs abort migraine attacks by blocking the CGRP receptor. CGRP (calcitonin gene-related peptide) is released during a migraine attack. Blocking this molecule or the receptor it attaches to relieves migraines in about 50% of people.
There are four CGRP monoclonal antibodies, or mAbs, that are injected once every one or three months to prevent migraine attacks. Gepants are taken by mouth. Two of them – ubrogepant (Ubrelvy) and rimegepant (Nurtec) – are approved for the acute treatment of migraine attacks. Rimegepant, along with atogepant (Qulipta), is also approved for the prevention of migraines.
Nasal sprays to treat migraines have the advantage of faster onset of action. They are particularly useful for people who have nausea or vomiting and have difficulty absorbing or holding down oral medications. Other migraine drugs in a nasal spray include sumatriptan, zolmitriptan, dihydroergotamine, and ketorolac. For patients for whom these older drugs are ineffective, cause side effects, or are contraindicated, zavegepant could be a very good option.
If there are no contraindications for the use of a triptan (e.g. heart or other vascular diseases), I would use sumatriptan first because of the cost. It is also likely that insurance companies will require that the patient fails sumatriptan before they agree to pay for a new and more expensive drug. This is what they usually require before paying for oral gepants.
Here is a list of what I consider to be the top 10 acute medications to treat migraine from the second edition of my book, The End of Migraines: 150 Ways to Stop Your Pain. I might add zavegepant to the next edition of this book.
- Sumatriptan
- Rizatriptan
- Eletriptan
- Naratriptan
- Zolmitriptan
- Rimegepant
- Ubrogepant
- Aspirin/caffeine/acetaminophen
- Naproxen
- Ibuprofen
I am honored to speak at this year’s Migraine World Summit on Sunday, March 12. My topic is Safety Update: DHE, Triptans, Magnesium, Butterbur, and more.
The Migraine World Summit gives you a chance to improve your understanding of migraine headaches. 2023 dates: March 8-16. Register for free access at MigraineWorldSummit.com Call: 8885256449, Email: info@migraineworldsummit.com Facebook: www.facebook.com/MigraineWorldSummit/ Instagram: @migrainesummit
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In a recent blog post, I wrote about the benefit of different types of exercises for the relief of migraines and other types of headaches. It mentioned that strength training may be more beneficial than aerobic (cardio) exercise. A study just published in Nature Communications suggests that the time of day when you exercise also matters. Not specifically for headaches but for “all-cause and cardiovascular disease mortality”.
This was a very rigorous study of 92,139 UK participants over an average of 7 years of follow-up which added up to 638,825 person-years. The timing of exercise was recorded by an activity tracker (accelerometer). Moderate-to-vigorous intensity physical activity at any time of day was associated with lower risks for all-cause, cardiovascular disease, and cancer mortality. However, the morning group (5:00 – 11:00), midday-afternoon (11:00 – 17:00), and mixed timing groups, but not the evening group (17:00-24:00), had lower risks of all-cause and cardiovascular disease mortality.
This study suggests that exercising before 5 PM has more health benefits than exercising after 5. It is likely that this may also apply to the relief of migraines and other headaches.
Read MoreIn a post last August, I mentioned that zinc could possibly extend the duration of the effect of Botox. A new report by Chinese neurologists in Headache describes their findings of an inverse association between dietary zinc intake and the occurrence of migraine in American adults.
The researchers used the data from a five-year study conducted by the CDC to assess the health and nutritional status of Americans. Data were collected using a computer-assisted dietary interview system which proved to be very reliable. Over 11,000 adults were included in the analysis of zinc intake. These subjects were divided into quintiles, according to their zinc intake. The data were adjusted for various confounding factors. These included age, sex, race, ethnicity, smoking status, body mass index, and others.
People in the lowest quintile were at least 30% more likely to suffer from migraine compared to people in the other four quintiles. Associaion does not mean causation and this study does not prove that taking zinc will prevents migraines. However, a few small studies did show the benefit of taking a zinc supplement in migraine patients.
Checking your blood for zinc levels before taking a supplement would be ideal. However, there is very little downside to taking 10-25 mg of zinc daily even if you don’t know your zinc level.
Zinc is very important for the normal functioning of the immune system, it possibly prevents macular degeneration, and has many other benefits. Taking too much zinc can cause serious side effects. The effects of zinc toxicity are mostly due to the lowering of copper levels.
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Insomnia is a very common problem. Sleep aids, over-the-counter and prescription have been proven to be harmful if taken long-term. They even raise the risk of Alzheimer’s.
A small dose of melatonin (300 mcg, or 0.3 mg) can help better than the usual 3 mg dose sold in most stores. You can also try valerian root and definitely adhere to sleep hygiene. This includes no reading or watching TV in bed, no screens for at least an hour before bedtime, no eating or exercising within two hours of going to bed, and sleeping in a cold room (65 to 68 degrees). Going to bed at the same time also helps.
If you still can’t fall asleep, try visualization. Actually, you don’t just use your visual memory but engage all the senses. This post was prompted by a WSJ article on this topic, A Happy Memory Can Help You Fall Asleep, if You Know How to Use It.
I usually imagine myself on a beach in a hammock under a tree, feeling a warm breeze on my body, seeing a beautiful view of the beach and the ocean, smelling fragrant flowers, and hearing the sound of waves lapping at the shore.
Once you find your happy place and can vividly recreate it, always use the same setting without variation. This way you will fall asleep within minutes.
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Migraine surgery is controversial. I would not consider it until most of the less invasive options have been tried. In my latest book, I give migraine surgery a score of 3, on a 1 to 10 scale. This rating may not be fair because clinical trials suggest that it can be very effective for some patients.
So, when is a referral to a surgeon warranted? Dr. Lisa Gfrerer is highly qualified to address this topic. She will speak on January 25th at a dinner of the NY Headache Club, an informal gathering of headache specialists who practice in the greater NYC area. If you are a headache specialist and would like to attend, send me a message. The meeting is not open to the lay public.
Here is Dr. Lisa Gfrerer’s short bio.
Dr. Gfrerer is an Assistant Professor in Plastic and Reconstructive Surgery at Weill Cornell Medicine (WCM). She received her MD degree at the Medical School of Vienna prior to completing a PhD in Genetics at the Harvard Stem Cell Institute. She graduated from the Harvard Integrated Plastic Surgery Residency Program and completed the Advanced Peripheral Nerve and Microsurgery at the Massachusetts General Hospital (MGH). Clinically, her focus is peripheral nerve surgery including headache surgery, treatment of nerve pain and compression, breast reinnervation, as well as advanced nerve reconstruction for restoration of motor and sensory function after an iatrogenic and accidental injury. She has built a multi-institutional and multidisciplinary research program for headache surgery, breast/chest reinnervation, as well as functional nerve disorders and nerve pain. As an affiliate of the Massachusetts Institute of Technology (MIT) she has further focused on innovation and device development to enhance peripheral nerve regeneration.
Read MoreDaily multivitamin use was compared to cocoa extract in more than 2,200 people over 65. After three years, taking a cocoa extract had no benefit while taking a multivitamin led to a significantly slower age-related cognitive decline. This included measures of global cognition, memory, and executive function.
Many physicians discourage their patients from taking a multivitamin. They should stop. There is little downside to taking a multivitamin. It is very inexpensive and safe. Many people also feel that if they eat a well-balanced healthy diet they should not need to take vitamins. Unfortunately, that is not the case. Even foods that are considered healthy are often processed, stored for a long time, or grown in depleted soil. Another problem is that as we age our body loses its ability to absorb vitamins and minerals (as well as protein, which is a different topic).
Taking a multivitamin should be a standard recommendation for those over 65. Many younger individuals need supplements as well. Ironically, a healthy diet (especially vegan or vegetarian) is often deficient in vitamin B12. Many young people whom I see for migraine headaches are deficient in vitamin D and magnesium. The role of vitamin D is also often underappreciated by primary care doctors. Multiple studies have shown that your vitamin D level should be not only within the normal range but in the upper half of the normal range for your brain to function normally. Most people who died of COVID had low vitamin D levels. And I’ve written many times about the importance of magnesium – just search this blog.
Ideally, to approach this problem scientifically, you should have your vitamin and mineral levels checked. This will allow you to take only those vitamins that you are deficient in. the difficulty is that there are too many vitamins to check and the insurance companies often refuse to pay for these tests. Taking at least a multivitamin is a reasonable alternative.
Read MoreOpportunities & Challenges in the Management of Headache is one of the two annual courses organized by the Diamond Headache Clinic Research & Educational Foundation. This year, it will be held in San Diego from February 16th through February 19th.
The other annual event, Headache Update 2023 will be held in Orlando, Fl from July 13th through July 16th. Both courses have been always well attended and have been receiving very high marks from the attendees.
It’s been my privilege to participate in these annual courses over the past 25 years. This year I will be speaking on February 17th on Nutritional Approaches and Alternative Therapies in Migraine.
Read MoreMultiple posts on this blog have described clinical trials that prove the benefit of exercise for the prevention of migraine headaches.
Simplifying the statistics, compared to no exercise, strength training was 3.55 times more effective, high-intensity aerobic exercise was 3.13 times more effective, and moderate-intensity aerobic exercise was 2.18 times more effective.
For general health and for the prevention of migraines, 2-3 weekly sessions of strength training and 2-3 sessions of aerobic exercise would be an ideal regimen. As I mentioned in a recent post, an additional benefit of exercise is a larger brain volume. The only other intervention that has been shown to expand the brain and prevent its shrinkage with age is meditation.
Exercise and meditation are the first two recommendations on my list of top 10 treatments described in my latest book, The End of Migraines: 150 Ways to Stop Your Pain.
Read MoreAccording to a new report by Spanish researchers published in The Journal of Headaches and Pain, effective preventive treatment of migraines can improve cognitive impairment in patients with frequent attacks.
Patients with migraines often complain that their memory is not as good as it used to be, that they have difficulty concentrating, or can’t think clearly.
There are many possible causes of such symptoms. Stress is probably the most common reason people have trouble with memory and concentration. There is just too much on their mind. Certain drugs, most notably topiramate (Topamax), can cause pronounced cognitive impairment. Nutritional deficiencies, particularly of vitamin B12 and other B vitamins, magnesium and vitamin D can cause brain fog and other cognitive problems. Alzheimer’s disease, which is what people fear most, thankfully is rare at the age when most people suffer from migraines.
I also see patients who do not have any of the above reasons. There are several possible explanations for why migraines alone can cause cognitive problems. We know that if a patient has only a few attacks a month, the brain remains hyperexcitable even between attacks. Some patients have a prodrome – one or two days of brain dysfunction prior to an attack. Others have post-drome – a feeling of exhaustion as if being hungover for a day or two after the attack. There is also a likely contributing effect of anticipatory anxiety – living in fear of the next attack.
Christina Gonzalez-Mingot and her colleagues in Lleida, Spain, compared 50 control subjects and 46 patients with chronic migraine. These patients were evaluated using a battery of tests prior to the use of preventive treatment based on botulinum toxin (Botox) or oral drugs and after 3 months of this treatment.
Compared with controls, patients with chronic migraine had lower scores on three standard tests of cognitive performance and had lower quality of life. Three months after the use of preventive treatment, improvement was observed in all but one cognitive parameters and in the quality of life.
Read MorePsychedelics are being actively studied for depression and post-traumatic stress disorder (PTSD). These trials usually involve hallucinogenic doses. Microdosing psychedelic substances such as psilocybin, lysergic acid diethylamide (LSD), and methylenedioxymethamphetamine (MDMA) has become a popular treatment for depression. Microdosing means that the amount of a psychedelic is too low to cause hallucinations or other overt sensory experiences.
There is an accumulation of evidence that psychedelics can provide pain relief. A case series just published in the journal Pain describes three patients with chronic pain who obtained significant relief from microdosing psilocybin-containing mushrooms.
The first patient was a 37-year-old man with severe pain due to traumatic quadriplegia. He had almost complete relief of pain and was able to stop taking tramadol, an opioid analgesic, diazepam (Valium), and marijuana. The relief was ongoing for six months when he was last seen by the doctors.
The second patient was a 69-year-old woman with complex regional pain syndrome (also known as reflex sympathetic dystrophy) secondary to left leg trauma. She had tried nerve blocks, other invasive procedures, stem cell injections, acupuncture, opioid analgesics, and many other medications, all with no relief. At the time of the published report, microdosing was providing continued significant relief for over a year.
The third patient was a 40-year-old woman with pain in her leg due to degenerative disk disease in her spine. Her pain did not improve with epidural injections, back surgery, muscle relaxants, opioid drugs, and physical therapy. Psychedelic mushrooms had a profound effect on her pain.
Psychedelic mushrooms have been reported by many patients to be effective in the treatment of cluster headaches (see ClusterBusters.org). A small double-blind study by Yale researchers showed a beneficial effect of synthetic psilocybin in treating migraine headaches.
It remains to be proven that sub-hallucinogenic doses of psychedelic drugs provide relief of painful conditions. If proven effective, however, such drugs will offer a much safer option than any opioid and NSAID analgesics, epilepsy drugs, antidepressants, or any other prescription drug. They are very safe even at hallucinogenic doses.
I am often asked about the practical side of using psychedelic mushrooms – where to buy them, how much to take, and for how long. Since the state of NY, unlike some other states, has not legalized or decriminalized the use of psychedelic mushrooms, I cannot answer these questions. Even if it was legal for me to do, I would not have reliable answers until clinical trials give us good data.
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