Migraine | Headache NewsBlog

Post-traumatic headaches are mostly migraines

By: Dr. Mauskop

24-04-2021

Brain disorders, Chronic migraine, Head trauma, Migraine

Post-traumatic headaches (PTH) are classified as a distinct category of headaches. There is growing evidence, however, that headaches that develop after a head injury are migraines.

A study just published in Cephalalgia by Dr. Ann Scher, her colleagues at the Uniformed Services University, and other researchers, showed that PTH and migraines are very similar. The only difference they found was that headaches occurring after a head injury tend to be more severe.

They studied 1,094 soldiers with headaches. 198 were classified as having PTH. These headaches were compared to those in the other soldiers. They looked for the presence of 12 migraine features: Unilateral location, photophobia, phonophobia, nausea, exacerbation of headache by routine physical activity, pulsatility, visual aura, sensory aura, pain level, continuous headache, allodynia (sensitivity to touch), and monthly headache days.

Soldiers with post-traumatic headache had a greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The authors concluded that post-traumatic headaches differ from non-concussive headaches only by severity and not by any other symptoms.

Another study published in 2020 by Dr. Håkan Ashina and his Danish colleagues showed similar results. They performed a detailed evaluation of 100 individuals with persistent PTH following a mild traumatic brain injury. They found that 90 of the 100 patients had migraines or migraines as well as tension-type headaches. The rest had only tension-type headaches.

These findings have important treatment implications. These patients should be treated like other patients with chronic migraine. Assigning these patients the diagnosis of chronic migraine allows them access to treatments such as Botox injections and CGRP drugs. Insurance companies will not pay for any of the expensive migraine therapies if a patient carries only the diagnosis of PTH.

Our experience and that of our colleagues suggest that Botox is indeed very effective for PTH.

Magnesium enhances the migraine prevention effect of valproate

By: Dr. Mauskop

10-04-2021

Chronic migraine, Headache medications, Migraine

This blog has many posts about the role of magnesium in the prevention of migraines and clinical trials of magnesium. Another study was just published by Iranian doctors in The Journal of Headache and Pain.

Unfortunately, like other studies, this one has a major flaw. Magnesium was given to all migraine sufferers, whether they were deficient in magnesium or not. If you are not deficient, taking extra magnesium will not help. For those who are deficient, however, the effect can be dramatic.

Another problem with this and several previous studies is the use of poorly absorbed salts of magnesium. In this case, magnesium oxide.

Patients in this study were divided into three groups. One group was given valproate (200 mg twice a day), the second group, valproate with magnesium oxide (250 mg twice a day), and the third group, magnesium oxide alone (also 250 mg twice a day). There were 82, 70, and 70 patients in each group, respectively.

Patients in the two groups that included valproate did better than those in the group taking magnesium alone. The combination of valproate with magnesium was more effective than valproate alone.

Surprisingly, the authors mention nothing about side effects. Valproate is one of the last drugs I use in migraine patients. It has many potential side effects, including weight gain, hair loss, tremor, nausea, and others. The majority of migraine sufferers are women of childbearing age and up to half of the pregnancies in the US are unplanned. So, another major reason I rarely prescribe this drug is that valproate is contraindicated in pregnancy. It can cause congenital malformations and developmental problems.

Dramatic weight loss with a diabetes drug; may help migraines and other neurological problems

By: Dr. Mauskop

01-04-2021

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

Weight loss in overweight migraine sufferers – including that produced by bariatric surgery – leads to a reduction in the frequency of migraine attacks. In a previous post and in my new book I mentioned the use of metformin, a diabetes drug that helps weight loss, in migraine patients.

A study published in the February 10 issue of The New England Journal of Medicine definitively confirmed that weekly injections of another diabetes drug, semaglutide (Ozempic) can lead to an average of 15% weight loss in obese individuals. Seventy percent of participants lost at least 10% of weight. This was a double-blind, placebo-controlled trial that included 1,961 participants. Individuals in both the placebo and the active group were counseled every four weeks to encourage maintenance of a reduced calory diet and increased physical activity. Semaglutide is very similar to dulaglutide (Trulicity).

Other drugs that are used for weight loss produce an average of 4% to 6% weight loss and tend to have more side effects. Nausea and diarrhea were the most common adverse events with semaglutide. They were typically transient and mild-to-moderate in severity and subsided with time. Only 4.5% of participants on semaglutide stopped taking the drug due to side effects.

Obesity is a risk factor not only for diabetes and increased frequency of migraines but also strokes, idiopathic intracranial hypertension (pseudotumor cerebri), obstructive sleep apnea, hypertension, and others.

This trial should lead to the FDA approval of semaglutide for weight loss in obese individuals without diabetes. Hopefully, the FDA approval will compel insurance companies to pay for it. The out-of-pocket cost of 4 pen-like syringes is $735.

Postural orthostatic tachycardia syndrome (POTS) and migraine

By: Dr. Mauskop

06-03-2021

Chronic migraine, Headaches, Migraine, Science of Migraine

The term postural orthostatic tachycardia means that the heart rate becomes very fast upon standing up. POTS is a disorder of the autonomic nervous system that is associated with abnormal blood flow regulation. Almost all patients with POTS suffer from migraines. POTS can present with a bewildering variety of additional symptoms besides headaches (see below). This is why the diagnosis is often missed. Unfortunately, there are very few effective treatments for POTS. Making the correct diagnosis, nevertheless, is very important. It explains the cause of symptoms that are often dismissed as psychological and in some patients, treatment can lead to a dramatic improvement.

This blog was prompted by a positive study of a drug, ivabradine, to treat POTS that was published by Dr. Pam Taub and her colleagues. Ivabradine (Corlanor) is approved by the FDA to treat heart failure, so its use for POTS is “off-label”. This means that insurance companies are not likely to cover an unapproved use of a drug that costs $500 a month. With additional trials confirming that ivabradine works and with a lot of persuasion by the doctor, insurers might cover it if other treatments fail. Currently, the drugs that are used to treat POTS include beta-blockers, midodrine, fludrocortisone, and others. Increased intake of salt and fluids, exercise, dietary changes, and correction of nutritional deficiencies such as vitamin B12 and magnesium cal also help.

Here is how the Cleveland Clinic website describes POTS:
POTS symptoms can be uncomfortable and frightening experiences. Patients with POTS usually suffer from two or more of the many symptoms listed below. Not all patients with POTS have all these symptoms.
High blood pressure/low blood pressure.
High/low heart rate; racing heart rate.
Chest pain.
Dizziness/lightheadedness especially in standing up, prolonged standing in one position, or long walks.
Fainting or near-fainting.
Exhaustion/fatigue.
Abdominal pain and bloating, nausea.
Temperature deregulation (hot or cold).
Nervous, jittery feeling.
Forgetfulness and trouble focusing (brain fog).
Blurred vision.
Headaches and body pain/aches (may feel flu-like); neck pain.
Insomnia and frequent awakenings from sleep, chest pain and racing heart rate during sleep, excessive sweating.
Shakiness/tremors especially with adrenaline surges.
Discoloration of feet and hands.
Exercise intolerance.
Excessive or lack of sweating.
Diarrhea and/or constipation.

Cyclic vomiting, a migraine variant

By: Dr. Mauskop

25-02-2021

Chronic migraine, Headaches, Headaches in children, Migraine, Science of Migraine

Cyclic vomiting is considered to be a form of migraine. It is most common in children. Surveys indicate that 2% to 3% of children may be suffering from this condition. These children often develop typical migraines as they get older. Cyclic vomiting can also occur in adults. The main and usually the only symptom is intense vomiting. Vomiting occurs several times an hour with bouts lasting anywhere from an hour to several days. It is different from abdominal migraines which manifest themselves mostly by stomach pains. Nausea and vomiting can also occur, but abdominal pain is the predominant symptom. Some children progress from cyclic vomiting to abdominal migraines and then, to typical migraine headaches. Many children and adults have a family history of migraines.

To diagnose cyclic vomiting we need to consider and rule out all other possible causes of vomiting. These include gastrointestinal disorders, genetic conditions, brain tumors, and infections. An endoscopy, abdominal ultrasound, MRI scan of the brain, and blood tests are some of the usual tests.

Physical and emotional stress can trigger an attack of cyclic vomiting. Treatment is very similar to the treatment of migraines. It begins with regular sleep, exercise, relaxation training or meditation, magnesium and COq10 supplements. If attacks are frequent, preventive medications such as tricyclic antidepressants and epilepsy drugs can be useful. For acute attacks, sumatriptan nasal spray (Imitrex NS, Tosymra) and zolmitriptan nasal spray (Zomig NS) or sumatriptan injections can be effective. Antinausea drugs such as ondansetron (Zofran), metoclopramide (Reglan) and aprepitant (Emend) can be given by injection. Prochlorperazine (Compazine) and promethazine (Phenergan) are available in rectal suppositories.

This post was prompted by a review of this topic in the last issue of the journal Headache by Dr. Kovacic and Li of the Medical College of Wisconsin. It is an open-access article – you can read the entire article for free.

Low dietary intake of magnesium increases the risk of migraines

By: Dr. Mauskop

18-02-2021

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

Magnesium supplementation for the prevention of migraine headaches has been gaining wider acceptance. Dozens of studies, including several of our own, have shown that migraine sufferers often have a magnesium deficiency. Studies have also shown that taking an oral supplement or getting an intravenous infusion of magnesium, relieves migraines.

The causes of magnesium deficiency include genetic factors, poor absorption, stress, alcohol, and low dietary intake of foods rich in magnesium. A study just published in the journal Headache looked at the dietary intake of magnesium, including supplements, in those with migraines compared to people without migraines.

The study included 3626 participants, 20- to 50-years old. A quarter of these people suffered from migraines. People who consumed the recommended daily amount (RDA) of magnesium had a lower risk of migraine. This risk was the highest in those who were in the bottom quarter of magnesium consumption.

This was a correlational study, meaning that it does not prove that taking magnesium prevents migraines. However, common sense and our clinical experience, combined with all the previously published studies, strongly support taking magnesium to prevent migraines.

There are many other benefits of magnesium that I’ve written about in this blog – just enter “magnesium” into the search box and you will find a few dozen posts.

Just published – The End of Migraines: 150 Ways to Stop Your Pain

By: Dr. Mauskop

17-01-2021

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, neurostimulation, Science of Migraine

My new book, The End of Migraines: 150 Ways to Stop Your Pain, was just published by Amazon. It is also available on Google Play and Kobo.
I am very grateful to all my colleagues who took the time to read the book and to provide advance praise for it.
This is a self-published book. This allows me to update it regularly and to set a very affordable price – the e-book version is only $3.95 and the paperback is $14.95. The e-book version has the advantage of having many hyperlinks to original articles and other resources.
If you read it, please write a brief review on Amazon or Google and spread the word about it.

Nerivio relieves migraine in adolescents

By: Dr. Mauskop

03-01-2021

Alternative Therapies, Headaches in children, Migraine

Nerivio device is approved by the FDA for the acute treatment of migraine attacks in adults. A study just published in the journal Headache indicates that it may be effective in the treatment of migraine in adolescents, aged 12 to 17.

This study was open-label, which means that it was not as rigorous as the one done to get FDA approval in adults. There was no placebo arm and it was not blinded.

Forty-five participants, out of 60 who were enrolled, performed at least one treatment. There was one device-related adverse event in which a temporary feeling of pain in the arm was felt. Pain relief and pain-free status were achieved by 71% (28/39) and 35% (14/39) of participants, respectively. At 2 hours, 69% (23/33) of participants had improvement in functional ability.

Nerivio is a remote electrical neuromodulation, or REN device. It is applied to the upper arm and the current is turned up to produce a strong sensation below the pain level. It works by stimulating endogenous pain-relieving mechanisms. A recent review of various neurostimulation methods found REN to be the only one clearly proven to be effective.

Nerivio requires a prescription from a health care provider. If you don’t have one, you can consult one at a telemedicine startup, Cove (I am a consultant for Cove). It is a disposable device that costs $99 for 12 treatments. Some insurance companies pay for it.

What to try first, Botox or CGRP mAbs?

By: Dr. Mauskop

13-12-2020

Botox, Chronic migraine, Headache medications, Migraine

This is a common question I get from patients. Botox was first approved by the FDA in 1989. The CGRP monoclonal antibodies (mAbs), in 2018. Long-term safety of Botox is well established. I’ve treated many pregnant women, children as young as 8, and one patient who reached 100. Botox acts locally and has no systemic effects. It means that it cannot affect your kidneys, liver, heart, or any other organ. Injections of CGRP mAbs appear to be safer than most old medications taken by mouth. But they do have some systemic side effects and we don’t know if there are any long-term side effects. We have some 5-year safety data but only in a small number of patients. We will know more in a few years, after these drugs have been in use in a large population of patients.

Long-term safety is the main reason why I recommend trying Botox before mAbs.

Another reason to prefer Botox was presented at the 62nd annual meeting of the American Headache Society. It was conducted by Allergan, the manufacturer of Botox, so bias could be a factor. They looked at a relatively large number of patients – 1,976. Of these, 333 (17%) were treated with Botox first. Another 1134 (57%) were started on erenumab (Aimovig), 298 (15%) initiated fremanezumab (Ajovy), and 211 (11%) started galcanezumab (Emgality). More patients (75%) who were started on Botox were still receiving it 6 months later compared to patients who were first given a CGRP mAb (erenumab: 47%; fremanezumab: 55%; galcanezumab: 45%).

Not all of my patients begin with Botox. Some prefer mAbs because they don’t like the idea of having multiple injections over their face and head. Others cannot obtain insurance coverage for Botox. During COVID, some patients were reluctant to come to the office for Botox injections and they preferred to start a mAb at home. Three of the four available mAbs can be self-administered. The fourth one, eptinezumab (Vyepti) is given intravenously every 3 months.

100 Migraine Drugs, A to Z: zonisamide

By: Dr. Mauskop

09-12-2020

Chronic migraine, Headache medications, Migraine

Zonisamide (Zonegran) is an epilepsy drug similar to topiramate in its mechanism of action. Unfortunately, it shares its side effects as well. These include fatigue, difficulty with concentration and memory, nausea, and other. However, because they are not identical drugs, some patients tolerate zonisamide better than topiramate.

One study showed that 44% of 172 patients who did not respond to topiramate did respond to zonisamide with 13% having an excellent response. A similar study in 63 patients who did not respond to topiramate also showed benefit from zonisamide as did 34 patients in another study. Zonisamide also helped 8 out of 12 children who did not respond to other medications.

The dose of zonisamide ranges from 50 to 400 mg a day, but most patients need 100-200 mg.

Migraine device, Cefaly no longer requires a prescription

By: Dr. Mauskop

03-12-2020

Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation

Cefaly is a neurostimulation device that was approved by the FDA in 2014. Until October of this year, it required a prescription. Several clinical trials proved the device to be not only effective but also very safe. Now it can be purchased without a prescription from the manufacturer’s website – Cefaly.com.

Cefaly is used for both prevention and acute treatment of migraine. It is applied to the middle of the lower forehead with an adhesive electrode. For acute therapy, the device is used for 60 minutes. For prevention, it is used daily for 20 minutes. Some of my patients find it effective on its own while others use it in conjunction with medications.

As far as side effects, the device is very safe. It can cause skin irritation from the adhesive or from the electrical current. Some of my patients reported worsening of their headaches. This tends to happen to patients who develop allodynia during their migraine attack. Allodynia means increased skin sensitivity. It can be so severe that sometimes a patient cannot even wear glasses or have a ponytail.

An electrical stimulation device that is better tolerated by patients with allodynia is Nerivio. It is applied to the upper arm for 45 minutes as needed. Nerivio requires a prescription but it is sometimes covered by insurance while Cefaly is not.

100 Migraine Drugs, A to Z: zolmitriptan

By: Dr. Mauskop

28-11-2020

Chronic migraine, Headache medications, Migraine

Zolmitriptan (Zomig, Zomig ZMT, Zomig NS) is one of seven triptans sold in the US. It is available in tablets, orally disintegrating tablets, and nasal spray. The nasal spray is approved for children 12 and older. Both tablets and the spray are available in 2.5 mg and 5 mg strength. The maximum daily dose is 10 mg.

However, it is washed out of the body within a few hours. This means that taking three 5 mg tablets spread out over 24 hours poses no danger. Three doses a day is the approved limit for rizatriptan (Maxalt). There is no reason why this should not apply to zolmitriptan and other triptans except for the long-lasting frovatriptan. Fortunately, it is uncommon that a patient requires three doses in one day. And if a patient does need to take a triptan more than twice a day, we usually try a different drug that may work with a single dose.

One advantage of the nasal spray is that it tends to have a faster onset of action. Another advantage is that can be taken when severe nausea or vomiting precludes the use of oral medications. My impression is that zolmitriptan spray is more effective than the original sumatriptan spray. The amount of fluid in a single dose of Zomig is less than that in sumatriptan and the spray droplets are of smaller size. This leads to better retention of fluid in the nasal passages and better absorption.

The new version of sumatriptan spray, Tosymra contains 10 mg of sumatriptan while the original spray contains 20 mg. However, it comes out in smaller droplets and contains an ingredient that allows for better absorption. This formulation of sumatriptan spray appears to be as effective as Zomig NS.

Zolmitriptan nasal spray is expensive (as is Tosymra) because it is available only as a branded product. It will lose its patent protection in 2021.