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Migraine

In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared with traditional prescription medications for managing chronic pain.

The study involved 440 patients using medical marijuana and 8,114 patients treated with prescription medications (nonopioid or opioid) in the same healthcare system. Both groups received comprehensive pain assessments and treatment plans.

Key Findings

Response Rates: At three months, 38.6% of the medical marijuana group and 34.9% of the prescription medication group showed significant improvements in pain, function, or overall well-being. The response rate in the medical marijuana group remained stable at six months.

Opioid Reduction: Among the 157 patients in the medical marijuana group who were also prescribed opioids, there was a significant reduction in opioid use, with a mean decrease of 39.3% in morphine milligram equivalents over six months.

Comparative Effectiveness: The study found that medical marijuana was more effective than prescription medications for treating chronic pain, with patients being more likely to respond positively to medical marijuana.

This study suggests that medical marijuana may be at least as effective as, if not more effective than, conventional medications for chronic pain. It also highlights the potential of medical marijuana in reducing opioid use, which is a significant public health concern.

I prescribe medical marijuana to our migraine patients when prescription drugs and non-drug therapies are ineffective. For many, marijuana helps relieve nausea; for some, it helps with migraine-related anxiety and insomnia; and for a smaller proportion, it helps with pain. My observations are probably skewed by the fact that I prescribe medical cannabis only for people with more severe migraines. It may be more effective for people with mild migraines or migraines of average severity.

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New research from McGill University published in the journal Pain suggests that the tempo—or speed—of music plays a crucial role in how well it helps reduce pain.

In this study, researchers explored whether music that matches a person’s natural rhythm—called their spontaneous production rate (SPR)—could provide better pain relief. SPR is the pace at which people naturally hum or tap out a tune, almost like a personal internal metronome.

Sixty participants first had their SPR measured by tapping out “Twinkle Twinkle Little Star” at a comfortable pace. Later, they were exposed to mild heat pain while listening to music specially adjusted to three tempos: their exact SPR, 15% faster, or 15% slower. A silent condition was also tested.

The results? Music alone reduced pain compared to silence, confirming what many of us know instinctively—music helps us cope. But the biggest surprise was that music adjusted exactly to each person’s SPR provided the most pain relief. Faster or slower versions just weren’t as effective.

Why does this happen? We think it may be because music at our natural tempo syncs better with our body’s internal rhythms, helping us relax and shift focus away from pain.

What does this mean for you? The next time you’re using music to manage discomfort—whether it’s during a workout, a medical procedure, or just a headache—try finding songs that feel “just right” in speed. It might be your body’s way of telling you it’s syncing up for maximum relief.

This research paves the way for more personalized music therapy—helping us move from simply picking our favorite songs to using science-backed soundtracks tuned just for us.

 

Here is a part of the chapter on music from my book, The End of Migraines, 150 Ways to Stop Your Pain, providing additional scientific evidence that music can relieve pain.

‘Music relieves experimental pain in healthy volunteers who are paid to endure pain and music. In one study, 18 volunteers were subjected to pleasant music, unpleasant music, and a silent period. Heat-induced pain was reduced only by pleasant music.

Children with migraines exposed to music improved as much as those given butterbur extract. Both groups improved more than a control group.

Music relieved the pain of osteoarthritis in the elderly. Those who listened to music for 20 minutes a day felt better than those who sat quietly for 20 minutes.

A study of 20 volunteers showed that both happy and sad melodies reduced heat pain. Listening to a lecture did not.

Another group of researchers examined the potential pain-relieving properties of three aspects of music: arousal, valence, and depth. Arousing music is characterized as “intense, forceful, abrasive, or thrilling”. Valence refers to “fun, happy, lively, enthusiastic, and joyful”. Depth means “intelligent, sophisticated, inspiring, complex, poetic, deep, emotional, and thoughtful.” The degree of arousal and the depth of music had a greater effect on pain than valence. The authors concluded, “With the advent of online music streaming services, this research opens new possibilities for music-based pain interventions.”

The new study suggests that tempo is another factor to consider when choosing soothing music.

 

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It was an honor to participate in the 35th Annual Winter Symposium of the Headache Cooperative of the Northeast, held on March 7 and 8. Leading headache experts from across the country covered many interesting topics. I had the privilege of discussing a presentation by Dr. Chiang Chia-Chun of the Mayo Clinic on artificial intelligence in Headache Medicine.

Here is my PowerPoint presentation: Artifical Intelligence discussion (1)

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A new study published in the Annals of Neurology by researchers at UCSF challenges our current understanding of what constitutes “normal” vitamin B12 levels, particularly regarding brain health. The findings suggest that even B12 levels currently considered adequate may not be optimal for maintaining brain function, especially in older adults.

Key Findings

The study examined 231 healthy older adults with B12 levels that would typically be considered normal. Surprisingly, those with lower B12 levels – though still within the “normal” range – showed several concerning signs:

Slower nerve conduction in visual pathways

Reduced cognitive processing speed, particularly in older participants

More white matter damage visible on brain MRI scans1

Why This Matters

The current normal levels for vitamin B12 were determined decades ago, and it is not clear how reliable the research that led to these values was. Quest and Labcorp, two major chains of laboratories, define normal levels as 200 – 1,000 pg/ml and 232 -1,245 pg/ml, respectively. The WHO considers 480 pg/ml to be the bottom of the normal range, while it is 500 pg/ml in Japan. Some experts suggest these higher standards may contribute to lower rates of Alzheimer’s and dementia in Japan.

What This Means for You

Your B12 levels might be worth checking if you are experiencing neurological symptoms like:

Mental fogginess

Memory issues

Balance problems

Numbness or tingling

Migraine headaches, especially with visual auras

Dizziness

If you have this blood test done, don’t accept “it’s normal” from your doctor, but ask about your actual level.

 Why are so many people deficient

Ironically, a healthy diet is low in vitamin B12. Vegetarians are at a greater risk of becoming deficient. Another common factor is antacid medications such as omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and others. Genetic factors also play a role.

 Special Considerations for Older Adults

The study found that older adults may be particularly vulnerable to the effects of lower B12 levels. This is especially important because:

B12 absorption tends to decrease with age

The impact of lower B12 on cognitive processing speed was more pronounced in older participants.

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Recent advances in neuroimaging are bringing us closer to an objective diagnosis of migraines. Korean researchers have published groundbreaking findings showing that migraine sufferers exhibit distinctive structural and functional brain characteristics visible on MRI scans. Their report, A robust multimodal brain MRI-based diagnostic model for migraine: validation across different migraine phases and longitudinal follow-up data, was published last month in the Journal of Headache and Pain.

Currently, migraine diagnosis relies on patients reporting specific symptoms. These include one-sided head pain, moderate to severe intensity, throbbing sensation, nausea, sensitivity to light and noise, and worsening pain with physical activity. A diagnosis typically requires the presence of at least three of these symptoms. 

This new research confirms that migraines affect multiple brain networks rather than one area. The study identified three key markers: reduced thickness of certain parts of the brain’s cortex, changes in cortical folding patterns, and abnormalities in the brain’s visual, sensory-motor, and emotional processing networks. These findings represent a significant step toward more precise diagnostic tools for migraines. In the future, we may see a comprehensive diagnostic approach combining clinical symptoms, neuroimaging, and potentially other objective measures to provide more accurate diagnoses and targeted treatments.

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FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be as effective as Vicodin (hydrocodone with acetaminophen) after surgery to remove a bunion and after a “tummy tuck”.

Suzetrigine is a selective NaV1.8 inhibitor, targeting a key sodium channel involved in pain signaling. The NaV1.8 channel is crucial in transmitting nerve pain signals to the brain. However, the drug does not enter the brain and works only on the nerves outside the brain and in the body.

Unlike traditional pain medications such as opioids, suzetrigine provides effective pain relief without addiction risk or severe systemic side effects. Early clinical trials suggest it may be beneficial for conditions like neuropathic pain, post-surgical pain, and chronic pain syndromes. Hopefully, it will also prove effective in the treatment of migraines and other types of headaches.

In clinical trials, about 37% of patients experienced adverse events, though most were mild. These included itching, rash, constipation, and muscle spasms.

As a non-opioid option, suzetrigine provides clinicians with an additional tool for acute pain management. The medication is expected to become available in the second quarter of 2025. The expected cost is about $15 a pill.

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A new Cochrane meta-analysis has reaffirmed the significant role of magnesium sulfate in reducing the risk of cerebral palsy (CP) and death in preterm infants. This comprehensive review, which analyzed six randomized controlled trials involving nearly 6,000 pregnant participants, provides compelling evidence for the use of this inexpensive intervention in preventing lifelong disability.

The review revealed that magnesium sulfate administration to pregnant women at risk of premature delivery:

*Significantly reduced the risk of CP in children up to 2 years of corrected age (relative risk of 0.71)

*Decreased the combined risk of death or CP (relative risk of 0.87)

*Moderately reduced the risk of severe neonatal intraventricular (brain) hemorrhage

These findings underscore the importance of magnesium sulfate as a neuroprotectant for preterm babies, a recommendation that has been supported by the World Health Organization since 2015.

While not directly related to the CP study, it’s worth noting that magnesium also plays a crucial role in migraine prevention and treatment. Magnesium deficiency, which is present in almost half of migraine sufferers, leads to increased migraine frequency and severity.

Many neurologists recommend magnesium supplements as part of a comprehensive migraine prevention strategy. We sometimes check RBC magnesium levels (the more accurate test than serum levels) before recommending supplementation. Chelated forms of magnesium, such as magnesium glycinate, are better absorbed than magnesium oxide, which is the type most commonly sold in stores. Oral magnesium can help the majority of people who are deficient. About 10%, however, do not absorb oral magnesium. We have these patients come into our clinic for monthly infusions.

Both oral and intravenous magnesium are safe in pregnancy.

However, I have heard some doctors and patients express concern about the harmful effects of magnesium in pregnancy. Indeed, mothers who receive very large amounts of intravenous magnesium (thousands of grams) over a period of more than 5-7 days may deliver babies suffering from osteoporosis, bone fractures, and other problems.

The amount of intravenous magnesium we give our migraine patients is one gram. So, pregnant women can safely take oral magnesium and receive regular intravenous infusions of 1-2 grams of magnesium.

 

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The Chordate System, using a technique called Kinetic Oscillation Stimulation (K.O.S), has shown promising results in reducing monthly headache days for people with chronic migraines, according to a study just published by European neurologists in the journal Neurology.

The treatment involves gentle stimulation inside the nasal cavity using a specialized catheter that delivers precise pressure and vibrations. Each session lasts 10 minutes per nostril and is administered weekly. The device works by potentially modulating the trigeminal nerve pathways involved in migraine attacks.

Study design: The study was randomized, double-blind, and sham-controlled.

Participants: Patients with chronic migraine (defined as headaches occurring on 15 or more days per month, with at least 8 of those being migraine days). The active treatment was given to 67 patients and the sham to 65.

Treatment: Weekly K.O.S sessions for six weeks.

Primary Endpoint: Change in monthly headache days with moderate to severe intensity (MHDs) from baseline to the performance assessment period (days 14–42).

Secondary Endpoints: These included changes in monthly migraine days (MMDs), reductions in headache severity, use of abortive medications, and improvements in quality of life.

Key Findings

The results demonstrated that K.O.S provided significant benefits for patients with chronic migraine:

Reduction in Monthly Headache Days (MHDs):

Active treatment resulted in a reduction of 3.5 MHDs during the assessment period, compared to a 1.2-day reduction with sham treatment.

This improvement persisted into the follow-up period, with a 2.7-day reduction in MHDs compared to sham.

Reduction in Monthly Migraine Days (MMDs):

Patients receiving K.O.S experienced a 2.4-day reduction in MMDs during the assessment period with effects lasting into follow-up (2.9 days).

Responder Rates:

A significant proportion of participants achieved a 30% or 50% reduction in moderate-to-severe headache days, demonstrating the clinical relevance of K.O.S.

Safety Profile:

Adverse events were mild and similar between the active and sham groups, with nasopharyngitis, dizziness, and minor nosebleeds being the most common. Importantly, no treatment-related serious adverse events were observed.

 

This non-drug approach offers a new option for people suffering from chronic migraines, especially those concerned about medication side effects. The treatment’s effectiveness is comparable to current standard medications while offering a non-pharmaceutical alternative.

The Chordate System (Ozilia) is not currently available in the United States, as it has not yet received FDA approval. However, the company, Chordate Medical, is actively working toward getting it approved.

We do have several FDA-approved devices to treat migraines. The most effective, practical, and affordable are Cefaly and Nerivio. Relivion, Savi Dual, and gammaCore are less so.

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As a 68-year-old physician, I’m often asked about my own supplement regimen. Here is my approach to supplementation.

The uncomfortable truth about our modern diet is that even those of us eating “healthy” may not be getting adequate nutrition. Our food supply, while abundant, often lacks the nutrient density of previous generations. Even fresh vegetables and fruits grown in depleted soils may not provide the nutrition we expect. Having practiced medicine for decades, I’ve observed this reality in countless blood tests and patient outcomes.

My own blood tests have revealed borderline-low levels of vitamins D, B12, and magnesium – technically “normal” but at the bottom of the range. Scientific studies have shown that laboratory “normal” ranges are often too wide. When you’re at the bottom of that range, you’re likely functioning sub-optimally.

With few exceptions, herbal supplements are rarely subjected to large, controlled clinical trials. A rigorous study of turmeric showed that it improves memory. Astragalus has been subjected to many small clinical and preclinical studies that point to many possible benefits. Other herbal supplements I take have various degrees of evidence for their efficacy and safety.

You can see all the supplements I take in the photo below. You can also see the brands of these products. To select the best brands, I usually consult Consumerlab.com. This independent testing organization is funded by membership fees and does not accept advertising or payments from manufacturers. They provide an extensive description of clinical trials and potential side effects and rank the brands according to their quality and cost.

Psyllium husk (Yerba Prima brand) is also part of my routine. Beyond maintaining regular bowel movements, it’s helped lower my cholesterol and apoB levels – crucial markers for cardiovascular health.

I include creatine in my regimen, timing it within an hour of exercise. While many associate creatine with bodybuilding, research shows it also supports cognitive function – particularly valuable as we age.

While I’m sharing my personal protocol, remember that supplementation needs vary significantly between individuals. Factors like age, medications, health conditions, and even genetic variations can affect what supplements are appropriate. What works for me may not be right for you.

The need for supplementation in our modern world stems from multiple factors: aging-related absorption issues, medication effects, chronic stress, and changes in our food quality. When I compare the taste and quality of foods during my travels in France and Italy to what we typically find in American supermarkets, the difference is notable.

Remember, supplements are exactly that – supplemental to a healthy diet and lifestyle. They’re not magic pills but tools to optimize health in our modern environment. Always consult with your healthcare provider before starting any supplement regimen, especially if you’re taking medications or have underlying health conditions.

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Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of repetitive transcranial magnetic stimulation (rTMS) on pain sensitivity offers some intriguing insights.

What is rTMS?

rTMS is a non-invasive method of brain stimulation. It involves sending magnetic pulses to specific areas of the brain through a coil placed on the scalp. This technique has been used to treat conditions like depression and chronic pain, but researchers are now looking at its potential to prevent pain. We used rTMS at the New York Headache Center to treat chronic migraine, other pain and neurological conditions that do not respond to usual treatment.

In a controlled experiment, researchers led by Nahian Chowdhury examined the role of rTMS in reducing future pain in healthy volunteers. The results were published in the latest issue of Pain, a journal of the International Association for the Study of Pain.

The subjects were divided into two groups:

Active rTMS Group: Received high-frequency rTMS to the area of the brain responsible for hand movements.

Sham rTMS Group: Received a fake treatment for comparison.

Both groups were then given an injection of nerve growth factor (NGF) into their jaw muscles, which causes prolonged pain similar to temporomandibular disorders (TMD), a condition causing jaw pain and dysfunction.

Results:

Pain Reduction: Participants who received active rTMS reported significantly less pain when chewing or yawning than the sham group. This effect was more pronounced in the early stages after the injection but persisted for days and weeks.

Brain Activity: The study found an increase in what’s known as peak alpha frequency (PAF) after rTMS, which is linked to lower pain sensitivity.

What Does This Mean for Pain Management?

Preventive Potential: This research suggests that rTMS could be used prophylactically to reduce pain sensitivity when pain is expected, like before surgery.

Future Directions: While promising, this study opens the door to further research into how rTMS can be optimized for pain control, potentially exploring different frequencies, duration, and areas of stimulation.

Pre-Surgery: rTMS might be used to reduce postoperative pain, potentially preventing the transition to chronic pain.

Chronic Pain Management: For those already dealing with chronic pain, understanding how brain activity changes with rTMS could lead to more effective treatments.

Conclusion

While we are still in the early stages, this study of rTMS offers hope for pain sufferers. It suggests a future where we might not only treat pain more effectively but also prevent it from becoming a long-term problem. This could revolutionize our approach to pain management, making it less about reducing and enduring pain and more about preventing it from taking root in the first place.

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It’s an honor to have contributed, alongside Andrew Blumenfeld and Sait Ashina, a chapter on Botox injections to the upcoming textbook Headache and Facial Pain Medicine. Edited by Sait Ashina of Harvard Medical School and published by McGraw Hill, the book is set for release in 2025 but is already available on Amazon.

The book includes chapters on Primary Headaches, Secondary Headaches, Facial Pain and Cranial Neuralgias, Special Treatments and Procedures, Special Populations, and Special Topics. It is an excellent textbook for health care providers.

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“Dr. Mauskop,
Congratulations on hitting a new milestone – over 3800 citations of your articles! This places you in the top 5% for citations within the Doximity community.”
Some of the most cited articles:
– Intravenous Magnesium Sulphate Relieves Migraine Attacks in Patients with Low Serum Ionized Magnesium Levels: A Pilot Study
– Botulinum toxin type A for the prophylaxis of chronic daily headache: Subgroup analysis of patients not receiving other prophylactic medications: A randomized double-blind, placebo-controlled study
– Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain
– Effect of noninvasive vagus nerve stimulation on acute migraine: an open-label pilot study
– Foods and supplements in the management of migraine headaches.
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