Results of a phase II study of a new headache medicine was published in journal Neurology. Merck and Co. is starting phase III trials of this drug, which works by blocking the release of a neurotransmitter CGRP. Previous migraine medicines, such as sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax) and other in the triptan family worked on serotonin receptors. While the triptans are very safe they very rarely can constrict blood vessels in the heart and cause a heart attack. The new medicine, which is known as MK-0974 does not constrict blood vessels. In the published trial it was at least as effective as Merck’s older drug, Maxalt. If phase III studies go well we could see this medicine on the market in a couple of years.

The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. We find that Imitrex injections are very underutilized, mostly because doctors don’t offer them as an option to their patients. Surprisingly, surveys indicate high acceptance of injections by patients. This should not be so surprising at all considering how disabling migraines can be. The ideal candidates for injectable Imitrex include patients who have severe nausea, those who wake up with a severe attack and need prompt relief, patients for whom oral triptans do not provide adequate relief and those with cluster headaches. We typically prescribe 6 mg injections and use 4 mg ones for patients who are very sensitive to drugs, have small weight or have side effects from 6 mg.

It is not clear how Botox relieves migraine headaches.

Oliver Dolly, an Irish researcher who devoted many years of his work to the study of botulinum toxin, has just published results of a new study which may help explain this question. Twelve years ago when I started using Botox for the treatment of headaches the only possible explanation for the way it worked was that it relaxed tight muscles. It is true that during a migraine attack muscles go into a contraction and many patients find some relief by massaging their temples, back of their head and neck. However, some people reported to me that injecting Botox relieved their headaches in the temples, forehead and back of the head, but not on the top of the head. I did not inject the top of the head because there are no muscles there. When I did inject those areas to my surprise pain on the top of the head improved as well. This has been also observed by many of my colleagues around the country. Dr. Dolly’s experiment showed that in addition to relaxing muscles, Botox prevents the release of CGRP (a chemical messenger – neurotransmitter) from nerve endings and stops painful messages from being transmitted along the nerves. It appears that relaxing muscles may be less important than stopping nerves from sending pain messages to the brain.

A study just published by Dr. Mathew and his colleagues in the journal Headache reports that patients with chronic migraine headaches responded to Botox better than patients with chronic tension headaches. Patients who had headaches predominantly on one side and those with scalp tenderness had a better response to Botox. Scalp muscle tenderness was also a predictor of response in chronic tension headaches. Overall, Botox was highly effective in patients with chronic migraine – 76%, (54 out of 71 patients) obtained relief. Of those 54 patients 37 or 69% had one-sided headaches. Having headaches on both sides does not preclude success with Botox – 17 patients with bilateral headaches also responded. This study confirms what I have observed in my 12 years of treating thousands of patients with Botox – it is a highly effective and safe treatment for frequent migraine headaches.

Prolapse or herniation of the upper cervical disc is known to cause not only neck pain but also so called cervicogenic headaches. Dr. Diener and his German colleagues reported (in journal Cephalalgia) on 50 patients who had prolapse of lower cervical disks and used as controls 50 patients with lumbar disk herniations. They found that 12 out of 50 patients with lower cervical disk herniations developed a headache and in 8 out of 12 headache stopped within a week following surgery. Only two of the patients with lumbar disk herniations developed a headache. Three months after surgery seven of 12 had no headaches and three were improved. It is not very surprising that these patients had headaches – neck muscles overlap all along the neck and form a supporting collar for the cervical spine. Muscle spasm in the lower neck that accompanies a herniated disk will often cause this spasm spread up the neck and cause a headache. Even patients with migraines at times develop a migraine attack from spasm of muscles in the neck or even shoulders. When treating these patients, both with migraines and cervicogenic with Botox injections are usually given not only into the muscles around the head, but also in the neck and shoulders. This makes Botox treatment significantly more effective.

Hemiplegic migraine can be safely treated with triptans (drugs like Imitrex, Maxalt and other).

This is the conclusion of a study published in the September issue of journal Cephalalgia. A group of Finnish doctors gave triptans to 76 patients who suffered from hereditary and non-hereditary forms of hemiplegic migraine – migraine that is accompanied by temporary paralysis of one side of the body. They found that triptans worked well and none of the patients had strokes or any other serious reactions. According to the FDA, triptans are not to be given to patients suffering from hemiplegic migraine because they potentially could cause a stroke. No strokes have ever been reported, but it was thought that constriction of blood vessels in the brain during hemiplegic migraine is responsible for the weakness and giving triptans could worsen this constriction and cause a stroke. In the past several years we have learned that weakness is caused by a disturbance of brain neurons rather than constriction of blood vessels. Many headache specialists use Imitrex and similar drugs in patients with hemiplegic migraine and several years ago Drs. Klapper and Mathew have already reported on their positive experience in a small group of patients.

I just received an announcement for the “2nd Annual Surgical Treatment of Migraine Headaches.” The event is sponsored by Case Western Reserve University and presented by its Department of Plastic Surgery. Ten of the 12 speakers on the program are plastic surgeons. Their premise is that since Botox injections relieve migraines, why not go a step further and cut those muscles in the forehead for permanent relief.

When I asked my friend Ken Rothaus, a plastic surgeon at the New York Hospital, about this approach, he was not excited—despite the potential new pool of patients. Here is what he said: “I think that when there exists a relatively non-invasive procedure such as Botox that works so well and costs less than the corresponding surgical procedure, it represents the better first line choice for the patient. All surgery has risks and complications, Botox can be injected in all the involved areas not just the glabellar, and the cumulative cost of 3-5 years of Botox may be less than that one surgical procedure.”

Another strong argument against surgery is the very nature of migraines. They come and go for long periods of time, and on their own improve with age in most patients.

An additional reason, and perhaps the most compelling: Plastic surgeons lack training in diagnosing and treating headaches. They do not know how to properly diagnose different types of headaches, how to detect potential triggers, and how to combine different treatments into a comprehensive plan.

A case can be made that if a neurologist is also involved in the care of a patient receiving surgical migraine relief, it may be a reasonable approach. However, injecting Botox only into the forehead is ineffective for most patients. We usually also inject the temples, the back of the head and, at times, the jaw and neck muscles. Surgery cannot be done in these areas, and cutting only forehead muscles is not likely to have a significant effect.

Finally, while we have about 100 scientific articles published on the use of Botox for headaches, there has been only one small, uncontrolled study published on the use of plastic surgery for migraines.

So, surgery for migraines? In my opinion, this is a treatment that’s not quite ready for prime time.

Restless leg syndrome (RLS) affects 10% of the population with 3% suffering from severe symptoms. Patients suffering from RLS complain of difficulty falling asleep because of uncomfortable sensation in their legs which is temporarily improved by moving their legs or getting up and walking around. The movement of the legs persists in sleep and interferes with the deep restful stages of sleep leading to tiredness during the day. Many patient do not realize they have a problem because they’ve had it all their lives and because one of their parents also had it.Researchers reporting in the recent issue of journal Nature Genetics say they have found proof of the genetic nature of RLS. However, not all patients with these symptoms have RLS. Iron deficiency, peripheral nerve damage and antidepressant medications can cause symptoms of RLS. Another sleep disorder, such as sleep apnea can at times mimic RILS and a sleep study may be needed to establish the diagnosis.Treatment of RLS involves the use of medications such as Requip, Mirapex, which belong to a category of drugs called dopamine agonists (they are also used to treat Parkinson’s disease, but these two conditions are not related). Some epilepsy drugs, including Neurontin and Topamax and particularly opioid analgesics, such as hydrocodone and oxycodone can be effective.Sleep deprivation or poor quality of sleep can be a major trigger for migraine headaches. We see many patients with RLS at the NYHC and treating their RLS will often improve their headaches.

A recent small study suggests that wearing red colored contact lenses can relieve pain of a migraine attack. A recent small study suggests that wearing red colored contact lenses can relieve pain of a migraine attack. At the NYHC we have tried this approach and in a several patients it made a dramatic difference. One woman has found that she no longer has to be confined to a dark room and is able to go outside wearing these lenses without developing a migraine from bright daylight. Some patients wear these lenses all the time, while others only when they have a headache. Sunglasses do not offer the same level of light filtering,uinless they are of wraparound type and fit tightly around the eyes.