Migraine | Headache NewsBlog

Virtual reality for pain relief

By: Dr. Mauskop

22-11-2020

Alternative Therapies, Headaches, Migraine, Pain

Many studies have shown that virtual reality experience can relieve pain. The first such study in burn patients was published 20 years ago. A comprehensive review of this topic, Immersive Virtual Reality and Virtual Embodiment for Pain Relief was published last year by Italian researchers.

A different group of Italian researchers tested the effects of visual distraction on pain in chronic migraine patients. They compared a classical hospital waiting room with an ideal room with a sea view. Both were represented in virtual reality (VR). They measured pain and brain responses induced by painful laser stimuli in healthy volunteers and patients with chronic migraine. Pain was induced in the hand of sixteen chronic migraine patients and 16 healthy controls. This was done during a fully immersive VR experience, where two types of waiting rooms were simulated. Patients with migraine showed a reduction of laser pain rating and brain responses during the sea view simulation. Control subjects experienced the same level of pain in both types of simulated rooms.

An older study of 30 patients with chronic pain showed that 20 patients had pain relief during a VR session. Ten of them reported complete pain relief. Of the 20 who had relief, 10 had continued relief after the VR session.

A combination of VR with biofeedback resulted in lasting benefits in 9 of 10 children with chronic headaches who completed 10 training sessions.

About 5% to 10% of people who try VR get cybersickness. This is a feeling of dizziness or vertigo, similar to motion sickness. This is why VR sessions are often limited to a maximum of 30 minutes.

It appears that there are several possible approaches to the treatment of pain using VR. One is by using VR for distraction. Another, by utilizing VR to facilitate biofeedback, which is proven to relieve migraine and tension headaches. The third way, yet to be proven, is by altering body perception.

100 Migraine Drugs, A to Z: verapamil

By: Dr. Mauskop

14-11-2020

Chronic migraine, Headache medications, Migraine

Verapamil (Calan, Isoptin) is an effective drug for the prevention of cluster headaches. It is sometimes used for migraines as well. However, the evidence for its efficacy is weak. A double-blind crossover trial by Dr. Glen Solomon and his colleagues in Ohio examined the effect of 320 mg of verapamil on 12 migraine patients. The drug was more effective than the placebo. Other small studies also suggested that it might help some patients.

Verapamil has a reputation among headache specialists as being effective for the prevention of frequent migraine auras and other neurological symptoms that occur with migraines. Unfortunately, there are no controlled trials to support this impression.

The starting dose of verapamil is 120 mg a day with a possible escalation up to 480 mg. For cluster headaches, the starting dose is 240 mg and the maximum dose is as high as 960 mg. Verapamil can cause arrhythmia (irregular heartbeat), especially at higher doses. I recommend an electrocardiogram before every increase of the dose above 240 mg.

The two most common side effects of verapamil are constipation and swelling of the feet. In some of my patients, constipation was severe and resistant to treatment. They had to stop taking the drug.

Botox for migraines in pregnancy

By: Dr. Mauskop

06-11-2020

Botox, Migraine

Fortunately, migraines improve during pregnancy in the majority of women. None of the preventive drugs for migraine are approved by the FDA for pregnant women. The only medicine that is considered safe is a beta-blocker, metoprolol. Other drugs are either labeled as dangerous (e.g. topiramate and valproate) or as not having enough information about their effect on the fetus.

Most women obviously would rather not take any drugs. However, having frequent and severe migraines can be also detrimental to the fetus. It is not only the distress caused by severe pain but also the dehydration from vomiting that can have a negative effect.

A group of British doctors collected data over a 9-year period and have found 45 patients who became pregnant while receiving Botox for chronic migraines. All patients had received Botox within 3 months prior to the date of conception. 32 patients wished to continue treatment during pregnancy while the remaining 13 stopped treatment. There was one miscarriage in the treatment group. All other patients had full-term healthy babies of normal birth weight and no congenital malformations.

A recent poster presentation at the last annual meeting of the American Headache Society by neurologists at the Medstar Georgetown University Hospital in Washington, DC described 9 women treated with Botox during 10 pregnancies. All babies were born healthy.

This is a small number of patients and we cannot make any conclusions about the safety of Botox in pregnancy. Other reports, however, also suggest that Botox is safe.

In my 25 years of using Botox for migraines, I’ve given it to more than a dozen pregnant women. A few of them continued to receive Botox throughout more than one pregnancy.

Botox has been in use for over 30 years and millions of women have been treated with it with no reports of fetal problems. Unlike oral or injected drugs, it has only a local effect. The amount of Botox given for chronic migraines is measured in nanograms. After injections, it cannot be detected in the blood. All this suggests that Botox is safer than drugs taken by mouth or given by injection.

Dry eyes and migraine

By: Dr. Mauskop

01-11-2020

Alternative Therapies, Migraine

People who suffer from migraines often have a variety of visual symptoms. These include seeing an aura prior to the onset of headache, blurred vision, difficulty reading on screens or even on paper, and eye pain.

Patients with migraines often have reduced visual quality of life (QoL). This is according to a study published in Headache by doctors at the University of Utah. They assessed the visual quality of life, headache impact, aura, dry eye, and photophobia in migraine patients.

The researchers concluded that “Dry eye seems to be the most important symptom that reduces visual quality of life and worsens headache impact.”

Research has consistently shown that dry eye disease has a significant impact on several aspects of patients’ QoL, including pain, vitality, ability to perform certain activities requiring sustained visual attention (e.g., reading, driving), and productivity in the workplace.

Some people may not be aware that their eyes are dry. Their eyes might just feel fatigued or irritated. Ophthalmologists perform the Schirmer test to detect dry eye disease. It is done by placing a strip of filter paper under the lower eyelid and measuring the length of the strip that gets wet.

It is not clear if treating dryness of the eyes will help migraine headaches but it is very likely to improve visual functioning and QoL. Some of the treatments for dry eyes include artificial tears, tear stimulation, and anti-inflammatory therapy.

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.