Pain | Headache NewsBlog

Medical Cannabis vs. Prescription Medications for Chronic Pain

By: Dr. Mauskop

23-03-2025

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared with traditional prescription medications for managing chronic pain.

The study involved 440 patients using medical marijuana and 8,114 patients treated with prescription medications (nonopioid or opioid) in the same healthcare system. Both groups received comprehensive pain assessments and treatment plans.

Key Findings

Response Rates: At three months, 38.6% of the medical marijuana group and 34.9% of the prescription medication group showed significant improvements in pain, function, or overall well-being. The response rate in the medical marijuana group remained stable at six months.

Opioid Reduction: Among the 157 patients in the medical marijuana group who were also prescribed opioids, there was a significant reduction in opioid use, with a mean decrease of 39.3% in morphine milligram equivalents over six months.

Comparative Effectiveness: The study found that medical marijuana was more effective than prescription medications for treating chronic pain, with patients being more likely to respond positively to medical marijuana.

This study suggests that medical marijuana may be at least as effective as, if not more effective than, conventional medications for chronic pain. It also highlights the potential of medical marijuana in reducing opioid use, which is a significant public health concern.

I prescribe medical marijuana to our migraine patients when prescription drugs and non-drug therapies are ineffective. For many, marijuana helps relieve nausea; for some, it helps with migraine-related anxiety and insomnia; and for a smaller proportion, it helps with pain. My observations are probably skewed by the fact that I prescribe medical cannabis only for people with more severe migraines. It may be more effective for people with mild migraines or migraines of average severity.

The Right Tempo in Music May Help Reduce Pain

By: Dr. Mauskop

17-03-2025

Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments, Pain, Pain Research, Psychology of headaches

New research from McGill University published in the journal Pain suggests that the tempo—or speed—of music plays a crucial role in how well it helps reduce pain.

In this study, researchers explored whether music that matches a person’s natural rhythm—called their spontaneous production rate (SPR)—could provide better pain relief. SPR is the pace at which people naturally hum or tap out a tune, almost like a personal internal metronome.

Sixty participants first had their SPR measured by tapping out “Twinkle Twinkle Little Star” at a comfortable pace. Later, they were exposed to mild heat pain while listening to music specially adjusted to three tempos: their exact SPR, 15% faster, or 15% slower. A silent condition was also tested.

The results? Music alone reduced pain compared to silence, confirming what many of us know instinctively—music helps us cope. But the biggest surprise was that music adjusted exactly to each person’s SPR provided the most pain relief. Faster or slower versions just weren’t as effective.

Why does this happen? We think it may be because music at our natural tempo syncs better with our body’s internal rhythms, helping us relax and shift focus away from pain.

What does this mean for you? The next time you’re using music to manage discomfort—whether it’s during a workout, a medical procedure, or just a headache—try finding songs that feel “just right” in speed. It might be your body’s way of telling you it’s syncing up for maximum relief.

This research paves the way for more personalized music therapy—helping us move from simply picking our favorite songs to using science-backed soundtracks tuned just for us.

Here is a part of the chapter on music from my book, The End of Migraines, 150 Ways to Stop Your Pain, providing additional scientific evidence that music can relieve pain.

‘Music relieves experimental pain in healthy volunteers who are paid to endure pain and music. In one study, 18 volunteers were subjected to pleasant music, unpleasant music, and a silent period. Heat-induced pain was reduced only by pleasant music.

Children with migraines exposed to music improved as much as those given butterbur extract. Both groups improved more than a control group.

Music relieved the pain of osteoarthritis in the elderly. Those who listened to music for 20 minutes a day felt better than those who sat quietly for 20 minutes.

A study of 20 volunteers showed that both happy and sad melodies reduced heat pain. Listening to a lecture did not.

Another group of researchers examined the potential pain-relieving properties of three aspects of music: arousal, valence, and depth. Arousing music is characterized as “intense, forceful, abrasive, or thrilling”. Valence refers to “fun, happy, lively, enthusiastic, and joyful”. Depth means “intelligent, sophisticated, inspiring, complex, poetic, deep, emotional, and thoughtful.” The degree of arousal and the depth of music had a greater effect on pain than valence. The authors concluded, “With the advent of online music streaming services, this research opens new possibilities for music-based pain interventions.”

The new study suggests that tempo is another factor to consider when choosing soothing music.

Suzetrigine: A Promising New Treatment for Pain

By: Dr. Mauskop

30-01-2025

Brain disorders, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research

FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be as effective as Vicodin (hydrocodone with acetaminophen) after surgery to remove a bunion and after a “tummy tuck”.

Suzetrigine is a selective NaV1.8 inhibitor, targeting a key sodium channel involved in pain signaling. The NaV1.8 channel is crucial in transmitting nerve pain signals to the brain. However, the drug does not enter the brain and works only on the nerves outside the brain and in the body.

Unlike traditional pain medications such as opioids, suzetrigine provides effective pain relief without addiction risk or severe systemic side effects. Early clinical trials suggest it may be beneficial for conditions like neuropathic pain, post-surgical pain, and chronic pain syndromes. Hopefully, it will also prove effective in the treatment of migraines and other types of headaches.

In clinical trials, about 37% of patients experienced adverse events, though most were mild. These included itching, rash, constipation, and muscle spasms.

As a non-opioid option, suzetrigine provides clinicians with an additional tool for acute pain management. The medication is expected to become available in the second quarter of 2025. The expected cost is about $15 a pill.

Can Magnetic Brain Stimulation (rTMS) Prevent Pain?

By: Dr. Mauskop

02-12-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine, TMJ

Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of repetitive transcranial magnetic stimulation (rTMS) on pain sensitivity offers some intriguing insights.

What is rTMS?

rTMS is a non-invasive method of brain stimulation. It involves sending magnetic pulses to specific areas of the brain through a coil placed on the scalp. This technique has been used to treat conditions like depression and chronic pain, but researchers are now looking at its potential to prevent pain. We used rTMS at the New York Headache Center to treat chronic migraine, other pain and neurological conditions that do not respond to usual treatment.

In a controlled experiment, researchers led by Nahian Chowdhury examined the role of rTMS in reducing future pain in healthy volunteers. The results were published in the latest issue of Pain, a journal of the International Association for the Study of Pain.

The subjects were divided into two groups:

Active rTMS Group: Received high-frequency rTMS to the area of the brain responsible for hand movements.

Sham rTMS Group: Received a fake treatment for comparison.

Both groups were then given an injection of nerve growth factor (NGF) into their jaw muscles, which causes prolonged pain similar to temporomandibular disorders (TMD), a condition causing jaw pain and dysfunction.

Results:

Pain Reduction: Participants who received active rTMS reported significantly less pain when chewing or yawning than the sham group. This effect was more pronounced in the early stages after the injection but persisted for days and weeks.

Brain Activity: The study found an increase in what’s known as peak alpha frequency (PAF) after rTMS, which is linked to lower pain sensitivity.

What Does This Mean for Pain Management?

Preventive Potential: This research suggests that rTMS could be used prophylactically to reduce pain sensitivity when pain is expected, like before surgery.

Future Directions: While promising, this study opens the door to further research into how rTMS can be optimized for pain control, potentially exploring different frequencies, duration, and areas of stimulation.

Pre-Surgery: rTMS might be used to reduce postoperative pain, potentially preventing the transition to chronic pain.

Chronic Pain Management: For those already dealing with chronic pain, understanding how brain activity changes with rTMS could lead to more effective treatments.

Conclusion

While we are still in the early stages, this study of rTMS offers hope for pain sufferers. It suggests a future where we might not only treat pain more effectively but also prevent it from becoming a long-term problem. This could revolutionize our approach to pain management, making it less about reducing and enduring pain and more about preventing it from taking root in the first place.

New Daily Persistent Headache may respond to TMS

By: Dr. Mauskop

06-10-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain

Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial magnetic stimulation (rTMS).

NDPH is a type of headache that begins suddenly and persists daily without specific features, distinct MRI presentation, or blood test abnormalities. It can present similarly to chronic migraines or chronic tension-type headaches. While published reports suggest NDPH is difficult to treat, this is often not the case. However, patients who do not respond to initial standard treatments may become discouraged.

The Indian researchers conducted a pilot study with 50 NDPH patients who received 10 Hz rTMS sessions on the left prefrontal cortex of the brain for three consecutive days. They found that after 4 weeks:

70% of patients had at least a 50% reduction in headache severity
Patients gained an average of 11 headache-free days per month
76% had significant improvements in headache-related disability
Depression and anxiety scores also improved significantly

The treatment was well-tolerated, with only minor side effects in a few patients. The benefits seemed especially pronounced in patients who had NDPH that resembled chronic migraine.

I never give the diagnosis of NDPH, but diagnose it as a condition it most resembles and treat the person with a wide variety of available options. Many respond. For those who do not, we offer rTMS, a procedure that uses magnetic fields to stimulate nerve cells in the brain. An electromagnetic coil device is placed against the scalp near the forehead. The coil painlessly delivers a magnetic pulse that stimulates the brain with the goal of reducing headache symptoms. The FDA has approved it for the treatment of depression, anxiety, and OCD. We use it for various neurological conditions, including headaches that do not respond to standard therapies. To treat migraines and other types of pain, we usually stimulate not only the left prefrontal cortex, as was done in this study, but also two additional sites that have been reported to help with pain and migraines. These additional sites are either the motor cortex or the occipital cortex, on both sides.

Sometimes, we obtain a functional magnetic resonance imaging (fMRI) scan to better target rTMS. fMRI is a research procedure that is not available commercially (and is not covered by insurance).

Disruption of brain networks by chronic pain can be prevented.

By: Dr. Mauskop

18-08-2024

Alternative Therapies, Brain disorders, Pain, Pain Research, Psychology of headaches

Chronic pain is known to alter the brain’s default mode network (DMN). The DMN is a group of interconnected brain regions activated when a person is not focused on the external world. Key DMN functions include mind wandering (daydreaming, thinking about the past or future, imagining scenarios), self-reflection (considering thoughts, feelings, and experiences), theory of mind (understanding others’ thoughts and intentions), and memory (retrieval and processing).

A recent study published in the journal Pain by German researchers investigated the relationship between chronic back pain and DMN alterations. The study, titled “Beyond the chronic pain stage: default mode network perturbation depends on years lived with back pain,” examined patients with chronic back pain (CBP), subacute back pain (SBP), and healthy controls using fMRI.

Results showed that the DMN is significantly altered in CBP patients compared to healthy individuals. Importantly, the degree of DMN disruption increased with the duration of pain, suggesting that the brain adapts to persistent pain over time. This adaptation is influenced by cognitive coping strategies or how individuals mentally manage their pain.

The study found that coping attitudes mediate the link between DMN changes and pain duration. This implies that how people think about and handle pain impacts their brain’s adaptation to it. Effective pain coping strategies could potentially lessen the negative effects of chronic pain on the brain, emphasizing the importance of psychological interventions like meditation, cognitive behavioral therapy (CBT), and acceptance-commitment therapy (ACT).

These findings also provide a scientific basis for treatments like transcranial magnetic stimulation (TMS) and other brain stimulation methods, which aim to restore normal brain connectivity, including DMN function.

Focused ultrasound to specific brain regions relieves pain

By: Dr. Mauskop

04-08-2024

Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments, Pain

The use of focused ultrasound to treat brain disorders was one of the topics discussed at the 2024 NYC Neuromodulation Conference in NYC.

Coincidentally, a study on this topic was published last month by Jan Kubanek and his colleagues in Pain, the journal of the International Association for the Study of Pain: “Noninvasive targeted modulation of pain circuits with focused ultrasonic waves”.

Researchers developed a technique that targets the anterior cingulate cortex, a deep brain region involved in processing pain. By using focused ultrasound, this region can be modulated without surgery. This breakthrough has the potential to revolutionize pain management.

Twenty patients with chronic pain participated in a randomized crossover trial. They received two 40-minute sessions of either active or sham stimulation and were monitored for one week. The results were remarkable:

60% of patients experienced a significant reduction in pain on day 1 and day 7 after active stimulation.
Sham stimulation only benefited 15% and 20% of patients, respectively.
Active stimulation reduced pain by 60.0% immediately after the intervention and by 43.0% and 33.0% on days 1 and 7.
Sham stimulation only reduced pain by 14.4%, 12.3%, and 6.6% on the same days.

The stimulation was well tolerated and the side effects were mild and resolved within 24 hours.

Since we have been using transcranial magnetic stimulation (TMS) to treat refractory migraines and other neurological conditions, it was good to read this part of the authors’ conclusion:

“The ultrasonic intervention is conceptually related to TMS applied to the motor cortex, which can provide improvements in chronic pain in certain groups of patients. The key difference is that ultrasonic waves can directly modulate the deep brain regions involved in chronic pain, including the anterior cingulate cortex. Transcranial magnetic stimulation is believed to modulate deep brain regions only indirectly, which may contribute to its variable response and the need for frequent re-administrations. Nonetheless, the effects of both modalities may be complementary, and their combined application may provide stronger effects than either approach alone.”

Abnormal functional connectivity in brains of patients with vestibular migraine

By: Dr. Mauskop

27-05-2024

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, post-traumatic headache, Science of Migraine

Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain regions like the insula, thalamus, somatosensory cortex, as well as visual cortex. Some patients also have changes in the default mode and salience networks involved in attention and stimulus processing.

A study published this month by Chinese researchers in the Journal of Headache and Pain reports on connectivity changes in people with vestibular migraines.

They found abnormal resting-state functional connectivity in brain regions involved in multi-sensory and autonomic processing as well as impaired ocular motor control, pain modulation, and emotional regulation.

Until now, there has been little practical application for fMRI findings. However, with the help of Omniscient Neurotechnology, we have just started using fMRI data to better target our treatment with transcranial magnetic stimulation (TMS). TMS applied to motor and visual cortices has been reported to help relieve migraine headaches. We have also found it effective in a significant proportion of patients who did not respond to various other treatments. We have not yet accumulated enough data to determine if fMRI-guided TMS treatment is superior to TMS administered over a predetermined set of targets.

The main obstacle to wider use of TMS in clinical practice is the cost. TMS is approved by the FDA and is covered by insurance for the treatment of anxiety and depression, but not migraines or pain. fMRI is an expensive research tool and is also not covered by insurance. Hopefully, the NIH and other research foundations will provide the funds needed to study this promising treatment.

Visit with the Nolan Williams’ TMS team at Stanford

By: Dr. Mauskop

24-04-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Nolan Williams has been at the forefront of developing breakthrough TMS protocols for the treatment of depression and other psychiatric indications. It was very stimulating and informative to discuss techniques, protocols, indications, and research into TMS for various neurological and psychiatric indications with the members of Nolan Williams’ lab Greg Sahlem and Ika Kaloiani. Thank you for sharing your knowledge.

Pain relief from transcranial magnetic stimulation is possibly opioid-mediated

By: Dr. Mauskop

07-04-2024

Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Headaches, Headaches in children, Migraine, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine

Repetitive transcranial magnetic stimulation (rTMS) is approved by the FDA for the treatment of depression and anxiety. We have been using it to treat migraine headaches and other neurological conditions that are not responsive to standard therapies. Improvement in headaches and pain may be at least in part due to improvement in depression. However, additional mechanisms play a role since we see patients who are not depressed but whose pain improves with rTMS.

A new study by Chinese and Australian researchers published in Pain suggests that opioid mechanisms (endorphins, encephalin, and other peptides) may underlie the mechanism of pain relief produced by rTMS.

This was a double-blind, placebo-controlled study. 45 healthy participants were randomized into 3 groups: one receiving rTMS over the primary motor cortex (M), dorsolateral prefrontal cortex (DLPFC), or sham stimulation. Experimental pain was induced by applying capsaicin (hot pepper extract) over the skin of the right hand followed by application of heat.

Participants received intravenous naloxone (an opioid receptor antagonist) or saline before the first rTMS session to block or allow opioid effects, respectively. After 90 minutes to allow naloxone metabolism, participants received a second rTMS session.

For the M1 group, naloxone abolished the analgesic effects of the first rTMS session compared to saline. Pain relief returned in the second session after naloxone was washed out of the body. For the DLPFC group, only the second prolonged rTMS session induced significant analgesia in the saline condition compared to naloxone. rTMS over M1 selectively increased plasma ?-endorphin levels, while rTMS over DLPFC increased encephalin levels.

The results suggest that opioid mechanisms mediate rTMS-induced analgesia. The specific opioid peptides and rTMS dosage requirements differ between M1 and DLPFC stimulation.

However, these results are far from definitive. The study was small and the study protocol was complicated (e.g. using a double dose of rTMS to DLPFC), which increases the likelihood of an error. Also, these results apply to conditions of acute pain. In patients with chronic pain and headaches, rTMS likely provides relief by improving network connectivity between different parts of the brain.

More on TMS

By: Dr. Mauskop

08-02-2024

Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headaches, Headaches in children, Migraine, neurostimulation, New treatments, Pain, post-traumatic headache, Trigeminal and other neuralgias

We use a neuronavigation system from Soterix (on the left) for precise targeting of transcranial magnetic stimulation (TMS). And we use the most advanced TMS machine from MagVenture (on the right) to treat chronic pain, migraines, fibromyalgia, and other neurological conditions.

TMS for medication overuse (rebound) headaches

By: Dr. Mauskop

28-01-2024

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache

Medication overuse or rebound headaches can occur as the result of excessive intake of caffeine, opioid analgesics, and short-acting barbiturate drug, butalbital (contained in Fioricet, Esgic and similar drugs). These three substances not only worsen migraine headaches, they are also addictive. Two of my patients with medication overuse headaches were able to stop the offending drugs with the help of repetitive transcranial magnetic stimulation (rTMS).

One patient, a 51-year-old man, had his migraines under control with Botox and infusions of eptinezumab (Vyepti) until he sustained a head injury with a skull fracture. His migraines worsened and he became disabled. A variety of therapies failed to reduce his pain. His pain was partially relieved by 60 mg of oxycodone a day, although he still was unable to work. After six weekly sessions of rTMS he was able to start reducing his oxycodone intake and after eight, he completely stopped it. He was able to return to work with the help of injections of fremanezumab (Ajovy).

Another patient, a 50-year-old woman, had been taking butalbital with caffeine and acetaminophen (Fioricet) for 20 years. The number of pills increased over time and for the previous several years, she had been taking 10 to 12 tablets every day. She was also receiving Botox injections, infusions of eptinezumab, and taking rizatriptan (Maxalt), 10 mg three times a day as well as 60 mg of nortriptyline, 12 mg of tizanidine nightly and atogepant, 60 mg. She had tried a wide variety of other treatments but was unable to reduce her Fioricet intake. Despite her persistent migraines, she was able to take care of her family. After three weekly sessions of rTMS she reduced her Fioricet intake to 3-4 a day, by the third month she was taking one a day, and after 6 months she was completely off it. She was also able to stop atogepant and tizanidine and reduced her nortriptyline to 25 mg.

In addition to helping relieve pain and migraines, rTMS has shown promise in the treatment of addiction, particularly in addressing withdrawal symptoms, depression, and cravings. While the use of rTMS for addiction is still relatively recent and not yet FDA-approved, some studies have demonstrated positive outcomes. For instance, a double-blind study showed that individuals receiving rTMS therapy for cocaine addiction had a higher rate of abstinence compared to those who received standard treatment. rTMS for addiction is still considered experimental, and more research is needed to fully understand its long-term effects and optimal treatment parameters.

Medical Cannabis vs. Prescription Medications for Chronic Pain

The Right Tempo in Music May Help Reduce Pain

Suzetrigine: A Promising New Treatment for Pain

Can Magnetic Brain Stimulation (rTMS) Prevent Pain?

New Daily Persistent Headache may respond to TMS

Disruption of brain networks by chronic pain can be prevented.

Focused ultrasound to specific brain regions relieves pain

Abnormal functional connectivity in brains of patients with vestibular migraine

Visit with the Nolan Williams’ TMS team at Stanford

Pain relief from transcranial magnetic stimulation is possibly opioid-mediated

More on TMS

TMS for medication overuse (rebound) headaches

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