The annual course, “The Shifting Migraine Paradigm 2024” will be held February 15-17, 2024 at the Plaza San Antonio Hotel & Spa. This three-day conference offers an excellent update on the treatment of migraine and other headaches.
It is always an honor to be invited to speak at this event. The topic of my presentation is Supplements and Medical Foods.
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Homocysteine, an amino acid crucial for cellular metabolism and protein synthesis, is naturally produced by the body. However, either too low or too high levels in the body can lead to significant health issues.
Insufficient homocysteine levels impair the production of glutathione, a vital substance for detoxifying the liver and the entire body. In some cases, patients are given glutathione infusions for its additional benefits.
Having too much homocysteine is also a problem. High homocysteine levels are associated with an increased risk of cardiovascular disease, cancer, and migraine with aura. High homocysteine levels may also mean you have a vitamin deficiency. Vitamins B12, B6 and folate break down homocysteine to create other chemicals your body needs. Replacing these vitamins often helps return the homocysteine level to normal.
Some drugs may lead to increased homocysteine levels. These include cholestyramine, metformin, methotrexate, nicotinic acid (niacin), and fibric acid derivatives (drugs that are used to lower lipids).
Besides migraine with aura, other symptoms of high homocysteine and low vitamin B12 levels may include memory difficulties, weakness, fatigue, tingling sensations in the hands, arms, legs, or feet, dizziness, mouth sores, and mood changes.
White matter lesions seen on the MRI scans of migraine patients are more common in those with high homocysteine levels. High homocysteine levels may be responsible for the increased risk of strokes in migraine patients.
The good news is that taking vitamins B12, folate, and B6 (pyridoxine) can lower homocysteine levels. Methylated forms of vitamin B12 and folate, methylcobalamin and methylfolate are better absorbed than cyanocobalamin or folic acid.
If you suffer from migraines, especially migraine auras (with or without headaches) you may want to have your homocysteine levels checked. In all of our migraine patients, we also check vitamin B12, folate, RBC magnesium, vitamin D, TSH (thyroid), and routine tests – CBC and CMP.
Read MoreLack of sleep is a common migraine trigger. A less common trigger is getting too much sleep. I always recommend that patients try to go to sleep at the same time and get up at the same time. Even on weekends. Instead of sleeping in on the weekend, take a 30-minute nap in the afternoon.
A new study by Australian researchers published in Neurology reports another important reason for sleep regularity. This was a large and rigorous study involving 88,094 UK subjects. All subjects wore an accelerometer that detected their sleep patterns. The researchers controlled for variables that are known to predispose to dementia – age, sex, ethnicity, material deprivation, retirement status, current shift work status, household income, highest level of education, smoking status, use of sedative, antidepressant, or antipsychotic medication, and genetics (APOE ?4 carrier status).
They “identified a nonlinear relationship between day-to-day sleep regularity and dementia risk such that dementia rates were highest in those with the most irregular sleep, dipped as sleep regularity approached the median, and then marginally increased at the highest estimates of sleep regularity.” In subjects who underwent brain MRI (n = 15,263), gray matter and hippocampal volume (area of the brain critical to memory) similarly tended to be lowest at the extremes of the sleep regularity index. This was surprising – subjects whose sleep patterns were extremely chaotic did slightly better than those with moderately irregular sleep.
Other sleep disorders that can contribute to migraines and increase the risk of dementia are restless leg syndrome, sleep apnea, and sleeping too much or not enough.
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Neurologists diagnose migraine by the description of symptoms provided by the patient. We have not had an objective test to confirm that a person suffers from migraines.
A group of researchers led by Dr. Yiheng Tu in the department of psychiatry at Harvard Medical School developed an AI program that can diagnose migraine using fMRI (functional MRI) scanning. The AI program was first fed information on fMRIs of 116 individuals with migraines and then had this data compared to healthy controls.
The AI program had 93% sensitivity and 89% specificity. This means that it missed the diagnosis of migraine in only 7 out of 1oo patients and diagnosed migraine in 11% of patients who did not have it. These are very good numbers, but clearly, the method is not error-proof.
When they compared people with migraines to those with other types of pain, the sensitivity dropped to 78% and specificity, to 76%. This can be explained by the fact that similar functional changes in the brain probably occur with any type of pain.
A major obstacle to the wide use of fMRI scans is the cost. They are more expensive to perform than a regular MRI. Insurance companies are not likely to cover it since this is an experimental procedure. Another potential difficulty is that fMRI takes much longer to do than a regular MRI – an hour vs 20 minutes. During this time you have to lie inside a tube while trying not to move and hearing loud banging noises.
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New daily persistent headache (NDPH) is condition that is defined solely by the fact that the headache begins suddenly one day and does not go away. There are no scientific studies to suggest possible underlying mechanisms or treatments. Some patients develop it after a viral infection while others, after a period of stress and many with no apparent trigger.
In my latest book, I mentioned how a seemingly benign idea of classifying medical conditions can cause harm. In case of NDPH, many anecdotal reports in medical journals indicate that this condition is not responsive to treatment. However, there are no controlled double-blind studies, only anecdotal reports. Many patients with this condition will look up this literature and conclude that there is no hope of getting better. I have seen many such devastated people. But this bleak picture is clearly wrong.
I have seen many patients with NDPH who responded to various treatments. In my 30 years of using Botox, I have found it to be one of the safest and most effective treatments for NDPH as well as migraine and other types of headaches.
At the recent meeting of the International Headache Society held in Seoul, two presentations described good responses of NDPH to Botox injections.
The first report was by S. Cheema and colleagues of Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK. They compared patients with NDPH (58) and those with chronic migraine (CM) with daily attacks (153) and chronic migraines without daily attacks (85). There was a 30% reduction in mean moderate and severe headache days in 33% of patients with NDPH, 43% with daily CM and 55% with non-daily CM.
The second report was by Shuu-Jiun Wang and colleagues of the Neurological Institute, Taipei Veterans General Hospital. They looked at the response of patients with NDPH who had predominately migraine features and those who had predominantly features of tension-type headaches. Of 228 patients diagnosed with NDPH, 199 patients (87%) had migrainous features and 29 patients (13%) had tension-type features. Their conclusion: “Through a mean follow-up duration of 2.5 years, around 40% patients with NDPH showed a favorable outcome at our headache center. Our results suggest NDPH might not be as grave as previously reported.”
Yes, these were also anecdotal reports rather than controlled trials, but they clearly show what I have also observed in my practice – NDPH is a very treatable condition. Hopefully, the next, fourth edition of the International Classification of Headache Disorders will no longer list NDPH as a diagnosis since it has no scientific basis.
Read MoreMost people have heard about the gut-brain connection. Research published in The Journal of Headache and Pain examined this connection in relation to migraine headaches. The researchers looked at whether the collection of microorganisms living in our guts (called the gut microbiome) could be linked to the development of migraine headaches and its different types – migraine with and without aura.
To do this, the scientists used information from a big genetic study that looked at the genes related to the gut microbiome. They also used data from studies that explored the genetics of migraine headaches. They employed sophisticated methods to analyze this data, and they also checked for other factors that could affect the results.
In the analysis, they found that certain types of bacteria in the gut were connected to migraine headaches, including ones with and without aura. They also found that some specific types of bacteria were more likely to be associated with certain types of migraines. Even after doing some statistical adjustments, these connections still held up.
So, this study suggests that the mix of bacteria in our guts might actually influence whether we get migraines and what kind they are. It shows that there might be a link between our gut and our brain when it comes to migraines.
They found that while some bacteria seemed to contribute to migraines, one type appeared to be protective. This protective effect was linked to the Bifidobacterium family. You can find Bifidobacterium in many probiotics, including a well-known brand called Align. Additionally, various fermented foods like milk kefir, sourdough bread, sauerkraut, kimchi, and other fermented vegetables contain Bifidobacterium.
However, it’s important to note that this research doesn’t mean other types of bacteria aren’t helpful too. A healthy human gut microbiome consists of many different types of bacteria. When there is an imbalance of these healthy bacteria, it can lead to various health problems, not just migraines. This imbalance can come in many different forms and may require different probiotics to correct it. That is why I recommend that patients try different types of probiotics for a few months at a time. Besides Bifidobacteria, some patients respond well to Saccharomyces, Lactobacillus, or other types, or even a combination of several.
Read MoreOur thoughts and emotions can impact the development of chronic pain. However, there haven’t been many studies exploring what causes pain to transition from being short-term (acute) to long-lasting (chronic).
Australian researchers conducted a study to investigate how our thought patterns, anxiety related to pain, and the tendency to avoid pain affect both acute and chronic pain. They conducted two studies for this purpose. In the first study, they interviewed 85 individuals experiencing long-term pain to understand their thoughts and emotions. In the second study, they observed 254 individuals who had recently started experiencing acute pain and followed up with them three months later.
In both studies, they examined interpretation bias using a word association task and assessed pain-related anxiety, pain avoidance, pain intensity, and how pain interfered with daily life. In both cases, they discovered that the way people think about pain was linked to how much it disrupted their daily lives. In the second study, they also found that people’s thought patterns about pain were connected to increased anxiety about pain. This heightened anxiety, in turn, made the pain more severe and disruptive after three months. While anxiety about pain also led people to try to avoid it, this avoidance behavior didn’t seem to affect the level of pain they experienced later on.
This research provides valuable insights into how pain can transition from acute to chronic. It suggests that our initial thoughts about pain might trigger anxiety related to pain, which can contribute to the pain persisting and becoming more troublesome over time. This finding could be crucial in developing strategies to prevent chronification of pain by addressing how people perceive and manage their anxiety about pain during its early stages. Cognitive-behavioral therapy, meditation, and other mind-body techniques could be some of such strategies.
Read MorePeople who suffer from migraines are twice as likely to develop benign paroxysmal positional vertigo (BPPV) than individuals without a history of migraines. BPPV, though benign, can be a terrifying experience, especially for those experiencing it for the first time. It has a sudden onset and is often accompanied by nausea and vomiting. The first thought that enters people’s mind is a stroke or a brain tumor.
The cause of BPPV is a loose crystal in one of the semicircular canals of the inner ear. Epley maneuver usually succeeds in trapping and immobilizing this crystal. I’ve had a patient who emailed me with a typical description of BPPV. I emailed her this link to a YouTube video with the instructions on how to perform the Epley maneuver. She emailed back 30 minutes later reporting that her vertigo stopped.
A new study by Dr. Michael Strup, a neurologist at the Hospital of the Ludwig-Maximilians University in Munich and his European colleagues compared two different maneuvers to relieve BPPV. They showed that Semont-Plus maneuver is more effective than the Epley maneuver.
Of the 195 participants 64% were women and the mean age was 63. Initially, the procedure was administered by a physician. Subsequently, patients were instructed to perform the maneuver independently—three times each in the morning, noon, and evening. The Epley group stopped having vertigo after an average of 3.3 days, while the Semont-Plus group, after an average of 2 days.
Read MoreThe fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have investigated this relationship, but the findings have been inconsistent. The reported weather triggers range from humidity and strong winds to heat, cold, and barometric pressure changes.
In a recent study, Japanese researchers analyzed data collected from a smartphone app used by 4,375 individuals who experience headaches. By employing statistical and deep learning models, they aimed to predict the occurrence of headaches based on weather factors. The results of their study have been published in Headache, the journal of the American Headache Society.
The research confirms that headaches are more likely to occur under specific weather conditions. Low barometric pressure, barometric pressure changes, higher humidity, and rainfall were identified as factors associated with a higher occurrence of headaches.
This finding is not just a matter of curiosity; it has practical implications. There are several options besides moving to a place with a consistently mild climate, such as Southern California. For instance, low barometric pressure headaches can sometimes be prevented with the use of acetazolamide (Diamox), a medication commonly prescribed for mountain sickness. Setting up a Google Alert or using an app like WeatherX can provide warnings when barometric pressure drops. This allows individuals to take preemptive measures such as taking acetazolamide to prevent a headache the following day. Adopting general measures such as regular exercise, meditation, a healthy diet, and sufficient sleep can also help mitigate the effects of weather-related headaches.
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On March 10, I will be speaking on the Treatment of a Refractory Headache Patient at the annual meeting of HCNE in Greenwich, CT. One of the seven broad strategies I will be speaking about is trying multiple drugs within each therapeutic category. For example, if you did not respond to one beta-blocker, a different one might work better or have fewer side effects. Here is a part of a recent email from a former patient that supports this idea.
“For over fifty years, I have had migraines. Ever since Imitrex came out and I started to take it, I would get a migraine every day! We thought it might be rebound headaches from the Imitrex, but it was not. I tried every kind of medicine, and I mean EVERY. Nothing worked, and I just figured this was the way it would be until I died.
This summer, my hand was hurting and the doctor prescribed Celebrex. It did not help my hand, but my migraines WENT AWAY!!! Yes, after 50 some-odd years, no migraines. I thought it was a fluke, but no… my migraines are gone.
I take a Celebrex every morning after breakfast. If I even start to feel a headache, I take 2 Advil, and the headache is gone for the day. Every once in a while, I do get a migraine and I will take sumatriptan, but it is rare.”
Celebrex, or celecoxib, belongs to the NSAID family. It is somewhat different from other NSAIDs in that it is a selective COX-2 inhibitor. This means that it has fewer gastrointestinal side effects (ulcers, heartburn, etc.). Many people find that one NSAID works for an acute migraine much better than another – naproxen is better than ibuprofen, or diclofenac is better than naproxen, etc. This also holds true for the use of NSAIDs in the prevention of migraines. Meloxicam, indomethacin, aspirin, mefenamic acid, and others have been reported to be uniquely effective for some of my patients.
You can read about almost every drug in every category in the second edition of my latest book, The End of Migraines: 150 Ways to Stop Your Pain.
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