Archive
Science of Migraine

Childhood abuse or neglect was reported by 58% of 1,348 migraine sufferers according to a study published in the current issue of Headache.  Emotional abuse and neglect was particularly common.  Patients with other chronic pain conditions also have high incidence of emotional, sexual, and physical abuse.  Migraine patients who suffered abuse are also more likely to have anxiety and depression.  We do not know what physiological mechanisms that are triggered by abuse lead to chronic pain.  This and similar studies suggest that greater attention should be directed at the psychological factors that contribute to migraine headaches.  One possible negative outcome of this study is that some physicians, who may already consider migraine to be a purely psychological disorder, will be even more inclined to avoid treating migraine as a biological disease.  In practice, it means that these doctors will be even more reluctant to prescribe appropriate acute migraine medications, such as triptans (Imitrex and other).  Migraine is clearly a biological disorder with documented genetic predisposition and should be treated as such.  At the same time, we know that psychological factors play a major contributing role and should be also addressed when treating headache and pain patients.

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Migraine headaches are more frequent in people who suffer from allergic rhinitis and who have more than 10 positive skin allergy tests.  This finding by Dr. Martin and his colleagues presented at the International Headache Congress last week is not surprising since many of my patients report that their migraines worsen during periods when their allergies flare up.  It is also not surprising because almost any medical condition affecting the head, whether it is an ear infection, a dental problem, or conjunctivitis, can trigger a migraine attack.

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Migraine headaches are three times more common in patients with multiple sclerosis than in people of similar age and gender without MS.  Ilya Kister and his colleagues at NYU who established this fact make a very important point – multiple sclerosis symptoms often overshadow the symptoms of migraine and this can result in migraine not being treated properly leading to additional avoidable disability.    

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Vertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology.  In this study researchers induced vertigo in patients who had a history of migraines and in a control group.  Almost half of those who had a history of migraines developed a migraine attack within 24 hours, compared with only 5% of those who were not known to have migraines.  The study suggests that vertigo due to an inner ear problem can trigger a migraine attack.  This finding will not come as a surprise to migraine sufferers who cannot ride a roller coaster or even go on bumpy a car ride without getting a migraine.

At times, migraine sufferers develop vertigo as part of their migraine attack and it can be difficult to tell if vertigo caused the migraine or was just one of the symptoms.  A detailed description of more than one attack usually gives a clear answer.

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Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to 14 who were diagnosed with this condition.  A year later 40% still had CDH, and after 2 years, 25% had symptoms of CDH.  They followed 103 of the original 122 for 8 years and found that only 12% still had daily headaches with 10 out of 12 diagnosed as having chronic migraines.  This is what we see in practice, but now we have good evidence and can be more certain when we tell our adolescent patients and their parents that they will “grow out” of their headaches.  Another piece of good news was that most kids were not actively treated and headaches improved on their own.  However, it may take months or years for headaches to improve and we should not just sit and wait while the child suffers.  Active treatment includes sleep hygiene, regular exercise, avoiding dietary triggers, biofeedback or relaxation training, magnesium, CoQ10 and other supplements, possibly acupuncture, Botox injections and medications.

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High homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid and vitamin B12 (cyanocobalamine).   A study by Spanish doctors published in Headache found elevated homocysteine levels in patients who have migraines with aura.  Patients who have migraine with aura are known to have increased risk of cardiovascular disease and it is possible that elevated homocysteine levels are at least in part responsible for this risk.  I routinely check homocysteine, vitamin B12 and folic acid levels in all of my patients.  One caveat is that vitamin B12 levels are not very reliable – you may have a normal level, but still be deficient.  While laboratories consider a level of over 200 to be normal, clinical deficiency is often present at levels below 400.  A single case report has been published of a severe deficiency with neurological symptoms and a vitamin B12 level of over 700.  This patient lacked the ability to transport vitamin B12 from his blood into the cells.  Injections of high doses of vitamin B12 corrected the problem.  Oral magnesium supplementation is not as effective as injections because vitamin B12 is poorly absorbed in the stomach.   Other ways to get vitamin B12 is by taking it sublingually (under your tongue) or by a nasal spray (it requires a prescription and is fairly expensive).  Many of my patients a willing to self-inject vitamin B12, which they do anywhere fro once a week to once a month.   Vegetarians are more likely to be deficient since meat (and liver) are the main sources of vitamin B12.  Smokers are also at a high risk because cyanide in smoke binds to vitamin B12.

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Lower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in Cephalalgia by German researchers.  One of the 517 migraine patients they looked at had lower facial pain as the leading symptom of migraine.  Some of my patients with lower facial pain wonder if they have a disorder of the temporo-mandibular joint (TMJ).   Some of them do benefit from an oral appliance that reduces grinding and clenching, in most however, a successful treatment of their migraines with abortive or prophylactic medications will often relieve the jaw pain as well.

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Headache diary plays an important role in the management of headache patients.  Drs. McKenzie and Cutrer from the Mayo Clinic compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in a questionnaire vs a daily diary.   Here are some of their findings “Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment.  As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.  209 patients completed a questionnaire and also maintained a daily diary over the 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P < .001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable. “

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A pharmacogenetic study by Italian researchers discovered that absence of a certain gene can predict therapeutic response in migraine patients who are treated with riboflavin (vitamin B2).   Pharmacogenomics has been a very promising field of medical science that may enable doctors to select the most effective and safe medicine for each patient based on their genetic profile.  This is a small but important step in utilizing this science to treat headache patients.

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Vertigo is a common symptom in patients with migraine headaches.  It appears that obverse is also true – migraine is very common in patients with vertigo.  A study just published in Cephalalgia looked at 208 patients with benign recurrent vertigo.  It turned out that 87%, or 180 of these patients had migraine headaches.  Of these 180 patients, 112 or 62% had migraine with aura and 38% had migraine without aura.  Thirty percent, or 54 patients always had vertigo without any migraine symptoms, while in 70% vertigo occurred with a headache or other migraine symptoms, such as visual aura, sensitivity to light and noise.  The duration of attacks of vertigo in most patients was between one hour and one day.

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Unfair teachers can cause headaches in adolescents, according to an Italian study published in the journal Headache.  About 40% of 4,386 adolescents suffered from headaches at least once a week.  Girls were more likely to have headaches and kids who had better classmate social support had fewer headaches.  The researchers used an established  “Teacher and Classmate Support Scale” to measure these effects and also took into account other factors that could have skewed the data.  They looked at family and friend empowerment, bullying, school achievement, and trust in people, and none of those factors seemed to play a role in causing headaches.  Psychological stress worsens headaches in adults too, but it seems to have a more pronounced effect in adolescents.

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Strokes in pregnant women who suffer from migraine headaches are very rare.  This is a letter I submitted to the British Medical Journal  in response to an article they just published on this topic:

The large amount of data and the statistical analyses in this paper look impressive and unfortunately may fool many readers into believing the conclusions made by the authors.  The authors do acknowledge that the discharge diagnostic codes miss many patients who suffer from migraine headaches.  This diagnosis is not only missed upon discharge, but it is an established fact that migraine is significantly underdiagnosed by the majority of primary care doctors.  Obstetricians are not likely to do a better job in distinguishing sinus and tension-type headaches from migraines, or diagnosing a migraine aura, particularly when managing a pregnant woman in the hospital.  It is true that migraines improve in pregnancy, but considering that about 18% of women suffer from migraine headaches, it is hard to believe that only one in 100 of these women will continue having migraines during pregnancy.  Obviously, when a complication, such as stroke occurs the diagnosis of migraine is much more likely to be recorded than when no complications occur. 
The authors provide many disclaimers and state that “On the basis of the select group of pregnant women with migraines coded during the hospital admission, this may not represent the population of women with migraine as a whole”.  Nevertheless, they go on to present and analyze this highly inaccurate data and even draw conclusions.  It is very unfortunate that the publicity associated with this paper (I first saw it reported on Yahoo.com) will cause unnecessary anxiety to millions of pregnant women. 

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