Migraine | Headache NewsBlog

100 Migraine Drugs, A to Z: venlafaxine

By: Dr. Mauskop

24-10-2020

Chronic migraine, Headache medications, Migraine

Venlafaxine (Effexor) is the first drug in the serotonin-norepinephrine reuptake inhibitors (SNRI) class. It was approved by the FDA for the treatment of depression in 1993.

At low doses, venlafaxine works as a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac). SNRIs are considered to be effective for the treatment of pain and migraine headaches. SSRIs are not. A review of studies that involved a total of 418 patients showed that SNRIs are effective for the prevention of migraines. The class of SNRIs includes duloxetine (Cymbalta), desvenlafaxine (Pristiq), milnacipran (Savella), and levomilnacipran (Fetzima). Milnacipran is the only SNRI that is approved by the FDA for the treatment of fibromyalgia rather than depression.

In treating migraines, a 60-patient trial showed that the 150 mg dose is more effective than 75 mg.

Another double-blind crossover study comparing venlafaxine with amitriptyline showed them to be equally effective. Venlafaxine had fewer side effects than amitriptyline.

Venlafaxine is started at 37.5 or 75 mg dose. After a week or two, the dose is increased to 150 mg. The maximum daily dose of venlafaxine is 450 mg.

Potential side effects include insomnia, drowsiness, fatigue, nausea, dizziness, suicidal thoughts in depressed children and young adults, and others.

Just like with other SNRIs, sudden discontinuation of venlafaxine can cause withdrawal symptoms. These may include one or more of the following: dizziness, headache, nausea, diarrhea, paresthesia (pins-and-needles), irritability, vomiting, insomnia, anxiety, sweating, and fatigue. SNRIs are stopped after a slow and gradual reduction of the dose.

Find out what a hangover headache feels like

By: Dr. Mauskop

18-10-2020

Headaches, Migraine, Science of Migraine

If you’ve never experienced a hangover headache, a group of Spanish researchers can tell you what it feels like. They set out to evaluate and characterize what the international headache classification calls the “delayed alcohol-induced headache”. Also known as a hangover headache. The results of their investigation were published in the leading neurology journal, Neurology.

They studied a group with a lot of experience in this area – university students. The students made a personal sacrifice for the sake of science and voluntarily consumed alcohol and experienced headache.

A total of 1,108 (!) participants were included (58% female, mean age 23 years, 41% with headache history). The mean alcohol intake was 158 grams. Spirits were consumed by 60% of the participants; beer was consumed by 41%, and wine was consumed by 18%.

The mean headache duration was 7 hours. The duration correlated with the total grams of alcohol consumed. The pain was bilateral in 85% of patients and predominantly frontal in location (43%). The pain was mostly moderate in intensity with pressing (60%) or pulsatile (39%) quality. It was aggravated by physical activity in 83% of participants. Criteria for a migraine diagnosis were fulfilled by 36%.

One interesting finding of the study is that 58% of students had a headache that was typical of one seen with low cerebrospinal fluid (CSF) pressure. This raises the question of whether alcohol can indeed cause low CSF pressure.

It is an interesting question but I am not sure if further studies are warranted. It is probably better to spend the money on trying to reduce alcohol consumption.

100 Migraine Drugs, A to Z: tramadol

By: Dr. Mauskop

11-10-2020

Chronic migraine, Headache medications, Headaches, Migraine, Pain

Tramadol (Ultram) is a mild narcotic (opioid) pain killer. Just like other opioids it is not a good choice to treat an acute migraine attack. Besides its addiction potential, it does not work well for most migraine patients, can cause nausea, and can lead to rebound or medication overuse headaches.

Tramadol is also available in combination with acetaminophen (Ultracet). This combination was tested in a study published in Headache, Tramadol/Acetaminophen for the Treatment of Acute Migraine Pain: Findings of a Randomized, Placebo-Controlled Trial. 305 patients took tramadol/APAP (75 mg/650 mg) or placebo for a typical migraine with moderate or severe pain.

Subjects in the tramadol/APAP group were more likely than those in the placebo group to be pain-free at 2 hours (22% vs. 9%), 6 hours (43% vs. 25%), and 24 hours (53% vs. 38%)
Side effects caused by the active drug included nausea, dizziness, vomiting, and somnolence.

Tramadol alone or in combination with acetaminophen is worth trying only if the first-line classes of drugs are ineffective or contraindicated. These include NSAIDs, triptans, and gepants.

Anti-inflammatory effect of cannabis

By: Dr. Mauskop

01-10-2020

Alternative Therapies, Migraine, Pain

Cannabis has known anti-inflammatory properties. A group of researchers from UCSD published a study, Recent cannabis use in HIV is associated with reduced inflammatory markers in CSF and blood. They measured a variety of inflammation markers in the blood and cerebrospinal fluid (CSF) of people with HIV.

They showed that “Recent cannabis use was associated with lower levels of inflammatory biomarkers, both in CSF and blood, but in different patterns. These results are consistent with compartmentalization of immune effects of cannabis. The principal active components of cannabis are highly lipid soluble and sequestered in brain tissue; thus, our findings are consistent with specific anti-neuroinflammatory effects that may benefit HIV neurologic dysfunction.”

Translating this into English, smoking pot reduces inflammation not only in the body but also in the brain. Not all substances reach the brain because of the so-called blood-brain barrier. But the two main ingredients of marijuana – THC and CBD – easily dissolve in fat which allows their entry into the brain.

Obviously, not all of the effects of marijuana are beneficial. The most harmful is the inhalation of smoke which causes lung damage. Vaping medical-grade marijuana or taking it by mouth is much safer.

I’ve been prescribing medical marijuana for the past 6 years since it became legal in NY. In NY patients have a choice of capsules taken by mouth, tincture drops placed under the tongue, or vaping. I find it particularly useful for symptoms associated with migraines more than the actual pain – nausea, anxiety, and insomnia. For some, it relieves pain as well.

Marijuana seems particularly effective for pain in the elderly. One of the most dramatic responses I’ve observed was in a 95-year-old woman with severe arthritis pain. She was mentally sharp but upset about her inability to go outside and get around on her own. A small amount of marijuana produced a greater than 80% reduction in her pain. The anti-inflammatory effect of cannabis reported in the current paper could be the explanation of why it works better for arthritis pain than migraines. Inflammation does occur during a migraine process but to a lesser degree and of a different type than in arthritis.

100 Migraine Drugs, A to Z: topiramate

By: Dr. Mauskop

26-09-2020

Headache medications, Migraine

Topiramate (Topamax) is one of the most popular preventive drugs for migraine. This is not because it is more effective than other approved drugs. It is because it can cause weight loss. The drug manufacturer tried to get it approved for weight loss. The FDA, however, felt that while the side effects may be acceptable when treating epilepsy or migraines, they are not acceptable when treating obesity. You can argue that obesity is as serious a disorder but the FDA decision underscores the fact that the drug can have serious side effects.

Cognitive side effects can be obvious to most patients but for some, they are not. People begin to attribute their memory and word-finding difficulties to stress, lack of sleep, early-onset dementia, and other reasons. They have told me that they feel stupid on this drug, hence the moniker, Dopamax. Topiramate can also cause irritability, depression, fatigue, osteoporosis, glaucoma, and in 20%, kidney stones (10% with symptoms and 10% without). Like the other FDA-approved epilepsy drug, valproate, it is contraindicated in pregnancy because it can cause birth defects. I urge patients who are taking these drugs to be very vigilant about contraception.

In large clinical trials, 55% of patients had relief and were able to tolerate the drug. Postmarketing studies show that 40% of epilepsy patients stop the drug. Of these, one-fifth stop it because of lack of efficacy, almost half due to side effects, 12% due to both, and the rest for other reasons. It is likely that even a higher percentage of migraine patients stop the drug. Having an epileptic seizure is much more dangerous than having an attack of migraine.

The starting dose of topiramate is 25 mg nightly with a weekly increase of 25 mg up to 100 mg. Occasionally, patients benefit from a higher dose, up to 200 mg. If cognitive side effects are mild but bothersome, it may be worth trying a long-acting form of topiramate which can have fewer side effects. There are two such products on the market in the US – Qudexy and Trokendi. They are much more expensive than generic topiramate.

Topiramate is also approved for migraines in adolescents, ages 12 to 17. In this age group, it can cause or worsen an eating disorder.

Because of its side effects, topiramate is not one of the top choices of preventive drugs. The only time I move it up my list is when a patient is obese and is struggling to lose weight.

An update on the Nerivio device

By: Dr. Mauskop

20-09-2020

Alternative Therapies, Migraine, neurostimulation

It’s been a year since the introduction of Nerivio, an electrical stimulation device for the acute treatment of migraines. One of the unique features of the device is that it is controlled by a smartphone app. This allows Theranica, the manufacturer of Nerivio, to collect data on its use. They just published real-world data on the use of Nerivio in the first 6 months after its introduction.

59% or 662 out of 1,123 patients treated by headache specialists and 74% or 23 out of 31 patients treated by non-headache specialists reported pain relief at two hours in at least half of their treated attacks. Complete pain freedom was achieved by 20% of the patients in the first group and 36% in the second group in at least half of their treated attacks. Only 0.5% of the patients reported device-related adverse events.

The number of patients treated by non-headache specialists is small. Nevertheless, because headache specialists tend to see patients who are more severely affected by their migraines, it is likely that the device will be more effective in the hands of non-headache specialists, or rather on the arms of patients treated by such doctors. Nerivio is a disposable device that is placed on the upper arm for 45 minutes.

My subjective impression correlates with this published data. Some of my patients use it along with their abortive medications such as triptans or NSAIDs. One patient finds that the stimulation not only relieves pain but is also very relaxing. Even though you can continue your normal activities, I recommend that patients try to relax or meditate during this treatment. The advantage of Nerivio is that is a drug-free treatment and is very safe. People who find Nerivio particularly appealing are those who have side effects from drugs, have multiple allergies, pregnant or nursing, and for whom drugs are ineffective.

Nerivio is available by prescription from your healthcare provider, by consulting (virtually or in-person) one of our headache specialists, or by connecting to a doctor on Cove, a telemedicine startup.

Disclosures: I have provided consulting services to both Theranica and Cove.

Benign paroxysmal positional vertigo – another benefit of vitamin D

By: Dr. Mauskop

16-09-2020

Alternative Therapies, Migraine

Vitamin D deficiency predisposes to or worsens many different medical problems. I’ve written at least a dozen blog posts on vitamin D.

A group of South Korean researchers just published in the journal Neurology a study, Prevention of benign paroxysmal positional vertigo with vitamin D supplementation. A randomized trial.

They selected 518 patients with confirmed BPPV who were successfully treated with canalith repositioning maneuvers (Epley maneuver) and who had a vitamin D level below 20. The primary outcome measure was the annual recurrence rate. Patients in the intervention group were given vitamin D 400 IU and 500 mg of calcium carbonate twice a day for 1 year. Patients in the observation group were assigned to follow-ups without further vitamin D evaluation or supplementation.

The intervention group had a significant reduction in the treatment group compared to the observation group.

The authors concluded that supplementation of vitamin D and calcium may be considered in patients with frequent attacks of BPPV, especially when serum vitamin D is subnormal.

BPPV, dizziness, vertigo, difficulty with balance are more common in people with migraines. Keeping your vitamin D level at least in the middle of the normal range may help prevent all these symptoms as well as migraines and other neurological problems.

Melatonin for migraines

By: Dr. Mauskop

11-09-2020

Alternative Therapies, Migraine, New treatments

Melatonin is a hormone produced by the pineal gland located in the brain. The release of melatonin helps us fall asleep. Melatonin supplements have been used to treat insomnia. The results of clinical trials, however, are contradictory. This may be because a wide variety of doses have been used. One study suggests that 3 mg of melatonin – a common dose sold in stores – is less effective than 0.3 mg. I usually recommend 0.3 mg (300 mcg) for both insomnia and jet lag.

Melatonin has been tested for the prevention and acute treatment of migraines.

Melatonin was not effective in a study by Norwegian doctors. They gave 2 mg of extended-release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo in a double-blind crossover trial. Migraine frequency did improve from an average of 4.2 a month to 2.8 in both the melatonin and the placebo groups.

Another blinded trial was done in Brazil by Dr. Mario Peres and his colleagues. It compared 3 mg of immediate-release melatonin with a placebo and with 25 mg of amitriptyline. The study involved 196 patients. The number of headache days dropped by 2.7 days in the melatonin group, 2.18 for amitriptyline, and 1.18 for placebo. Melatonin significantly reduced headache frequency compared to placebo. Amitriptyline did not. Not surprisingly, melatonin was much better tolerated than amitriptyline. Considering its safety and very low cost, it is worth considering a trial of 3 mg of melatonin for the prevention of migraine headaches.

It is possible that, unlike with insomnia, a higher dose is more effective for the prevention of migraines. And, the immediate-release form could be more effective than the sustained-release one.

Melatonin may be effective as an acute treatment for pediatric migraine, according to a study just published by Dr. Amy Gelfand and her colleagues at UCSF. This was an 84-patient trial, although only 46 children completed it. Both low and high doses of melatonin were associated with pain reduction. Higher dose and napping after treatment predicted greater benefit. The benefit was likely an indirect one – melatonin helped children fall asleep and sleep, often in children but also in some adults, can relieve a migraine attack.

100 Migraine Drugs, A to Z: tizanidine

By: Dr. Mauskop

04-09-2020

Headache medications, Migraine

Tizanidine (Zanaflex) is a muscle relaxant that has been shown to relieve chronic migraines in a 200-patient double-blind study by Dr. Joel Saper and his colleagues. It may be particularly effective in people with neck and shoulder muscle spasm and pain. The majority of migraine sufferers have such muscle pains. It is also a good choice when you have insomnia along with migraines.

The main side effect of tizanidine is drowsiness and dizziness. This is why it is usually taken at night. The starting dose is 4 mg. It can be gradually increased to 8, and then 12 mg. In the double-blind study, the median dose was 18 mg. Some patients went up to 24 mg with 8 mg taken three times a day. Very few of my patients can take that much tizanidine during the day. At most, they will take 2-4 mg twice during the day and a higher dose at night.

Oxygen for migraines

By: Dr. Mauskop

29-08-2020

Alternative Therapies, Migraine

People who live at high altitudes tend to have lower oxygen levels in their blood. A higher percentage of them suffer from migraines than people who live at sea level.

Oxygen is effective for a significant percentage of patients with cluster headaches. It is much less effective for the treatment of migraines. Two small studies showed that oxygen under normal pressure is ineffective for the acute treatment of migraine but oxygen under pressure, or hyperbaric oxygen, is. The first study had 10 patients, the second, only eight.

Norwegian researchers conducted a double-blind, placebo-controlled study to assess the prophylactic effect of hyperbaric oxygen therapy on migraine. The effect of three daily sessions of hyperbaric oxygen was compared to the effect of three hyperbaric air treatments. Oxygen under pressure appeared to be more effective. However, because the number of patients was small – 19 in the oxygen and 15 in the air group – no statistical significance was found.

Even if proven effective, using hyperbaric oxygen for the acute treatment of migraines, is highly impractical. There are few hyperbaric chambers to be found. It is also a very expensive treatment.

100 Migraine Drugs, A to Z: timolol

By: Dr. Mauskop

23-08-2020

Chronic migraine, Headache medications, Migraine

Timolol (Blocadren), is the second of the two beta-blockers approved by the FDA for both hypertension and the prevention of migraines. Among the dozen or so beta-blockers, it is not very popular for either hypertension or migraine. An ophthalmic solution of timolol is often used for glaucoma.

A study of 107 migraine patients compared prophylactic treatment with timolol, 20 to 30 mg per day with matching placebo. The study was a double-blind crossover study that lasted 20 weeks. Timolol was significantly better than the placebo in decreasing the frequency of headaches, numbers of patients who had a 50% reduction in headache frequency, global response, and patient preference. The overall response was 65% with timolol compared with 40% with placebo. The severity and duration of headaches that occurred were unchanged. Few side effects were reported with either timolol or placebo.

Another study compared timolol, 10 mg twice a day with propranolol, 80 mg twice a day, and with placebo in 83 migraine patients. Timolol and propranolol were equally effective and had a similar rate of side effects.

The side effects of timolol are typical of all beta-blockers – chest discomfort, tiredness, lightheadedness, dizziness, fainting, shortness of breath, slow or irregular heartbeat.

The usual dose of timolol is 10 mg twice a day.

You can read about the use of timolol eye drops to treat acute migraines in a previous post.

Histamine and migraine

By: Dr. Mauskop

17-08-2020

Alternative Therapies, Headache medications, Headaches, injections, Migraine

Histamine is best known as a part of the defense against allergies. But it is also an important neurotransmitter – a brain chemical involved in arousal, anxiety, the stress-related release of hormones, activation of the sympathetic nervous system, pain relief, and other functions.

Increased sensitivity to histamine may lead to an excessive allergic reaction which is relieved by anti-histamine drugs. It can also increase pain. One strategy thought to reduce this over-reaction is desensitization – injecting small amounts of histamine which can lead to a reduced reaction.

This approach seems to help some migraine and cluster patients. It was first reported in 1941 by a Mayo clinic doctor, Bayard Horton in an article entitled The use of histamine in the treatment of specific types of headaches. Another article, Intravenous histamine in the treatment of migraine was published in 1946 by W.A. Thomas and S. Butler.

A group of Mexican doctors compared subcutaneous (under the skin) injections of small doses of histamine to injections of placebo in 60 patients. They found histamine to be more effective. The same group of doctors conducted three more double-blind trials of histamine injections. A double-blind study of 90 migraine patients compared twice-weekly injections of histamine with 100 mg of oral topiramate, which is an FDA-approved treatment for migraines. These treatments were equally effective. They then compared twice-weekly injections of histamine to 500 mg of valproate, which is also an FDA-approved migraine drug in 92 migraine patients. Histamine was superior to valproate. They compared histamine to the injection of a relatively small dose of Botox (50 units, while the standard dose is155 units) in 100 patients and found them to be equally effective.

These results would be more convincing if another group confirmed these findings. When I asked the opinion of an allergy specialist in NYC, Dr. Michael Chandler he told me that the idea of histamine desensitization has been discredited and that it is not being used to treat allergies.