Migraine | Headache NewsBlog

Update on medical marijuana from the founder of the field

By: Dr. Mauskop

05-05-2017

The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other night I attended a lecture in NYC by the “father of cannabis”, Raphael Mechoulam.

According to Wikipedia, “Dr. Mechoulam is an Israeli organic chemist and professor of Medicinal Chemistry at the Hebrew University of Jerusalem in Israel. Mechoulam is best known for his work (together with Y. Gaoni) in the isolation, structure elucidation and total synthesis of THC (?9-tetrahydrocannabinol), the main active ingredient of cannabis and for the isolation and the identification of the endogenous cannabinoids anandamide from the brain and 2-arachidonoyl glycerol (2-AG) from peripheral organs together with his students, postdocs and collaborators.”

Dr. Mechoulam identified THC in 1964 and in his lecture he lamented the paucity of research into the many potential healing properties of cannabis in the past 50 years. He strongly feels that the two main active ingredients in marijuana, THC and CBD should be tested rigorously in large double-blind studies just like any other prescription drug. This will allow doctors to prescribe a proven medicine, rather than rely on anecdotal reports and go through trial and error, as we are doing now. His research suggests that cannabis ingredients could possibly help a wide variety of conditions, from diabetes and cancer to pain and nausea.

Prescribing medical marijuana is at least possible in New York and 20 other states, so that we do not have to wait, possibly up to 10 years, for a cannabis-based drug to be approved by the FDA (one CBD-containing drug might be approved soon for a rare form of epilepsy).

At this time we have to go through trials of various ratios of THC and CBD and various modes of delivery (inhaled, sublingual or oral) to determine the best treatment for each patients. Another obstacle is the fact that no insurance company pays for medical marijuana. After a year of prescribing medical marijuana for patients with migraine and other painful conditions it is clear that it works for a minority of my patients. However, I prescribe it only after more traditional methods fail, so my results may not be as good as if I used medical marijuana earlier. Our standard approach involves lifestyle changes, regular exercise, dietary changes, magnesium, CoQ10, and other supplements, followed by drugs and Botox injections. These are mostly well-studied treatments and with the possible exception of drugs, should precede the use of medical marijuana. Having said that, For a few of my patients medical marijuana dramatically improved their quality of life and I am very glad that we have this treatment option available.

Dr. Rafael Mechoulam and Dr. Alexander Mauskop
May 4, 2017, NYC

Non-drug treatment of insomnia helps headaches

By: Dr. Mauskop

01-05-2017

Alternative Therapies, Chronic migraine, Headaches, Migraine, Psychology of headaches

Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days.

Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine.

The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to sleep restriction – not being allowed to sleep for more hours than the patients reported getting prior to treatment, in the hope that this will lead to better sleep in the long term. The sham group was instructed to eat some protein in the morning, eat dinner at the same time, keep up with their fluid intake, perform range of movements exercise, and regularly press on an acupuncture point above the elbow.

After two weeks of this intervention headaches improved in the sham group slightly more than the active group, but six weeks later, headache frequency dropped by 49% in the active group and 25% in the sham group. Improvement in insomnia symptoms strongly correlated with the headache frequency. The cognitive-behavioral group had a significant increase in the total sleep time and the quality of sleep.

This was a relatively small study, but there is a large body of evidence that behavioral therapies do relieve insomnia. And it is no surprise that better sleep is associated with fewer headaches since sleep deprivation is a common migraine trigger. Sleep restriction is the only part of this treatment that has contraindications – it should be avoided in patients with bipolar disorder or epilepsy.

Another simple method, which I’ve used over the years whenever I cannot fall asleep, is visualization. You have to use not only visual images, but engage all of your senses. For example, imagine yourself in a place where you tend to feel relaxed (lying on a beach, on a cool lawn, on a float in a pool, etc). See all the details and also hear the sound of the wind or waves, smell the ocean or the grass, feel the touch of the wind or sand. It takes an effort at first, but use the same image every time and after a while, as soon as you go to that place, you fall asleep in minutes. Here I found more detailed instructions for this method.

Learn from The Migraine World Summit

By: Dr. Mauskop

26-04-2017

Alternative Therapies, Migraine

I am certain that you will learn a lot of useful information from listening to the top headache experts in the world. The event is free during the week when it is held (April 23 – 29), but afterwards you will have to pay for full access to all interviews. The Migraine World Summit is in its second year and it again assembled excellent speakers to address a wide variety of headache-related topics. Last year I spoke on non-drug therapies and this year the speakers are again addressing not only medications, but many alternative treatments and self-care. In addition to many leading neurologists, the event features Ping Ho, MA, MPH, a UCLA expert on alternative therapies, meteorologist, Michael Steinberg of Accuweather, Vidyamala Burch, a mindfulness expert, an Australian psychologist, Paul Martin, a geneticist, Professor Lyn Griffiths of Queensland UT (the event is organized by an Australian migraine sufferer Carl Cincinnato, so there are many Australians represented), and over 30 other experts.

Here is a blurb from the organizers:

In it’s first year, The Migraine World Summit became the largest ever conference for migraine patients. In 2017, we’re back with 36 brand NEW interviews where you’ll discover even more about…

What are the best treatments for migraine?
What can I do when I’ve already tried everything?
What are the secrets to finding effective natural alternatives?
How can I cope with the anxiety, judgment and social stigma of chronic migraine?
What new treatments are coming that I should be aware of?
What are the most common challenges that could appear?
The 2017 Migraine World Summit is online and free from April 23 – 29, 2017!

http://www.migraineworldsummit.com?afmc=4b

Blood vessels, stroke and migraine

By: Dr. Mauskop

24-04-2017

Brain disorders, Migraine

Stroke is slightly more common in migraine sufferers. There are two main types of stroke: hemorrhagic, which results from a burst blood vessel in the brain and ischemic, which is due to a blood clot closing off blood supply to a part of the brain. Closure of a blood vessel by a clot can be due to a blood clotting disorder, cholesterol plaque, or dissection of a blood vessel. Dissection is a lengthwise tear in the blood vessel wall.

A study just published by Italian researchers in JAMA Neurology included 2,485 patients aged 18 to 45 years with first-ever acute ischemic stroke. Of these patients 334 or 13% had a dissection and 2151 or 87% had a stroke not caused by dissection. Migraine was more common in the dissection group 31% vs 24% in non-dissection group. These differences are relatively small, but the importance of the study is that it should make doctors consider the possibility of a dissection when a patient with migraines develops a different type of headache or has a new onset of neck pain. If a dissection is suspected, a CT angiogram or an MRA should be done. Luckily, many dissections do not cause strokes and heal on their own. However, we do recommend blood-thinning medications (anticoagulants) for several months after the dissection even in the absence of a stroke.

My previous post described a scientific review on this topic, that showed a two-fold increase in the risk of dissection in migraine sufferers. Another practical aspect of these studies, which is mentioned in that previous post, is that if you suffer from migraines, avoid neck manipulation by chiropractors. If you do see a chiropractor, ask them not to do high velocity manipulations (sudden jerky movements), as I did when I visited a chiropractor.

Sensitivity to light (photophobia) and migraine

By: Dr. Mauskop

16-04-2017

Alternative Therapies, Migraine

Photophobia, or sensitivity to light is one of the most common symptoms that accompany a migraine attack. Many patients remains photophobic even after the headache has resolved. In some, a prolonged exposure to bright light or as little as a momentary reflection of the sun in the window glass or water surface can bring on a severe attack.

It is not unusual for some of my patients to wear sunglasses indoors. Once, when I had a migraine while driving at night I had to put on my sunglasses because the headlights of oncoming cars made the pain worse (luckily, I had a sumatriptan injection with me and as soon as I got off the highway and to a traffic light, I gave myself a shot).

Dr. Kathleen Digre, a professor Neurology and Ophthalmolgy at the University of Utah, whose article on dry eyes and migraines I quoted a couple of years ago, recently stated that staying in the dark may actually make photophobia worse. It may be better to gradually expose yourself to more light when you are not in the middle of an attack.

A small study suggested that people who suffer from photophobia between migraine attacks are more likely to experience anxiety and depression than those without photophobia between attacks and those without migraines. It is not clear if anxiety and depression in these patients is due to more severe migraines.

Treatments for photophobia mentioned by Dr. Digre include botulinum toxin (Botox) injections, nerve blocks, medications such as gabapentin, and a natural supplement, melatonin. I should add that any effective acute and preventive treatment that leads to reduced frequency and duration of the attacks can lead to a reduction in photophobia. Effective treatment is also likely to improve phonophobia (sensitivity to noise) and osmophobia (sensitivity to smells), which are somewhat less common.

Wireless electric patch for migraines

By: Dr. Mauskop

24-03-2017

Alternative Therapies, Migraine, neurostimulation

A new electric device is being tested for the treatment of migraine by an Israeli company, Theranica. Transcutaneous electric nerve stimulation (TENS) has been successfully used for the treatment of musculoskeletal disorders for decades. The theory behind it is the so-called gate theory of pain. It is thought that by stimulating larger nerve fibers we can block pain messages sent by smaller pain-sensing nerve fibers.

Cefaly is a TENS device which became available in 2014 and it provides electrical stimulation of the supraorbital nerves in the forehead. Only small studies have been conducted, so it is not clear how well Cefaly relieves migraines. As far as our experience, we at the NY Headache Center usually treat more severely affected patients, so it is possible that the results are better in people with less severe migraines.

The new wireless patch that is being developed by Theranica is applied to the upper arm. The results of the first study of this patch were published in Neurology, the medical journal of the American Academy of Neurology.

The study author, is a well-known neurologist and pain researcher, Dr. David Yarnitsky of Technion Faculty of Medicine in Haifa, Israel. He was quoted saying, “People with migraine are looking for non-drug treatments, and this new device is easy to use, has no side effects and can be conveniently used in work or social settings.”

The patch device is controlled by a smartphone app. It was studied in 71 patients with episodic migraine who had two to eight attacks per month and who were not on any preventive medications for migraines. The device was applied soon after the start of a migraine and kept in place for 20 minutes.

The devices were programmed to randomly give either a very weak stimulation to serve as placebo or different levels of stronger electrical stimulation.

A total of 299 migraine attacks were treated by these 71 patients. Two hours after the start of real treatment, pain was reduced by at least 50% in 64 percent of patients, compared to 26 percent of patients who received the sham stimulation.

Starting treatment early produced better results, which is similar to what we see with all migraine medications as well. None of the participants found the treatment to be painful.

The device is very safe and we hope that the ongoing trial that Theranica is conducting in the US will confirm its efficacy. It is not yet available in this or any other country.

An update on contraceptives in migraine with aura

By: Dr. Mauskop

09-02-2017

Migraine, Science of Migraine

Estrogen-based oral contraceptives are usually contraindicated for women who have migraines with aura. In the latest issue of the journal Headache, Dr. Anne Calhoun of the Carolina Headache Institute argues that this contraindication is no longer valid.

She analyzes research studies that consistently show that stroke risk is not increased with today’s very low dose combined hormonal contraceptives containing 20-25 µg ethinyl estradiol and that continuous ultra low-dose formulations (10-15 µg) may even reduce the frequency of migraine auras. The past prohibitions were mostly based on the risk associated with contraceptives containing over 30 µg and often 50 µg of estradiol.

We often use continuous contraception (not having a period for 3 to 12 months) in women with menstrually-related migraines, which usually are not accompanied by aura.

There is no doubt that the risk of strokes in women with migraines with aura who take oral contraceptives is significantly increased by smoking and other stroke risk factors, such as hypertension, diabetes, high cholesterol, and other. So, women who have migraine with aura and take estrogen-based contraceptives should not smoke, should exercise regularly, have a healthy diet and have regular check-ups to detect conditions that may augment the risk of strokes. If such risk factors are present, progesterone-only or non-hormonal contraceptives should be used.

Dr. Calhoun also points out other benefits of oral contraceptives, besides the reduction of the chance of undesired pregnancy, relief of painful periods, excessive bleeding, acne, and PMS. These include reduction in death rate from any cause, 80% reduction in the risk of ovarian and endometrial cancers and reduced risk of colorectal cancer. On the other hand, oral contraceptives do increase the risk of breast cancer.

Attachment style correlates with headache features and psychological symptoms in children and adolescents with migraines

By: Dr. Mauskop

01-02-2017

Alternative Therapies, Migraine, Science of Migraine

Italian researchers published a study in the journal Headache that attempted to correlate the attachment style in children with migraines with headache severity and psychological symptoms.

Attachment style typically develops in the first year of life. The premise of the study was derived from the attachment theory which suggests that early interpersonal relationships may determine future psychological problems and painful conditions. Previous studies have shown that people with insecure attachment styles tend to experience more pain than people with secure attachment style.

The study involved 90 children with migraines. The mean age was 12 years and there were 54 girls and 36 boys in the study. The kids were divided into a group with very frequent headaches (1 to 7 a week) and those with infrequent attacks – 3 or fewer per month. They also grouped them into those with severe pain, which interrupted their daily activities and those with mild pain that allowed them to function normally. The children were tested for anxiety, depression, and somatization (tendency to have physical complaints as a manifestation of psychological distress). They were also evaluated for the attachment style and were assigned into “secure,” “avoidant,” “ambivalent,” and “disorganized/confused” groups.

Interestingly, the researchers found a significant relationship between the attachment style and migraine features. Ambivalent attachment was present in 51% of children with high frequency of attacks and in 50% of those with severe pain. Anxiety, depression, and somatization were higher in patients with ambivalent attachment style. They also showed an association between high attack frequency and high anxiety levels in children with ambivalent attachment style.

The authors concluded: “We found that the ambivalent attachment style is associated with more severe migraine and higher psychological symptoms. These results can have therapeutic consequences. Given the high risk of developing severe headache and psychological distress, special attention should be paid to children with migraine showing an ambivalent pattern of attachment style. Indeed, a prophylactic and psychological therapy could often be necessary for these patients.”

People who have an anxious–ambivalent attachment style show a high desire for intimacy but often feel reluctant about becoming close to others and worry that people will not reciprocate their feelings. It is possible to mitigate the negative effects of the ambivalent attachment style even in adulthood. It does require a major effort and help from a psychotherapist.

How to reduce the cost of Botox for migraines

By: Dr. Mauskop

24-01-2017

Botox, injections, Migraine

Botox is by far the safest and the most effective preventive treatment for chronic and frequent episodic migraine headaches. The only downside is the cost. A 200-unit vial of Botox costs about $1,200. Most insurance companies cover Botox if you have chronic migraines (15 or more headache days each month) and if you’ve tried and failed (it did not help or caused side effects) 2 or 3 preventive medications. The copay for a vial of Botox is often as high as $400 or more. If your insurance does not cover Botox at all, or you have “only” 10 to 14 headache days each month, or you do not want to take daily drugs because of potential side effects, you may have to pay the entire cost. To reduce this cost, you may want to ask the doctor to start with 100 units instead of the standard dose of 155 units. Since the manufacturer makes only 100 and 200 unit vilas, the remaining 45 units are discarded. Some doctors are very accommodating, but I’ve heard of many that will not deviate from the FDA-approved protocol of 155 units injected into 31 spots. I discussed some of this in a recent post.

Another way to avoid excessive costs when paying out of pocket for Botox is to avoid large hospitals. A few years ago, while giving lectures at the Mayo Clinic, Cleveland Clinic, and Beth Israel Hospital in Boston, I discovered that they all charged $6,000 for one Botox treatment. What prompted this post is that I recently saw a patient who had Botox injections at the Cedars-Sinai Hospital in Los Angeles and had to pay $11,000. Every charge for a procedure done in a hospital or even at a doctor practice that is owned by the hospital, includes a hefty “facility fee”. This is why hospitals often buy doctor practices – they can triple the charges and even insurers such as Medicare and Medicaid will pay at an inflated rate.

A brilliant writer on how we take care of people with difficult-to-treat migraines

By: Dr. Mauskop

19-01-2017

Alternative Therapies, Migraine

Atul Gawande is a surgeon at the Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School. He is also a very talented writer who has written four books and has been writing for the New Yorker since 1998. I had the privilege of meeting him and found him to be very humble and low-key, despite him being a surgeon, MacArthur “genius” award recipient, famous writer, etc. His last book, Being Mortal should be read by everyone who is dealing with elderly parents, grandparents, or friends.

His last article in the New Yorker, The Heroism of Incremental Care describes how headache specialists approach patients with severe and persistent migraine headaches. Fortunately, these are a minority of our patients, but require our unflagging attention and care. Some tell me that they’ve tried “everything” and ask, “please do not abandon me”. My response is to reassure the person that I will never stop trying to help and also that I’ve never seen anyone who has tried everything – we always find medications, supplements, devices, procedures, and other treatments that the patient has not yet tried.

Just like with the man in Gawande’s story, some patients improve very slowly and over a long period of time, so patience and perseverance are essential. I must admit that we cannot be sure if it is our treatment or just the passage of time that leads to improvement. However, it may not matter since our support helps avoid a sense of helplessness and hopelessness that can lead to depression and a decline in the ability to function.

Glaucoma and migraines

By: Dr. Mauskop

02-01-2017

Migraine

Severe headache is a common symptom of acute glaucoma. It comes from a sudden increase in the intra-ocular pressure caused by the closure of channels that drain fluid from the eyeball. This headache can be similar to a migraine with nausea and light sensitivity. Acute glaucoma is rarely misdiagnosed as a migraine because typically, there is no history of migraines and the eye often gets red, painful with profuse tearing. Cluster headache is sometimes more similar to acute angle closure glaucoma because it also can cause redness of the eye and tearing.

This post was prompted by patient I just saw. This 52-year-old woman has had right-sided migraines for 10 years and about a year ago was found to have mildly elevated intra-ocular pressure (IOP). She has been under my care for almost a year and after receiving three Botox treatments needed only magnesium infusions every 3 weeks. She was still having 2-3 migraines each month, but they were relieved by sumatriptan with naproxen (Treximet). On a recent visit to her ophthalmologist her IOP was higher than usual and she underwent a laser procedure to improve fluid drainage. She reported that it felt as if a balloon was punctured and pressure came out of her eye. The procedure was first done on her right eye where the pressure was higher. Although it’s been only a couple of weeks since the procedure, she feels much improved, without any migraines and without constant mild pressure in her eye, which she was barely aware of until it was gone. Chances are that she will remain susceptible to migraines as they preceded her glaucoma by many years, but she is very likely to have fewer and milder migraines. She may also need to continue intravenous infusions of magnesium because she has a documented severe magnesium deficiency (her RBC magnesium level was 3.7 with the normal range of 4.2 to 6.8), which did not respond to oral magnesium supplements.

The main point of her story is that migraines of long duration can be made worse by a new trigger, such as slow increase in the eye pressure. It is a general rule we teach our neurology residents – if headaches worsen for no obvious reason, search for possible new causes. Another patient who confirmed this rule was a woman who did very well for several years with Botox injections, but then one treatment provided much less relief. Despite the fact that she had no new symptoms or neurological findings, I obtained an MRI scan. Unfortunately, it showed metastatic brain cancer, which originated from undiagnosed breast cancer. Such cases of worsening headaches without other new symptoms of a serious underlying problem are very rare, but require constant vigilance because the temptation is to attribute worsening of migraines to stress, hormones, weather, and other triggers. On the other hand, this needs to be balanced against getting an MRI scan after each unusually severe attack or an increase in headache frequency.

Women living together have a higher frequency of menstrual migraine

By: Dr. Mauskop

10-12-2016

Migraine

Many women are more likely to have migraines around the time of their menstrual period and in some, those migraines can be more severe. Previous studies have determined that women living together often synchronized their menstrual periods. A group of Brazilian researchers decided to compare the frequency of menstrual migraines in women who live together and those who live alone. The results were just published in the journal Headache.

The study looked at female students at a university between the ages of 18 and 30 years, all of whom suffered from migraines. One group of women lived together with two or more other students and the second group lived alone. They were asked to keep a headache diary for three months. The researchers recorded the frequency of headaches, presence of menstrual migraine, intensity of headaches, medications used including contraceptives, and triggering factors such as diet, sleep deprivation, and stress. Half of the women living together had menstrual migraines compared with 17% of women living alone. This finding was not related to the use of a contraceptive, test stress, or sleep deprivation. Women living together also tended to have menstrual cycle at the same time as their roommates.

It was a small study – it had 18 women in each group, so the results are not highly reliable.