Migraine | Headache NewsBlog

More evidence that Botox relieves not only migraines, but also depression

By: Dr. Mauskop

14-10-2019

Alternative Therapies, Botox, Brain disorders, Chronic migraine, Migraine

A large study confirms previous reports of the beneficial effect of onabotulinumtoxinA (Botox) injections on depression as well as anxiety. In my two previous blog posts from 2011 and 2014 I mentioned reports of cosmetic Botox injections relieving depression but those involved a relatively small number of patients.

A study published in the Journal of Neurology, Neurosurgery, & Psychiatry under the title Effects of onabotulinumtoxinA treatment for chronic migraine on common comorbidities including depression and anxiety ,described the COMPEL trial (Chronic Migraine OnabotulinumtoxinA Prolonged Efficacy Open-Label). It was a multicenter, open-label, prospective study assessing the long-term safety and efficacy of 155 units of onabotulinumtoxinA (Botox) over nine treatments (108 weeks) in adults with chronic migraines.

OnabotulinumtoxinA treatment was associated with sustained reduction in headache days and depression and anxiety scores in the 715 patients over 108 weeks. The anxiety and depression scores were significantly reduced at all time points in patients with clinically significant symptoms of depression and/or anxiety at baseline. By week 108, 78% and 82% had clinically meaningful improvement in depression and anxiety symptoms, respectively. Sleep quality and symptoms of fatigue also improved.

In an earlier poster presentation of this data at a scientific conference the authors reported that the improvement in anxiety and depression was seen even in patients whose migraines did not improve with Botox. Even if that were true, we need a separate large study of Botox for anxiety and depression. The one study that treated patients with major depression in a double-blind, placebo-controlled trial involved only 74 patients.

In my practice, I’ve treated one young woman with severe bipolar disorder which did not respond to multiple drugs and who had a dramatic response to Botox. She has been receiving injections for over two years with sustained improvement. Another young man with depression had a very significant response as well, but has had only one treatment so far. I came to treat them accidentally – both were adopted children of my migraine patient who read about this possible effect of Botox and asked me to try it.

100 Migraine Drugs, A to Z: mefenamic acid

By: Dr. Mauskop

06-10-2019

Headache medications, Migraine

Mefenamic acid (Ponstel) is one the nonsteroidal antiinflammatory drugs (NSAIDs) and like all other NSAIDs it is being used for the treatment of acute migraine attacks.

Mefenamic acid is popular for the treatment of menstrual migraines, which probably stems from the fact that in addition to the treatment of mild or moderate pain, it is also approved for the treatment of dysmenorrhea, or pain of menstruation. In a small study mefenamic acid was found to be specifically effective for the treatment of menstrual migraines, which can be more severe and more difficult to treat than non-menstrual attacks.

Mefenamic acid was found to be superior to acetaminophen (called paracetamol in Europe), which is no surprise since acetaminophen has little antiinflammatory action and therefore does not reduce inflammation that occurs during a migraine attack.

Ergotamine was the mainstay of migraine treatment before the introduction of triptans in 1992. A study comparing ergotamine with mefenamic acid was found them to be equally effective, but ergotamine caused more side effects, especially nausea, which is a common side effect of ergot derivatives.

A small trial suggests that it can be also used for the prevention of migraines and it is as effective as propranolol.

For the treatment of pain and primary dysmenorrhea, the initial dose is 500 mg, followed by 250 mg every 6 hours, as needed. Just like other NSAIDs, it can cause heartburn, stomach upset, bleeding ulcers, and other side effects.

Caffeine and migraine headaches

By: Dr. Mauskop

01-10-2019

Alternative Therapies, Headaches, Migraine

Medication overuse headache (MOH) is not proven to occur from the frequent intake of triptans (Imitrex, or sumatriptan and other) or NSAIDs (ibuprofen, naproxen, and other). However, there is good evidence that caffeine (and opioid analgesics) which can help relieve an occasional migraine, can definitely make them worse if taken frequently. Caffeine withdrawal is a proven trigger of headaches, including migraines.

While we know that caffeine withdrawal causes headaches, a study just published by Harvard researchers in The American Journal of Medicine addressed an unexamined question – does drinking coffee directly triggers a migraine?

This was a rigorous prospective study of 98 adults with episodic migraine who completed electronic diaries every morning and evening for a minimum of 6 weeks. 86 participants were women and 12 were men, with mean age of 35 and the average age of onset of headaches of 16. Every day, participants reported caffeinated beverage intake, other lifestyle factors, and the timing and characteristics of each migraine headache. The researchers compared incidence of migraines on days with caffeinated beverage intake to the incidence of migraines by the same individual on days with no intake. In total, the participants reported 825 migraines during 4467 days of observation.

There was a significant association between the number of caffeinated beverages and the odds of migraine headache occurrence on that day. This association was stronger in those who normally drank 1-2 cups of coffee daily – they were more likely to get a migraine on days when they drank 3 or more cups.

Even after accounting for daily alcohol intake, stress, sleep, activity, and menstrual bleeding, 1-2 servings of caffeinated beverages were not associated with headaches on that day, but 3 or more servings were associated with higher odds of headaches, even after accounting for daily alcohol intake, stress, sleep, activity, and menstrual bleeding. The researchers also considered the possibility of reverse causation, meaning that people might have drank coffee to treat a headache, but this was also not the case.

My advice to migraine sufferers is to drink not more than 1 cup of coffee a day, and I don’t mean a Venti (24 oz) cup from Starbucks, but an 8-ounce cup of regular strength coffee. During a migraine attack having an extra cup along with your usual medication may provide additional relief.

100 Migraine Drugs, A to Z: lidocaine

By: Dr. Mauskop

23-09-2019

Headache medications, Migraine

Lidocaine (Xylocaine) is an old local anesthetic used by surgeons, dentists, and other doctors to numb parts of the body. Lidocaine drops given into the nostrils were compared to saline drops for the acute treatment of migraine attacks in a double-blind placebo-controlled 113-patient trial by Dr. Morris Meizels and his colleagues. This study showed that lidocaine nose drops were much more effective than saline drops, but relieved migraines in only about one third of patients. Another, but smaller (49 patients) study did not find a difference between lidocaine and saline.

I’ve had a handful of patients with difficult to control migraines respond to an intravenous infusion of lidocaine and one of these patients continues to do well with a monthly infusion of lidocaine. There have been no double-blind studies of intravenous lidocaine for migraines, but an observational study of 68 hospitalized patients who failed to respond to other treatments, suggests that this treatment can be effective for some patients.

Intravenous administration of lidocaine is usually done in a hospital or an outpatient facility that has cardiac monitoring because lidocaine can cause arrhythmias (irregular heart beat). Otherwise, lidocaine is safe and well tolerated.

The widest use of lidocaine in migraine is for nerve blocks. An occipital nerve block has been scientifically proven to relieve an acute migraine attack. Combining blocks of occipital nerves (in the back of the head) with a block of supraorbital nerves (in the forehead) has been also shown to be more effective than injections of saline. We often add blocks of the temporal branches of the trigeminal nerve (in the temples) when a patient has pain in those areas.

Nerve blocks sometimes help stop a persistent migraine when other treatments fail. It is also a very good option for pregnant women who cannot or would rather not take any medicine by mouth.

By: Dr. Mauskop

15-09-2019

Migraine

On September 12, 2019, Dr. Mauskop spoke on Advances and Controversies in Migraine at Charité – Universitätsmedizin Berlin, Europe’s largest university hospital. In the top photo Dr. Mauskop with Professor Uwe Reuter of Charité and Dr. Zoltan Medgyessy of Detmold Medicum. The middle photo shows the entrance to the renown Psychiatric and Neurologic Clinic at Charité. Bottom photo is of Dr. Mauskop in the lecture hall, where at the top you can see six portraits of physicians, who after 1933 were dismissed and persecuted for political or racial reasons.

Vitamin D and migraine

By: Dr. Mauskop

11-09-2019

Alternative Therapies, Migraine, Science of Migraine

At the biennial International Headache Congress held last week in Dublin a group of Italian researchers presented a paper, Relationship between severity of migraine and vitamin D deficiency: a case-control study.

They examined 3 groups of subjects: 116 patients with chronic migraine, 44 patients with episodic migraine, and 100 non-headache controls. Ninety-two migraine patients had vitamin D insufficiency (borderline low levels), whereas 40 had a clear vitamin D deficiency. They found a strong inverse correlation between vitamin D levels and the severity of attacks as well as migraine-related disability.

This is only a correlational study, meaning that it does not prove that taking vitamin D will help relieve migraines. However, several neurological disorders seem to be associated with low vitamin D levels, suggesting that vitamin D is very important for the normal functioning of the nervous system. So it makes sense to keep your vitamin D levels at least in the middle of normal range.

100 Migraine Drugs, A to Z: levetiracetam

By: Dr. Mauskop

03-09-2019

Headache medications, Migraine

Levetiracetam (Keppra) is an epilepsy drug that has been reported to help some patients with migraines. However, unlike divalproex sodium (Depakote) and topiramate (Topamax, Trokendi, Qudexy), the evidence for its efficacy in migraines is weak.

This evidence consists mostly of uncontrolled observational studies without a comparison to placebo. One small double-blind placebo-controlled study compared 500 mg of levetiracetam (27 patients) to 500 mg of divalproex sodium (32 patients) and to placebo (26 patients). Both epilepsy drugs were superior to placebo.

In one of the reports the mean dose of levetiracetam was 1,125 (and up to 2,000), while the maximum dose for epilepsy is 3,000). It is possible that the drug may work better at a higher dose. However, with an increase in the dose there is an increase in side effects. These include weakness, drowsiness, dizziness, anxiety, depression, irritability and aggressive behavior, and other.

Since this drug is not proven to be effective and can have serious side effects, I never prescribe this drug.

Migraine Associated With Dementia, Alzheimer’s in Women

By: Dr. Mauskop

26-08-2019

Alternative Therapies, Brain disorders, Migraine

An alarming study entitled Association Between Migraine Headaches and Dementia in More than 7,400 Patients Followed in General Practices in the United Kingdom was just published in the Journal of Alzheimer’s Disease. The researchers found that the risk for ALzheimer’s and other dementias is increased only in women with migraines and not in men.

The first large study to discover an association between migraines and dementia was done in Taiwan. Interestingly, a follow-up study in Taiwan discovered that people who used traditional Chinese medicine (mostly herbal products Jia-Wei-Xiao-Yao-San and Yan-Hu-Suo) had lower risk of dementia than those who did not.

There is no need to panic since other studies have found no such association and there is a wide range of preventive measures that are proven effective.

Controlling ones blood pressure, blood glucose, cholesterol level, and avoiding smoking are extremely important in lowering the risk of Alzheimer’s.

The single most effective preventive measure is regular physical exercise, which is more effective than mental exercise. Engaging in mental activities, such as learning languages, solving crossword puzzles, and playing bridge (which adds the benefit of social contacts) can also help. Dancing and tai chi combine physical and social benefits. Meditation appears to be effective in preventing shrinkage of the brain, which used to be thought a normal part of aging. This was confirmed in more than one study.

In addition to Chinese herbal products mentioned above, there are several other supplements that are also less proven but are safe and may help prevent Alzheimer’s. These include vitamins B12 and D, magnesium, curcurmin, nicotinamide, and possibly other.

100 Migraine Drugs, A to Z: ketorolac

By: Dr. Mauskop

19-08-2019

Headache medications, Migraine

Ketorolac (Toradol) is one of many nonsteroidal anti-inflammatory (NSAID) pain medications used to treat migraine headaches. In a tablet form it is no more effective than ibuprofen, naproxen or any other NSAID, but has more side effects and its use is limited to 5 days. On the other hand, ketorolac in an injection is a unique and very useful drug. It provides pain relief comparable to that of opioid (narcotic) drugs without the side effects or addiction potential of those drugs.

Intravenous ketorolac has been proven to be an effective drug for the treatment of severe migraine attacks. A study done by Dr. B. Friedman and his colleagues at the emergency department of the Montefiore Medical Center in the Bronx compared intravenous infusion of 30 mg of ketorolac with an infusion of 10 mg of metoclopramide (Reglan) and 1,000 mg of valproate (Depacon). There were over 100 patients in each group, making this a highly reliable study. Ketorolac and metoclopramide were more effective than valproate, but metoclopramide caused severe restlessness in 6 (6%) of patients. This is a well known side effect of metoclopramide and a similar drug, prochlorperazine (Compazine). This side effect is extremely unpleasant, but can be relieved by diphenhydramine (Benadryl).

Intramuscular injection of 60 mg of ketorolac was compared to intravenous infusion of 25 mg of chlorpromazine (Thorazine) and they were found to be equally effective. Just like prochlorperazine, chlorpromazine carries a risk of restlessness, as well as involuntary movements and sedation. These two drugs belong to the phenothiazine family of drugs, which are also used for severe nausea and vomiting, and psychiatric disorders.

A review of eight published trials of ketorolac found it to be more effective than meperidine (Demerol) and sumatriptan and a little less effective than metoclopramide, chlorpromazine and prochlorperazine. However, ketorolac lacks the addiction potential and the risk of severe restlessness, sedation, and involuntary movements.

We given intravenous ketorolac to our patients whose migraine has not responded to an injection of sumatriptan or oral triptans, although we almost always give an infusion of magnesium before or along with ketorolac.

Here is a blog post with my advice on what to ask for if your migraine lands you in an emergency room.

tDCS, which we are testing for migraines, may relieve depression

By: Dr. Mauskop

12-08-2019

Alternative Therapies, Chronic migraine, Migraine

Transcranial direct current stimulation (tDCS) has been definitively shown to alter brain connectivity and function. We are still enrolling patients in our double-blind study of tDCS for the prevention of migraines, so please contact us if you are interested.

A group of Iranian researchers used tDCS to treat “treatment-resistant major depression”. The results of this double-blind randomized sham-controlled trial were published in Clinical EEG and Neuroscience.

Patients with less than 50% decrease in the intensity of depression after 8 weeks of treatment with selective serotonin reuptake inhibitors (drugs like Prozac or fluoxetine, Lexapro or escitalopram, and other) were included in the trial. 16 women and 14 men were randomly allocated to an active group, which received 2-mA stimulation for 20 minutes per session, or the sham group. The Hamilton Depression Rating Scale was used to measure the severity of depression. There were statistically significant differences in the mean Hamilton scores in favor of the active treatment compared to the sham group. The difference in improvement persisted for a month after the treatment ended.

The authors’ conclusion that “tDCS is an efficient therapy for patients with resistant major depression, and the benefits would remain at least for 1 month” may be premature because of the small sample size. However, other studies have also indicated that tDCS may be effective in depression. Considering its low cost and very high safety, tDCS may be worth trying in patients with depression.

The same may apply to patients with migraines since several small studies have found this method effective. We hope that our larger study will confirm these findings. Our study differs from the previous ones and the ones for depression in that patients sue the device at home daily, rather than coming to the clinic to get the treatment. We hope that this difference will result in better outcomes.

Migraine does not increase the risk of strokes in postmenopausal women

By: Dr. Mauskop

10-08-2019

Brain disorders, Migraine

Migraine with and without aura carries an increased risk of strokes and heart attacks, according to several large studies. Most migraine sufferers are young women and until now there have been no studies looking at postmenopausal women.

At the last annual scientific meeting of the American Headache Society, Dr. Pavlovic and her colleagues at the Albert Einstein College of Medicine in the Bronx presented data of their study of over 70,000 postmenopausal women who were followed annually for 22 years. Ten percent of them had a history of migraines (compared to 18% seen in surveys of all women). Surprisingly, those with a history of migraine did not have a higher risk for strokes or heart attacks.

This somewhat contradicts another study mentioned on this blog last year. Doctors in South Carolina established that people with migraine with aura who were 60 or older, were more likely to have atrial fibrillation (a type of arrhythmia, or irregular heart beat), a condition that increases the risk of strokes.

Despite some inconsistencies in various studies, the practical implications are that those with migraines (and those without) should try to control modifiable risk factors. These include smoking, high blood pressure, diabetes, high cholesterol. If atrial fibrillation is present, a blood thinner is usually indicated as it may prevent strokes. Control of modifiable risk factors includes not only medications, but also regular exercise, healthy diet, stress management, and good sleep habits.

Probiotics for migraine

By: Dr. Mauskop

03-08-2019

Alternative Therapies, Chronic migraine, Migraine

Many migraine sufferers have gastro-intestinal problems, such as irritable bowel syndrome, constipation, sensitivity to gluten, dairy, and other types of foods. Nausea and vomiting and gastric stasis are common symptoms of migraine. All this indicates a close relationship between the gut and migraines. Considering that we contain more bacterial cells than our own (you may want to read a fascinating book by Ed Yong, I Contain Multitudes: The Microbes Within Us and a Grander View of Life), it is not surprising that certain types of bacteria may help prevent migraines.

Bio-Kult is a probiotic that contains 14 different strains of bacteria. It was tested for the prevention of migraine headaches in a double-blind placebo-controlled trial. I mentioned the preliminary results of this study presented in 2017 at the International Headache Congress, but the final results were only recently published in Cephalalgia. The researchers enrolled 100 patients and placed 50 of them into the placebo group and 50 into the probiotic group. 43 patients on the active therapy and 36 on placebo completed the trial. Patients with both chronic and episodic migraines (15 or more headache days a month makes it chronic) were included.

After 2 month of treatment, the mean frequency of migraine attacks and their severity were significantly reduced in the probiotic group compared to the placebo group. There was also a significant reduction of the number of abortive migraine medications taken by those in the probiotic group.

This was a small study with a high dropout rate, which means that it is far from proven that this type of probiotic is effective in treating migraine headaches. However, considering the safety of this product and its reasonable cost ($21 for a month supply on Amazon.com), it is worth a try after or in addition to more proven supplements such as magnesium and CoQ10.

Although the study was conducted in Iran, Bio-Kult is manufactured in the UK, which assures good quality. It has received “The Queen’s Awards for Enterprise”.