Dr. Rami Burstein of Harvard University and his colleagues discovered the way to predict who is going to respond to Botox injections. Patients who have pain that is constricting, crushing, or “imploding” with pressure going from outside in and those with pain in the eye respond much better than those whose pain is “exploding” or with a sensation of pressure building up from inside the head. This was true for patients with episodic, as well as chronic migraine headaches. About 83% of non-responders had “exploding” headaches and 84 of responders had “imploding” headaches. Fortunately, many more patients suffer from imploding headaches or headaches with pain in the eye than with “exploding”headaches.
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Cluster headaches, which arguably cause the worst pain of any headache, are not likely to be cured by trigger point injections, according to a group of Spanish doctors. They treated 12 patients with trigger point injections and some of the patients reported some relief, but they all needed medications as well. This is a small study without placebo control, which means that no conclusions can be made about usefulness of this treatment. We do have better evidence that occipital nerve blocks can be helpful in aborting cluster headaches. This is a procedure similar to trigger point injections, but it involves injection not only of a local anesthetic, but also a long-acting steroid into an area of the occipital nerve on the side of the headaches. It is a simple and safe procedure and it should be tried in most patients, particularly those who in addition to pain around the eye have pain or tenderness in the back of the head or upper neck.
Read MoreTreatment of menstrual migraines often is more difficult than of non-menstrual attacks. A double-blind study by Marcelo Bigal and his collaborators just published in Headache shows that a combination of 10 mg of rizatriptan (Maxalt) and 4 mg of a steroid medication, dexamethasone (Decadron) is more effective than either drug alone. Both drugs are effective in treating many refractory migraine attacks (although I usually use 8 mg of dexamethasone), this is the first trial of two drugs together. While the results are not very surprising, the study may lead to wider acceptance of combination therapy and better relief for many women. While in the past the emphasis was placed on finding a single drug to treat a disease, in recent years combination therapy has become a standard approach in many conditions. Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) was also shown to be better than either of the two ingredients alone.
Read MoreRefractory migraines may respond to occipital nerve stimulation, according to Dr. Joel Saper who led a multicenter trial of this treatment. An electrode was surgically implanted in the back of the head, where the occipital nerve is located, and a pacemaker-size device was implanted under the skin. The trial looked at 110 patients who had more than 15 days with migraines each month and who did not respond to a variety of medications. 66 patients completed the diary information for three months following the start of treatment. The results were encouraging – 39% of patients improved, compared with 6% in the control group. None of the patients had any adverse events.
Read MoreBotox is effective for chronic migraines, according to a statement released by Allergan, maker of Botox. The company reported that a large multi-center trial (the New York Headache Center was one of the trial sites) yielded positive results. This report did not surprise us or our colleagues who routinely use Botox in treating patients with chronic migraines. The excitement we feel is due to the fact that many of our colleagues have been skeptical about the efficacy of Botox. Much more importantly, we hope that this definitive study will compel insurance companies to pay for this treatment.
Read MoreCluster headaches cause the worst pain imaginable, leading some patients to thoughts of suicide. They occur in about 0.1% of the population, while migraine headaches afflict 12%, which may explain why so much less research has been conducted on cluster than on migraine headaches. Injectable sumatriptan (Imitrex) is the only drug approved by the FDA for cluster headaches. We do use many other medications “off-label” for both acute and prophylactic treatment, but none have been subjected to rigorous research. That is none, until recently – zolmitriptan nasal spray (Zomig NS) has been shown to be effective in relieving cluster headaches within 30 minutes. While the dose of Zomig NS for migraines is 5 mg, in this latest trial both 5 and 10 mg dose was studied. The 10 mg dose was better than 5 mg dose in patients with episodic cluster headaches (74% vs 52%), but these two doses were equally effective in patients with chronic cluster headaches (41% vs 42%). The advantage of Zomig NS over Imitrex injection is that it is easier to use and does not involve a painful injection, while the advantage of Imitrex is that it works faster. Zomig NS is now approved for acute treatment of cluster headaches in Germany, Netherlands and Denmark.
Read MoreWomen with menstrual migraines who also have chronic migraines can be successfully treated with hormonal therapy, according to a study by Drs. Calhoun and Ford published in journal Headache. Surprisingly, controlling menstrual migraines led to improvement in chronic migraines as well. Chronic migraine is defined as a headache with migraine features that occurs on more than 15 days each month and it affects a staggering 4%-5% of the population. Hormonal therapy usually consists of taking an oral contraceptive continuously for many months, thus eliminating menstrual periods and often headaches and PMS symptoms. Oral contraceptives should not be taken by patients who have visual aura – visual disturbance that usually lasts 30 minutes and precedes the headache.
Read MoreTreating migraines in adolescents presents some unique challenges. Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks. And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers. The problem has been proving to the FDA that these drugs work in kids. Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo. Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks). Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents. A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age. The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches. I am often asked by other physicians, what is the youngest age I would prescribe a triptan? Because of a shortage of pediatric neurologists I feel compelled to see children as young as 10 and this is the youngest age at which I will prescribe triptans.
Read MoreMenstrual migraines are at times very difficult to treat. Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief. Corticosteroid drugs, such as prednisone and dexamethasone can help some patients. Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two. Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women. We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried. Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects.
Read MoreTreximet, a new migraine treatment was approved today by the FDA. Treximet is a combination of two old drugs – sumatriptan (Imitrex), 85 mg and naproxen (Aleve), 500 mg. The combination is more effective than Imitrex alone because naproxen provides additional relief through its anti-inflammatory and pain relieving effects. Imitrex is losing its patent protection and is going to be available as a generic drug in 2009. The maker of Treximet, GlaxoSmithKline is hoping to switch most of the patients currently taking Imitrex to Treximet before patent expiration, in order to reduce its losses to generic competition. However, it is likely that insurance companies will force physicians to prescribe generic Imitrex and generic naproxen rather than pay for Treximet. GSK argues that the combination drug, just like Imitrex are fast-dissolving and therefore faster acting drugs than the generic naproxen is and the generic Imitrex is going to be.
Read MoreBotulinum toxin injections relieve tension headaches, according to a study just published in the European Journal of Neurology . Most of the previous studies had been conducted in patients with migraines or chronic migraines (more than 15 days of headaches a month). There is much less evidence that Botox also helps tension headaches. Our experience at the NYHC treating patients with tension headaches with Botox injections has been also very positive. In this European study doctors used Dysport – a version of botulinum toxin type A that is not available in the US. However, Dysport is very similar to Botox. On the other hand, Myobloc, which is botulinum toxin type B, is a very different version of botulinum toxin and in several aspects is inferior to Botox.
Read MoreMigraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine. Dr. Seymour Diamond of the Diamond Headache Clinic in Chicago has pioneered the use of histamine in cluster headaches. We have found that in cluster headache patients for whom nothing else works histamine often provides excellent relief. A recent study published in the journal European Neurology suggests that histamine injections may also help migraine patients.
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