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.
Read MoreHigh 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.
Read MoreLower 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.
Read MoreHeadache 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. “
Read MoreA 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.
Read MoreVertigo 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.
Read MoreUnfair 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.
Read MoreStrokes 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.
Migraine headaches in patients with post-traumatic stress disorder tend to be more frequent and disabling, according to a study in soldiers led by Dr. Jay Erickson. Soldiers with PTSD had almost twice as many headaches as soldiers without PTSD and were more likely to have chronic migraines (headaches on more than 15 days a month). Treatment with preventive medications was slightly less effective in the PTSD group. Botox injections were not tried in these patients. It is a well established fact that patients with a history of abuse are more likely to have chronic pain, including headaches. This is an important part of history since inclusion of psychotherapy may improve treatment outcomes in these patients and, at least in theory, using antidepressants rather than other classes of preventive drugs may be more appropriate.
Read MoreBoth overweight and underweight people are more likely to have migraine headaches, according to a recent study published in journal Cephalalgia. Being overweight has been shown to increase the risk of chronic migraines in a previous large study, but the discovery of the link between being too thin and migraines is new. These findings do not mean that regaining normal weight will lead to improvement in headaches, but only that there is an association. This is not to say that we do not encourage our overweight patients to lose weight. The best way to achieve this is not only by dieting, but also by engaging in frequent aerobic exercise, which has been found to be associated with fewer migraine headaches.
Read MorePatients who suffer from migraine headaches are 30% less likely to develop breast cancer. It is well established that fluctuating estrogen levels throughout the menstrual cycle can trigger migraine attacks. These fluctuations are reduced during pregnancy and menopause, resulting in cessation of migraine attacks in two thirds of women. At this point it is not clear what common estrogen-based mechanisms are responsible for the reduction of breast cancer risk in migraine sufferers.
Read MoreIt is well known that if you take a snapshot of the population, about 18% of women and 6% of men suffer from migraine headaches. However, a report by Dr. Stewart and his colleagues in the latest issue of Cephalalgia indicates that cumulative lifetime migraine incidence is much higher – 43% of women and 18% of men have migraine headaches at some point in their lives. Migraine incidence peaked between the ages of 20 and 24 in women and 15 and 19 in men. In 75% of cases migraine started before the age of 35.
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