Migraine | Headache NewsBlog

The role of a physical therapist in treating migraines

By: Dr. Mauskop

14-08-2023

Alternative Therapies, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their contribution can be profoundly impactful, provided they have a keen interest in the nuances of migraine care.

One such physical therapist to whom I refer patients, Pete Schultz, just co-wrote an article, A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist’s Perspective.

This article shows how experienced physical therapists approach migraine patients. They usually perform a very thorough examination and they can sometimes detect a serious problem that was missed by a physician.

The physical therapist often discovers general weakness, muscle tension, poor posture, diminished endurance, neck pain, teeth clenching, visual symptoms, dizziness, poor balance and coordination and high stress levels.

The interventions may include exercise directed at strengthening neck and upper back muscles, manual therapy, general conditioning exercise, biofeedback and mindfulness techniques, and vestibular therapy.

There is a wealth of data on the therapeutic effect of exercise in migraine patients. Interestingly, weight training seems to be more effective in the prevention of migraines than aerobic exercise.

Vestibular symptoms, such as dizziness and unsteadiness, are very common and are highly responsive to vestibular therapy.

Biofeedback is typically done by mental health professionals, but also by physical therapists. Over 100 clinical trials have been performed utilizing biofeedback in the treatment of headaches. The consensus is that this is a very effective technique.

An additional benefit that physical therapists can provide is what psychologist call a shift in locus of control, from internal to external. This means that instead of feeling like a victim of external uncontrollable circumstances, people acquire agency and cam actively do things to help themselves. This shift has been consistently shown to increase the efficacy of headache and pain treatment.

Depakote, oral and infusion, for migraines in children

By: Dr. Mauskop

10-08-2023

Chronic migraine, Headache medications, Headaches in children, Migraine, Migraine in pregnancy

A recently published study suggests that valproic acid (Depakene) given intravenously in an emergency room can relieve migraine headaches in children. The researchers also showed that giving these children an oral version of this drug, divalproex sodium (Depakote), does not reduce the frequency of future migraine attacks.

Divalproex sodium was first approved by the FDA in 1983 for the treatment of epilepsy. Subsequently, it was also approved for the treatment of mania and for the prevention of migraine headaches. Notably, the FDA-approved label does not place any age limit on the use of this drug. It took years to discover all the risks associated with this medication. In rare instances, the drug may lead to liver failure and severe pancreatitis, both of which can be fatal. Moreover, divalproex sodium can result in significant congenital malformations, as well as diminished IQ scores and neurodevelopmental disorders when the fetus is exposed to the drug in utero. It is strictly contraindicated in pregnant women. Women of childbearing age must use effective contraception. Divalproex can also cause many other less dangerous but unpleasant side effects.

With all this in mind, why would anyone want to take this drug? It is certainly not on the list of my top 20 or 30 drugs for the prevention of migraines. I do, however, have several patients whose migraines did not respond to many drugs but are significantly improved with divalproex sodium. Such patients must have proper monitoring with regular blood tests.

We do occasionally give intravenous valproic acid in the office but only if 5 or 6 other acute treatments fail to stop a severe persistent migraine. It works in about half of our patients. I am even more reluctant to give this drug to children.

Botox in pregnancy

By: Dr. Mauskop

24-07-2023

Alternative Therapies, Botox, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant women receiving Botox for various medical and cosmetic reasons, and no evidence suggests that the fetus gets harmed during this treatment. The botulinum toxin molecule is too large to cross the placenta and enter the circulation of the fetus, which further supports its safety during pregnancy.

An analysis of pregnancy outcomes after onabotulinumtoxinA exposure over a 29-year period was conducted to gain more insights into the safety of the treatment during pregnancy. The researchers examined data from the Allergan Global Safety Database from 1990 to 2018, focusing on pregnant women or those who became pregnant within three months of receiving onabotulinumtoxinA treatment. They analyzed the outcomes of these pregnancies to estimate the prevalence of birth defects in live births.

Out of 913 pregnancies, the study considered 397 with known outcomes. The majority of the mothers were 35 years or older, and most of the onabotulinumtoxinA exposures occurred before conception or during the first trimester of pregnancy. Among the 197 fetuses from 195 pregnancies, there were 152 live births and 45 fetal losses (including spontaneous and elective abortions). Four of the 152 live births had abnormal outcomes, with one major birth defect, two minor fetal defects, and one birth complication. The overall prevalence of fetal defects in live births was 2.6%, with a prevalence of 0.7% for major defects, similar to the rates seen in the general population. Among the cases with known exposure times, one birth defect occurred with preconception exposure and two with first-trimester exposure.

While the study has some limitations due to the nature of the data collected, the results indicate that the rate of major birth defects in live births exposed to onabotulinumtoxinA is consistent with the rates seen in the general population. However, it is important to note that there is limited data available for exposure during the second and third trimesters of pregnancy. Nevertheless, this updated and expanded analysis provides valuable real-world evidence for healthcare providers and their patients when considering Botox treatment during pregnancy.

I’ve treated more than a dozen pregnant women in my 30 years of using Botox for migraines. Some of them received Botox during more than one pregnancy. Some pregnant women sought Botox treatment specifically because they preferred to avoid taking any medications during pregnancy. Their decision was justified. When it comes to migraine drugs, including over-the-counter pain medications, they carry a higher likelihood of causing harm during pregnancy.

Controlled trial of meditation for migraines

By: Dr. Mauskop

17-07-2023

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

Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to 45 minutes. I have found that sumatriptan has always been very effective and migraines have never disrupted my daily life, even when I experienced prolonged periods of daily headaches. Because of meditation I hardly ever need to take sumatriptan. My personal experience and that of many of my patients align with the viewpoint of a small group of headache specialists who believe that triptans do not cause medication overuse headaches.

Mindfulness has been gaining a lot of attention as a potential way to manage migraines, but there haven’t been many scientific studies to support this. A group of Italian researchers investigated whether a specific mindfulness-based treatment, consisting of six sessions of mindfulness practice and daily self-practice, would be effective when added to the usual treatment for patients with chronic migraine and medication overuse headaches.

They conducted a study with 177 patients. Half of the participants received the usual treatment alone, which included withdrawing from overused medications, education on proper medication use and lifestyle, and tailored prevention. The other half received the usual treatment plus the mindfulness-based intervention.

They looked at various factors to assess the effectiveness of the mindfulness-based treatment, including headache frequency, medication intake, quality of life, disability, depression and anxiety, sensitivity to touch, awareness of inner states, work-related difficulties, and disease-related costs.

After analyzing the data, they found that the patients who received the mindfulness-based treatment in addition to the usual treatment had better outcomes. They were more likely to achieve a significant reduction in headache frequency compared to their baseline (at least 50% reduction), and they also showed improvements in other areas such as quality of life, disability, headache impact, productivity loss due to headaches, medication intake, and healthcare costs.

They concluded that adding a six-session mindfulness-based treatment, along with daily self-practice, to the usual treatment is more effective than the usual treatment alone for patients with chronic migraine and medication overuse headaches.

Weather and headaches – AI confirms the connection

By: Dr. Mauskop

05-06-2023

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine

The fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have investigated this relationship, but the findings have been inconsistent. The reported weather triggers range from humidity and strong winds to heat, cold, and barometric pressure changes.

In a recent study, Japanese researchers analyzed data collected from a smartphone app used by 4,375 individuals who experience headaches. By employing statistical and deep learning models, they aimed to predict the occurrence of headaches based on weather factors. The results of their study have been published in Headache, the journal of the American Headache Society.

The research confirms that headaches are more likely to occur under specific weather conditions. Low barometric pressure, barometric pressure changes, higher humidity, and rainfall were identified as factors associated with a higher occurrence of headaches.

This finding is not just a matter of curiosity; it has practical implications. There are several options besides moving to a place with a consistently mild climate, such as Southern California. For instance, low barometric pressure headaches can sometimes be prevented with the use of acetazolamide (Diamox), a medication commonly prescribed for mountain sickness. Setting up a Google Alert or using an app like WeatherX can provide warnings when barometric pressure drops. This allows individuals to take preemptive measures such as taking acetazolamide to prevent a headache the following day. Adopting general measures such as regular exercise, meditation, a healthy diet, and sufficient sleep can also help mitigate the effects of weather-related headaches.

Structural brain connectivity predicts pain

By: Dr. Mauskop

29-05-2023

Head trauma, Headaches, Migraine, Pain, Pain Research, post-traumatic headache

In a recent post, I mentioned a study in which researchers using functional MRI (fMRI) were able to link functional connectivity within the default mode network (DMN) and between DMN and executive control network (ECN) with the degree of disability in migraine patients.

In a new study published in the journal Pain, researchers examined the brains of patients with mild traumatic brain injury (mTBI) using fMRI imaging to understand the brain networks associated with early acute pain following a motor vehicle collision. Here are some key findings:

The properties of the brain’s white matter explained a significant portion of the variation in pain experienced after mTBI. This suggests that certain brain features make patients more likely to report higher levels of pain after the injury.
These white matter connections are associated with physiological and psychological characteristics related to pain sensitivity. The interactions between these connections and parameters of sensory testing and pain sensitivity can explain about one-third of the variability in pain.
The connectivity patterns in the brain’s white matter do not change over time, as observed up to a year after the injury. The same connectivity measures collected shortly after the injury and at six months post-injury can predict the level of pain reported by patients at the six-month mark.
The study further indicates that the strength of white matter connections in the sensorimotor, thalamic-cortical, and default-mode networks is associated with pain severity. These findings highlight the involvement of these brain networks in pain perception and suggest that connections within these networks can influence the experience of pain.

Over the past decade, scientists have been increasingly interested in functional connectivity, which is a way of finding networks in the brain that are related to particular activities, including resting. One of the most prominent networks is the default mode network.

The DMN is most active when the brain is at rest. When the brain is directed towards a task or goal, the default network deactivates. The DMN involves low-frequency oscillations of about one fluctuation per second.

The DMN is thought to be involved in a variety of cognitive functions, including self-awareness, social cognition, memory, thinking about the future, and daydreaming. The DMN is also thought to be involved in some psychiatric disorders, such as depression, post-traumatic stress disorder, obsessive-compulsive disorder, schizophrenia, and others.

The findings of this study suggest that the brain’s white matter networks plays an important role in pain perception, and that understanding these brain-pain relationships may lead to new treatments for pain in individuals with mTBI.

These brain networks are not fixed and we already have tools to improve their function. Meditation is one of the most effective and accessible such tools. Meditation has been shown to increase connectivity between different brain regions, including those involved in pain perception. It has also been shown to reduce the activity of pain-related brain regions. In addition to meditation, other things that people can do to improve the function of their brain networks and reduce pain include exercise and sleep.

Migraine, strokes, and oral contraceptives

By: Dr. Mauskop

22-05-2023

Brain disorders, Headaches, Migraine, Migraine in pregnancy

Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for individuals with migraines. The results of their study were recently published in the journal of the American Headache Society, Headache.

The overall stroke risk among OCP users in this study was low. Out of the 203,853 women aged 18-55 who used OCPs, 127 were confirmed to have had a stroke. The case group had a higher proportion of individuals diagnosed with migraines (34/127, 26.8%) compared to a control group of 635 women (109/635, 17.2%; p = 0.011). The risk of stroke was higher among those using OCPs with 30 mcg or more of estrogen compared to those using OCPs with less than 30 mcg. Having a personal history of migraines increased the likelihood of stroke compared to those without migraines. There was no significant increase in stroke risk among those with migraine with aura, but migraine without aura did increase the risk.

Interestingly, previous studies have suggested the opposite—that migraine with aura carries a higher stroke risk compared to migraine without aura. The researchers speculate that this discrepancy could be because patients with migraine with aura are rarely prescribed OCPs, and the number of such patients in this study was small.

Traditionally, young and healthy women diagnosed with migraine with aura have been advised against using estrogen contraceptives due to concerns about increased stroke risk compared to those without aura. However, the risk of unintended pregnancies should be weighed against the risk of a stroke. The authors emphasize the need for proper patient education and shared decision-making when it comes to starting contraceptives in women with a history of migraines, including those without aura. OCP formulations with less than 30 mcg of estrogen are preferred to minimize the risk of stroke.

Avoid screen time after a concussion

By: Dr. Mauskop

15-05-2023

Brain disorders, Head trauma, Headaches, Headaches in children, Migraine

A new study published in JAMA Pediatrics found that engaging in screen time within the first 48 hours after concussion may prolong recovery time. The study was conducted by researchers at UCSF. They looked at data from 125 patients aged 12 to 25 who had recently been diagnosed with a concussion. The participants were divided into two groups: one group was allowed to use screens, and the other group was asked to abstain from screen time.

The study found that the group permitted to use screens had a significantly longer median recovery time of 8.0 days compared to 3.5 days in the group that abstained from screens. Additionally, individuals who used screens reported experiencing more symptoms such as headaches, dizziness, and fatigue. The screen time permitted group reported a median screen time of 630 minutes during the intervention period, while the screen time abstinent group reported 130 minutes.

The study’s authors concluded that avoiding screen time in the first 48 hours after concussion may help to shorten the duration of symptoms. However, this was a relatively small study and more research is needed to confirm these findings.

In a recent post, I mentioned a large Canadian study that showed that early return to school after a concussion was associated with better outcomes. These two reports are not contradictory. Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations. Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental.

Magnesium makes your brain bigger, according to a 6,000 person study.

By: Dr. Mauskop

08-05-2023

Alternative Therapies, Brain disorders, Migraine, New treatments

Our research at the New York Headache Center and that of many of our colleagues, as well as the clinical experience of doctors and thousands of patients, have proven the role of magnesium in treating migraine headaches. I’ve written many blog posts on the role of magnesium in a wide variety of other medical conditions.

A new report in the European Journal of Nutrition suggests that dietary intake of magnesium is related to the size of the brain.

This study looked at how the amount of magnesium in people’s diets is related to the size of their brains and the presence of white matter lesions (which are abnormalities in the brain seen on the MRI scan) as they get older. The researchers used data from 6,000 middle-aged to older adults in the UK. They measured magnesium intake through a questionnaire and used statistical models to analyze the data.

The results showed that people who had higher magnesium intake generally had larger brain volumes, including the gray matter and specific areas called the left and right hippocampus. When they looked at different patterns of magnesium intake over time, they found three groups: one with high magnesium intake that decreased over time, one with low magnesium intake that increased, and one with stable and normal magnesium intake. In women, those in the high-decreasing group had larger brain volumes compared to the normal-stable group. On the other hand, women in the low-increasing group had smaller brain volumes and more white matter lesions.

The researchers also looked at the relationship between magnesium intake and blood pressure, but the results were not significant. Additionally, they found that the positive effect of higher magnesium intake on brain health was more pronounced in women who had gone through menopause.

In conclusion, having a higher intake of magnesium in the diet is associated with larger brain volumes.

Omega-3 fatty acids have also been shown to have a positive effect on brain volu me in older adults.

Vitamin B12 is another nutrient that is probably involved in preserving brain volume.

Multiple studies have shown that meditation is associated with larger brain volumes.

Exercise is also a proven way to prevent cognitive decline.

All these interventions have no side effects and I would recommend them to everyone regardles of age.

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

How to reduce pain recollection

By: Dr. Mauskop

24-04-2023

Brain disorders, Headaches, Migraine, Pain, Pain Research, Psychology of headaches

A recent study published in the journal Pain showed that adding a non-painful stimulus at the end of a Pap smear can reduce pain recollection. The study, titled “Adding a Nonpainful End to Reduce Pain Recollection of Pap Smear Screening: A Randomized Controlled Trial,” was conducted by Taiwanese researchers and involved 266 women.

The study involved an intervention group that received a modified Pap test, where the operator kept the speculum still in the vagina for an additional 15 seconds after rotating it back, instead of immediately removing it. Participants in the modified Pap test group were unaware of this additional step, as they were behind a privacy curtain.

The outcomes of the study included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects, the modified Pap group experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale and on a 0 to 10 visual analog scale. Subgroup analyses showed that these results were not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Additionally, the modified Pap test attenuated 1-year recalled pain on both pain scales and increased the 1-year willingness grade to receive further Pap tests.

This technique could potentially be applied to many other painful procedures, including Botox injections, blood draws, vaccine injections, dental procedures, and more.

How long to rest after a concussion

By: Dr. Mauskop

03-04-2023

Botox, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine

The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate for this approach, several studies have suggested that an early return to activity after a concussion may lead to better outcomes.

Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations.

The latest pediatric study was done in Canada. It examined data for 1630 children aged 5 to 18 with a mean age of 12 and of whom 38% were girls. The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory. Missing fewer than 3 days after concussion was defined as an early return to school.

An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group.

Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental, as it can be challenging for many people to remain inactive for such an extended period. This approach, which involves refraining from activities such as reading, writing, screen time, and exercise, can lead to depression, increased anxiety, and may even delay recovery.

After a brief period of rest lasting 24 to 48 hours, I typically recommend a gradual return to full activities. The key is to monitor for any exacerbation of post-concussion symptoms such as headaches, dizziness, brain fog, or fatigue. If an activity does not worsen symptoms, patients can continue to increase the level of physical and cognitive activities at a steady pace.