Headaches | Headache NewsBlog

Primary stabbing headache

By: Dr. Mauskop

22-05-2022

Primary stabbing headache is a rare disorder. Because it is rare, it is often misdiagnosed and not treated properly. This post was prompted by a patient with this condition I saw last week. She went undiagnosed for 45 years.

This 57-year-old woman has been having intermittent headaches since age 12. Her headaches would occur in bouts lasting anywhere from a few days to a couple of weeks. She’s had periods of up to a year without any headaches. Her latest period of daily headaches has been the longest – it has lasted almost 4 weeks and was still ongoing. Her headaches were left-sided and localized to the temple. The pain was very severe in intensity (9 on a 1 to 10 scale), sharp and stabbing in character. The pain lasted only a second but occurred 1-2 times an hour. She was having difficulty working as her work involved being in a videoconference all day long. She had no associated tearing, nasal congestion, nausea, or sensitivity to light or noise. She was taking 400 to 800 mg of ibuprofen with modest relief. During one of her previous bouts, she had tried gabapentin, 100 mg three times a day, which helped initially, but then became ineffective and she stopped it.

As is the case with all rare conditions, controlled treatment trials are very difficult to do. Anecdotally though, indomethacin, a strong anti-inflammatory drug, seems to be very effective. Gabapentin, which the patient tried in a small dose, has been also reported to help. I prescribed indomethacin as her first treatment.

If headaches persist or if indomethacin causes stomach upset or other side effects, I will start her on gabapentin, 300 mg three times a day. There are two other rare indomethacin-sensitive headache types – hemicrania continua and chronic paroxysmal hemicrania. A few reports suggested that an herbal supplement, Boswellia can be effective for patients who cannot tolerate indomethacin. After that, another reasonable option would be to try Botox injections. Botox has been reported to help hemicrania continua, chronic paroxysmal hemicrania, cluster, and other types of headaches. Because the area where she experiences pain is small and circumscribed, she will need a very small amount of Botox, making it relatively inexpensive.

Attend RetreatMigraine, online or in person

By: Dr. Mauskop

17-03-2022

Headaches, Migraine, New treatments, Psychology of headaches

I am honored to speak (in person) at this patient advocacy event. My topic will be, When treatments stop working, what’s next?

Here is some information and a link:

RetreatMigraine 2022: April 1-3 at Hilton Charlotte University Place
RetreatMigraine is a conference specially designed by and for adults living with migraine disease. The multi-day event brings together patients, care partners and migraine experts to support and strengthen our community. In 2022 RetreatMigraine will be a hybrid event. In-person capacity is for 300+ attendees and virtual capacity is unlimited. The conference offers interactive sessions that provide disease and treatment education, advocacy training and complementary therapy experiences.
This conference is organized by CHAMP – Coalition for Headache and Migraine Patients.

Migraine World Summit is on again and it offers a wealth of information

By: Dr. Mauskop

24-02-2022

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

I am happy to announce that you can attend the Migraine World Summit free of charge. It is back on March 16-24, 2022 for its 7th annual virtual event. As one of the former presenters, I can tell you that you may greatly benefit from learning about the latest research on how to best manage migraine.

Migraine World Summit is a 9-day event where 32 of the world’s leading experts on migraine and headache research are interviewed on topics voted on by real patients. These interviews are online and can be accessed from anywhere in the world, but are only available free during the 9-day event.

Get your ticket today at MigraineWorldSummit.com

Repetitive transcranial magnetic stimulation relieves migraines

By: Dr. Mauskop

18-12-2021

Alternative Therapies, Headaches, Migraine, neurostimulation, New treatments

Magnetic stimulation with a single pulse has been shown to be effective in aborting a migraine attack with the eNeura Spring TMS device.
Repetitive magnetic stimulation (rTMS) of the brain has been shown to relieve depression. A pilot study just published in the journal Brain Stimulation examined the effectiveness of repetitive magnetic brain stimulation for the prevention of migraine attacks.

German and Moldovan researchers conducted a double-blind, randomized controlled study in patients with episodic migraine. They compared real and sham stimulation in 60 patients. Participants received six treatment sessions over two weeks. The primary outcome measure was the number of patients whose migraine days dropped by 50% or more. The frequency and intensity of migraine attacks over a 12-week period were also assessed.

Real rTMS produced at least a 50% reduction in migraine days in 42%. This number was 26% in the sham group. The mean migraine days per month decreased from 7.6 to 4.3 days in the real rTMS group and from 6.2 to 4.3 days in the sham rTMS group. The reduction in migraine attack frequency was also higher in the real rTMS compared to the sham group. No serious adverse events were observed.

There are a couple of practical issues with this treatment approach. The rTMS equipment is already being used for depression, which in theory should make it easy to adapt for migraines. However, this treatment is time-consuming and expensive and is not likely to be covered by insurance. Another problem, which we also encountered in our study of transcranial direct current stimulation, is that there are many variables to consider. Placement of electrodes, the strength of stimulation, frequency, and duration of treatments are some of these variables.

Sublingual ketamine for pain

By: Dr. Mauskop

28-11-2021

Headache medications, Headaches, Migraine, Pain

Ketamine was approved by the FDA in 1970 and was originally used for the induction of anesthesia. It has been shown to relieve depression and is also widely used to treat pain. For depression, it is approved by the FDA in a nasal spray form. For severe pain, it is often given intravenously. Oral ketamine is probably the least effective.

In a recent study, Australian researchers compared the pain-relieving effect of oral and sublingual ketamine in 16 patients. The study was double-blind. Sublingual administration of ketamine resulted in a faster onset of pain relief – 7 minutes with sublingual and 13 with oral. Side effects were also more common with the sublingual route. In all other measures, sublingual and oral administration produced similar pain-relieving effects.

Oral and sublingual ketamine are not available at regular pharmacies. It is, however, easily made up by compounding pharmacies. The sublingual ketamine is available as a lozenge which is also called troche. I usually prescribe ketamine infusions or troches only after a wide variety of other treatments do not provide relief.

Ketamine is a controlled drug with a potential for misuse. It can also cause psychiatric side effects such as hallucinations, disinhibition, delusional thinking, and depression.

Zürich headache conference

By: Dr. Mauskop

08-11-2021

Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine

With Swiss colleagues Drs. Caterina Podella, Livia Granata, and Reto Agosti at the headache conference held on November 4, 2021, in Zürich.
Dr. Podella presented a very comprehensive approach to the treatment of migraine headaches. Dr. Granata expertly covered the topic of cluster headaches. I spoke about the challenges of treating refractory migraine headaches and Dr. Agosti provided a lively and insightful discussion of all these topics.

Dr. Mauskop to speak on refractory migraines in Zurich, Switzerland

By: Dr. Mauskop

14-10-2021

Chronic migraine, Headaches, Migraine, New treatments

I am honored to participate in a symposium on headache management,
“THE CHALLENGE OF MIGRAINE AND CLUSTER HEADACHES”. The title of my presentation is The challenge of migraine: new perspectives in refractory cases

This interactive neurological conference will be held in-person on Thursday, November 4, 2021 at the Zurich Marriott Hotel, Zurich, Switzerland

Response to drugs is influenced by psychological factors

By: Dr. Mauskop

11-10-2021

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

To gain FDA approval a drug has to be shown to be better than a placebo. The placebo effect is a well-established psychological contributor to the efficacy of most treatments.

A group of Italian researchers just published an interesting study looking at other psychological factors that might influence the response to treatment.

They evaluated chronic migraine patients who were treated with erenumab (Aimovig). Erenumab is a monoclonal antibody that targets CGRP, a neurotransmitter involved in the development of migraine attacks.

Monthly erenumab injections were given for one year to 75 patients with chronic migraine who had already failed at least three other oral preventive drugs. A full psychological evaluation assessed personality disturbances, mood and anxiety disorders, as well as childhood traumas, and ongoing stressors.

After 12 months of treatment, 53 patients had at least a 50% drop in the number of headache days per month. The other 22 did not. When compared to responders, non-responders were more likely to have personality disorders with anxious-fearful, avoidant, dependent, and obsessive-compulsive features. Non-responders were also more likely to suffer anxiety disorders and had a higher number of current major stressors.

A very practical application of these findings is that doctors need to address anxiety when treating migraine and chronic pain patients. I’ve seen a number of patients whose migraines improved with an SSRI antidepressant such as fluoxetine (Prozac) or escitalopram (Lexapro). SSRIs do not possess pain-reliving properties. However, they are good at relieving anxiety and so can indirectly improve migraines. Most of the time, I prescribe SNRIs such as duloxetine (Cymbalta) or a tricyclic antidepressant such as nortriptyline (Pamelor) because they relieve anxiety and can have a direct pain-relieving effect.

The old dogma in psychology was that you cannot change your personality. We now know that such change is possible. Different types of cognitive-behavioral therapy (CBT) can be very helpful. Swedish researchers showed that even a brief internet-based CBT can produce long-term changes in personality traits.

A large study shows that the weather affects pain

By: Dr. Mauskop

27-09-2021

Alternative Therapies, Chronic migraine, Headaches, Migraine, Pain, Pain Research

Many migraine sufferers report that their migraines are brought on by the weather. High humidity, high temperatures, and changes in barometric pressure are the most commonly reported triggers. I’ve seen some patients for whom changes in the weather is the only trigger. Research studies looking at this connection, however, have been contradictory.

A very large study just published in Pain, the journal of the International Association for the Study of Pain examined a possible connection between the weather and pain tolerance.

The data from 18,000 Norwegians aged 40 years or older from the general population were examined. All of them underwent pressure pain tolerance (PPT) test using a blood pressure cuff and cold pain tolerance (CPT), tested by immersing the dominant hand in cold water.

The results showed a clear seasonal variation in CPT. Cold pain tolerance was worse during the warmer times of the year compared with January. There was no seasonal variation in PPT.

The authors also found that temperature and barometric pressure have “a causal and dynamic effect on pain tolerance, which supports the common belief that weather affects pain.”

There is not much you can do about the weather except for moving to a place with an unchanging and mild climate. Some of my patients with barometric pressure-induced headaches do respond to acetazolamide (Diamox). This is a diuretic that prevents mountain sickness in climbers. Patients do not need to constantly check the weather forecast. For more information on acetazolamide, see my previous blog post.

A new, better DHE nasal spray is approved for acute migraines

By: Dr. Mauskop

06-09-2021

Chronic migraine, Headache medications, Headaches, Migraine, New treatments

Trudhesa is a new formulation of dihydroergotamine (DHE) nasal spray just approved by the FDA. It appears to be more effective than the original DHE nasal spray (Migranal) that was introduced in 1997.

Ergotamine, the first migraine-specific drug was developed in 1926. It is still available in tablet form but is not widely used because it causes nausea, constriction of blood vessels, and other side effects. DHE, approved in 1946, was the first synthetic migraine drug. It was derived from ergotamine in an attempt to reduce side effects. DHE is not effective when taken by mouth and was originally approved for intravenous use. It is still being used now – 75 years later – intravenously, intramuscularly, and subcutaneously. DHE injection is a very effective medicine, often used when no other migraine drug provides relief. It does cause nausea and vomiting in a significant number of patients. This is why it is often given along with an anti-nausea drug such as ondansetron (Zofran), prochlorperazine (Compazine), or metoclopramide (Reglan).

The original DHE nasal spray has been a relative disappointment. It is not very effective, although there are some patients for whom it works well. Despite being on the market for over 20 years, it is still very expensive – $100 a dose. The manufacturer of Trudhesa, which is a better product than Migranal, is promising to make their product more affordable. Nasal delivery of DHE causes less nausea than an injection.

Trudhesa is more effective despite delivering a smaller dose of DHE than Migranal. This is because Trudhesa is delivered as a fine mist into the upper reaches of the nasal cavity. It will become available in about two months. I will prescribe it to patients for whom oral medications are ineffective.

Placebo really works, even if you know it’s placebo

By: Dr. Mauskop

30-08-2021

Alternative Therapies, Headache medications, Headaches, Migraine, Pain, Pain Research, Psychology of headaches

The placebo effect is a bane of clinical trials. A drug is considered ineffective if it is only as good as a placebo. And placebo can be quite good. Intriguingly, the placebo effect in clinical trials has been getting stronger over the past few decades. Lately, placebo has been receiving a lot of attention from researchers.

A rigorous study just published in the journal Pain looked at the effect of a placebo when patients were clearly told that they are taking a placebo. These patients were compared to those who were given a placebo in a double-blind study of peppermint oil capsules for irritable bowel syndrome (IBS). These two different types of placebo were compared to a control group of patients who were not given any pills.

Participants treated with an open-label placebo and a double-blind placebo reported similar and clinically meaningful improvements in IBS symptoms. These improvements were significantly greater than in those who were not given any pills. The results were statistically significant for the primary outcome measure (IBS Symptom Severity Scale) as well as for mean global improvement scores.

Twice as many patients in the double-blind placebo group had side effects (mostly gastrointestinal, such as heartburn) than those in the open-label placebo. It is probably because the first group was told about the possible side effects of peppermint oil.

The authors concluded that an open-label placebo “could play a role in the management of patients with refractory IBS”.

Just like migraines, IBS involves central sensitization and hypersensitivity of the nervous system. And just like with migraines, placebo response in clinical trials of IBS tend to be high. This is not to suggest that these conditions are psychological. Especially with migraines, the biological basis is well documented. Psychological factors, however, cannot be ignored. About 40% of patients with chronic pain, including migraines, have a history of emotional, physical, or sexual abuse. Post-traumatic stress disorder of other types also causes hypersensitivity of the central nervous system. Psychological factors can even be the cause of such potentially deadly conditions as broken heart syndrome (Takotsubo cardiomyopathy). It is likely that the placebo effect is stronger in conditions where psychological factors are more pronounced.

It is considered unethical to prescribe a placebo to patients without telling them that they are getting a placebo. This latest study suggests that some patients may improve even if they know that they are taking a placebo.

I do prescribe herbal supplements such as feverfew and boswellia and on a rare occasion, a homeopathic remedy, all of which lack rigorous proof of their efficacy. For that matter, many drugs we prescribe for migraines lack such definitive proof. I would suggest that we should first prescribe less harmful unproven remedies rather than unproven prescription drugs.

Dividing migraines into chronic and episodic was a costly mistake

By: Dr. Mauskop

17-06-2021

Botox, Chronic migraine, Headaches, Migraine, Science of Migraine

The international classification of headache disorders lists many different types of migraines – migraine with aura, hemiplegic, retinal, chronic, and others. Chronic migraine is present if a person has a headache on 15 or more days each month. If the headache is present on fewer than 15 days, the condition is called episodic migraine.

The division into chronic and episodic migraine is not based on any scientific evidence. Research by Dr. Richard Lipton and his colleagues showed that patients often cycle from chronic into episodic migraines and back. This happens even without any treatment.

An international group of headache experts (some of whom participated in the decision to split migraines into chronic and episodic) just published a repudiation of this arbitrary designation.

They concluded: “Our data suggest that the use of a 15 headache day/month threshold to distinguish episodic and chronic migraine does not capture the burden of illness nor reflect the treatment needs of patients.”

One damaging aspect of having a category of chronic migraine as it applies to clinical practice is the fact that Botox is approved only for chronic migraines. I know from 25 years of experience injecting Botox that it works very well for some patients who have as few as four migraines a month. Unfortunately, insurance companies do not pay for Botox unless you have chronic migraine. This deprives many patients of this very effective and safe treatment.

The second very costly effect is on the research of new preventive drugs. The FDA requires a separate set of studies for chronic and episodic migraines. These additional trials of the four approved injectable CGRP monoclonal antibodies added many millions of dollars to the development costs. The trials showed good relief for both episodic and chronic migraine sufferers.

Hopefully, the next, fourth classification of headache disorders will eliminate the category of chronic migraines.