Migraine | Headache NewsBlog

The pendulum swings and hits hard patients on opioid drugs

By: Dr. Mauskop

17-05-2021

Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Pain, Pain Research

The opioid epidemic has claimed many lives. Overprescribing by doctors has certainly played a role. The push to use opioids more liberally started in the late 1980s. This promotion by many pain experts even led to pain being adopted as the fifth vital sign. One impetus for this push was the mistaken belief in the low rates of addiction when opioids are used to treat pain. Another was the results of surveys of patients being discharged from hospitals. Poor pain control was the main complaint of 40% of such patients. Centers for Medicare & Medicaid Services (CMS) got into the act as well and included good pain control as one of the measures required for the recertification of hospitals. In January 2018, however, the three survey questions about pain management were replaced by three questions about communication about pain. In October of 2019, even these three items about communication about pain were completely removed from the CMS’ HCAHPS Survey. So hospitals and doctors no longer need to worry about relieving pain and the suffering that goes with it. Doctors have to worry more about losing their license or even being put into jail. I’ve testified in front of a disciplinary panel on behalf of a doctor who was at risk of losing his license. An adult patient’s mother complained to the state health department about her son getting prescriptions for opioid drugs. In this case, the doctor was exonerated but the financial and the emotional toll will certainly make him very unlikely to continue prescribing opioids drugs.

These drugs, despite their potential for causing addiction and other side effects, are life-savers for many people. When used judiciously and as part of a multidisciplinary approach, they can provide not only improved quality of life but can make a difference between disability and normal functioning.

A study just published in the journal Pain looked at the difficulties patients taking opioid drugs have in finding a primary care doctor.

This study examined if primary care clinics “are more or less willing to accept and prescribe opioids to patients depending on whether their history is more or less suggestive of aberrant opioid use”. They conducted an audit survey of primary care clinics in 9 states from May to July 2019. They had simulated patients call the clinics and give one of two scenarios for needing a new provider: their previous physician had either (1) retired or (2) stopped prescribing opioids for unspecified reasons. Of 452 clinics responding to both scenarios (904 calls), 193 (43%) said their providers would not prescribe opioids in either scenario, 146 (32%) said their providers might prescribe in both, and 113 (25%) responded differently to each scenario. Clinics responding differently had greater odds of willingness to prescribe when the previous doctor retired than when the doctor had stopped prescribing.

The authors concluded that “…primary care access is limited for patients taking opioids for chronic pain.” and that “This denial of care could lead to unintended harms such as worsened pain or conversion to illicit substances.”

Hopefully, the pendulum will soon begin moving closer to the middle. Another hope is that the researchers will finally discover the holy grail of pain management – a non-addictive pain medicine with few other side effects.

ER treatment of posttraumatic headaches

By: Dr. Mauskop

09-05-2021

Brain disorders, Head trauma, Headache medications, Headaches, Migraine

Almost 1.5 million Americans visit emergency rooms every year for the treatment of head trauma. Headache, not surprisingly, is one of the most common symptoms of head trauma. What is very surprising is that until now, there have been no controlled studies of acute therapies for posttraumatic headaches.

Dr. Benjamin Friedman and his colleagues at the Montefiore Hospital in the Bronx just published a “Randomized Study of Metoclopramide Plus Diphenhydramine for Acute Posttraumatic Headache” in the journal Neurology. Emergency rooms often use metoclopramide (Reglan) as the first-line drug for the treatment of migraines. Diphenhydramine (Benadryl) was added to reduce the chance of side effects from metoclopramide. These side effects of restlessness and involuntary movements can be very unpleasant.

The study involved 160 patients. Their pain severity was measured on a 0 to 10 verbal scale. Patients who received a placebo reported a mean improvement of 3.8, while those receiving two medications improved by 5.2 points. Side effects occurred in 43% of patients who received medications and 28% of patients who received placebo.

My recent post was devoted to a study that showed dramatic similarities between migraines and posttraumatic headaches. The outcome of Friedman’s study, therefore, is not unexpected.

The overall efficacy of metoclopramide is fairly modest. It provides only partial relief that often does not last. And some patients get no relief at all. It also causes unpleasant side effects.

It is puzzling why emergency room doctors are not using a migraine-specific drug, sumatriptan for both migraines and posttraumatic headaches. An injection of sumatriptan works well within an hour for 70% of migraine patients. It has significantly fewer side effects than metoclopramide. Vials of sumatriptan (but not autoinjectors) are relatively inexpensive.

As far as the use of sumatriptan for posttraumatic headaches, we have only a few anecdotal reports. One of the reports, however, describes seven patients who did not respond to other drugs and had very good relief of their posttraumatic headaches with sumatriptan.

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.