Archive
Science of Migraine

Cyclic vomiting is considered to be a form of migraine. It is most common in children. Surveys indicate that 2% to 3% of children may be suffering from this condition. These children often develop typical migraines as they get older. Cyclic vomiting can also occur in adults. The main and usually the only symptom is intense vomiting. Vomiting occurs several times an hour with bouts lasting anywhere from an hour to several days. It is different from abdominal migraines which manifest themselves mostly by stomach pains. Nausea and vomiting can also occur, but abdominal pain is the predominant symptom. Some children progress from cyclic vomiting to abdominal migraines and then, to typical migraine headaches. Many children and adults have a family history of migraines.

To diagnose cyclic vomiting we need to consider and rule out all other possible causes of vomiting. These include gastrointestinal disorders, genetic conditions, brain tumors, and infections. An endoscopy, abdominal ultrasound, MRI scan of the brain, and blood tests are some of the usual tests.

Physical and emotional stress can trigger an attack of cyclic vomiting. Treatment is very similar to the treatment of migraines. It begins with regular sleep, exercise, relaxation training or meditation, magnesium and COq10 supplements. If attacks are frequent, preventive medications such as tricyclic antidepressants and epilepsy drugs can be useful. For acute attacks, sumatriptan nasal spray (Imitrex NS, Tosymra) and zolmitriptan nasal spray (Zomig NS) or sumatriptan injections can be effective. Antinausea drugs such as ondansetron (Zofran), metoclopramide (Reglan) and aprepitant (Emend) can be given by injection. Prochlorperazine (Compazine) and promethazine (Phenergan) are available in rectal suppositories.

This post was prompted by a review of this topic in the last issue of the journal Headache by Dr. Kovacic and Li of the Medical College of Wisconsin. It is an open-access article – you can read the entire article for free.

Read More

Magnesium supplementation for the prevention of migraine headaches has been gaining wider acceptance. Dozens of studies, including several of our own, have shown that migraine sufferers often have a magnesium deficiency. Studies have also shown that taking an oral supplement or getting an intravenous infusion of magnesium, relieves migraines.

The causes of magnesium deficiency include genetic factors, poor absorption, stress, alcohol, and low dietary intake of foods rich in magnesium. A study just published in the journal Headache looked at the dietary intake of magnesium, including supplements, in those with migraines compared to people without migraines.

The study included 3626 participants, 20- to 50-years old. A quarter of these people suffered from migraines. People who consumed the recommended daily amount (RDA) of magnesium had a lower risk of migraine. This risk was the highest in those who were in the bottom quarter of magnesium consumption.

This was a correlational study, meaning that it does not prove that taking magnesium prevents migraines. However, common sense and our clinical experience, combined with all the previously published studies, strongly support taking magnesium to prevent migraines.

There are many other benefits of magnesium that I’ve written about in this blog – just enter “magnesium” into the search box and you will find a few dozen posts.

Read More

Transient global amnesia (TGA) is a very frightening condition. Suddenly, you feel confused and disoriented. You don’t know where you are, what time it is, what you are supposed to be doing. You can’t remember what you were just told and keep asking, what time it is, where you are, what is going on. Fortunately, it is a benign condition and tends to last four to six hours.

A study published last year by the Mayo Clinic researchers analyzed records of over one thousand patients who experienced TGA. The majority (86%) had a single episode and 14% had more than one. The mean age was 65. History of migraines was present in 20% of people with a single episode and in 36% in those with multiple attacks. Family history of migraines was found in 19% and 31% respectively.

TGA is a benign disorder. MRI scan and EEG were abnormal only in a small number of patients. The authors speculate that a similar mechanism may be responsible for TGA and migraines. This may apply to those with a personal or family history of migraines, but the majority of patients did not have either. It is not clear why TGA tends to occur in older people and why a family history of TGA is uncommon.

A review of several prior studies that looked at the incidence of TGA in large groups of migraine patients was published last month. This meta-analysis showed that people who suffer from migraines are 2.5 times more likely to have an episode of TGA.

A study from Taiwan showed that patients with an attack of TGA are more likely to develop dementia, but mostly in those who were older and suffered from diabetes. People with a history of TGA are not at an increased risk of a stroke.

Despite the low yield, most people who experience a TGA undergo an MRI scan for a possible tumor or a stroke. An EEG, or brain wave test is done because some types of epileptic seizures can present with confusion.

Read More

My new book, The End of Migraines: 150 Ways to Stop Your Pain, was just published by Amazon. It is also available on Google Play and Kobo.
I am very grateful to all my colleagues who took the time to read the book and to provide advance praise for it.
This is a self-published book. This allows me to update it regularly and to set a very affordable price – the e-book version is only $3.95 and the paperback is $14.95. The e-book version has the advantage of having many hyperlinks to original articles and other resources.
If you read it, please write a brief review on Amazon or Google and spread the word about it.

Read More

Researchers in Cincinnati, OH led by Dr. Andrew Hershey reviewed information about the diagnosis, headache features, medication overuse, functional disability in a group of 1,170 children and adolescents with continuous headaches. They compared patients given the diagnosis of chronic migraine with those who were diagnosed as having new daily persistent headache.

The mean age was 14 and 79% of the group were girls. The authors reported that “The overwhelming majority of these youth had headaches with migrainous features, regardless of their clinical diagnosis. Most youth with continuous headache experienced severe migraine-related functional disability, regardless of diagnostic subgroup.”

They concluded that “Overall, youth with continuous chronic migraine and new daily persistent headache did not have clinically meaningful differences in headache features and associated disability. Findings suggest that chronic migraine and new daily persistent headache may be variants of the same underlying disease.”

Here is my take on NDPH adapted from the soon-to-be-released book, The End of Migraine: 150 Ways to Stop Your Pain:

New daily persistent headache (NDPH) is one of the dozens of types of headaches listed in the classification of headaches. This particular listing causes more harm than good. NDPH is defined by the single fact that the headache begins on a certain day and persists without a break. The classification says that NDPH may have features suggestive of either migraine or tension-type headache.

There are no parallels to NDPH in medicine. There is no new daily persistent asthma, or new daily persistent colitis, or any other “new daily” disease.

There does not appear to be any justification for having NDPH as a distinct condition. It does not have a typical clinical presentation and it has not led to any research or treatment. When you search for this condition on the internet, you will not find any effective treatment for it. The suffering of many patients is magnified by the loss of hope, worsening depression, and flagging will to live.

Most importantly, some patients with NDPH do respond to treatment. According to anecdotal reports and in my experience, Botox injections, intravenous magnesium, preventive drugs for migraines, and other treatments can be effective.

Read More

If you’ve never experienced a hangover headache, a group of Spanish researchers can tell you what it feels like. They set out to evaluate and characterize what the international headache classification calls the “delayed alcohol-induced headache”. Also known as a hangover headache. The results of their investigation were published in the leading neurology journal, Neurology.

They studied a group with a lot of experience in this area – university students. The students made a personal sacrifice for the sake of science and voluntarily consumed alcohol and experienced headache.

A total of 1,108 (!) participants were included (58% female, mean age 23 years, 41% with headache history). The mean alcohol intake was 158 grams. Spirits were consumed by 60% of the participants; beer was consumed by 41%, and wine was consumed by 18%.

The mean headache duration was 7 hours. The duration correlated with the total grams of alcohol consumed. The pain was bilateral in 85% of patients and predominantly frontal in location (43%). The pain was mostly moderate in intensity with pressing (60%) or pulsatile (39%) quality. It was aggravated by physical activity in 83% of participants. Criteria for a migraine diagnosis were fulfilled by 36%.

One interesting finding of the study is that 58% of students had a headache that was typical of one seen with low cerebrospinal fluid (CSF) pressure. This raises the question of whether alcohol can indeed cause low CSF pressure.

It is an interesting question but I am not sure if further studies are warranted. It is probably better to spend the money on trying to reduce alcohol consumption.

Read More

Having given Botox injections to thousands of patients, I know that some patients tolerate pain better if they curse during the procedure.

A British psychologist Richard Stephens seems to have made a career out of studying the effect of cursing on pain. His first paper Swearing as a response to pain, appeared in 2009 in NeuroReport. It showed that swearing improves pain tolerance in volunteers whose hand was submerged in icy water. His next paper, which I mentioned in a post in 2011, Swearing as a Response to Pain—Effect of Daily Swearing Frequency was published in The Journal of Pain.

In this study, Stephens looked at the effect of repeated daily swearing on experimental pain. The volunteers were again subjected to pain by submerging their hand into icy water. And they again showed that swearing reduces pain. However, people who tended to swear frequently throughout the day had less of a pain-relieving effect than those who did not.

His latest paper, Swearing as a Response to Pain: Assessing Hypoalgesic Effects of Novel “Swear” Words, was just published in the Frontiers in Psychology. The authors show that made-up “swear” words are not as effective as the good old four-letter f-word.

The conclusion of this 6,500-word research paper suggests that there is still a lot more swearing …er … I mean, studying to be done on this subject. Whether this is a good use of the British taxpayers’ money is another matter. Is the ultimate goal to save the British National Health Service money by replacing pain medications with scientifically validated swear words?

Read More

A group of American and Chinese researchers reported an objective way to diagnose migraine headaches using functional magnetic resonance imaging (fMRI). The paper just published in Neurology used machine learning to examine differences between the brains of migraine sufferers, patients with chronic pain, and healthy controls.

MRI scans of migraine patients typically show normal brain structure. fMRI scans can visualize connections between different parts of the brain, or so-called connectome. The researchers discovered abnormal functional connectivity within the visual, default mode, sensorimotor, and frontal-parietal networks that allowed them to distinguish migraineurs from healthy controls with 93% sensitivity and 89% specificity. They verified the specificity of this diagnostic marker with new groups of migraineurs and patients with other chronic pain disorders (chronic low back pain and fibromyalgia) and demonstrated 78% sensitivity and 76% specificity for discriminating migraineurs from nonmigraineurs. They also found that the changes in the marker correlated with the changes in headache frequency in response to real acupuncture.

If confirmed, these findings could offer a very accurate way to diagnose migraine, rather than relying on subjective clinical description. This test could also allow for an objective way to test various new treatments. Because of the cost of fMRIs, it will be a long time before it becomes a routine clinical test. It is also possible that genetic testing and testing of blood samples for biochemical markers will lead to other accurate diagnostic tests and tests to predict responses to various therapies.

Read More

If you suffer from migraines you are at a higher risk of having certain other medical problems, or comorbidities. They are not the result of having migraines, nor do those condition cause migraines. Most likely, they may have common underlying genetic, environmental, or behavioral factors. You should be aware of this link because treatment choice may be affected by the presence of these comorbidities.

Here is the list of conditions more common in migraines: anxiety, asthma, bipolar disorder, chronic pain, depression, fibromyalgia, reflux (GERD, or heartburn), irritable bowel syndrome (IBS), high cholesterol, hypertension, obesity, sleep apnea, TMJ syndrome. Having these coexisting diseases increases the risk of worsening (chronification) of migraines.

Migraine often coexists with another one or more painful conditions listed above – chronic pain (low back and other), fibromyalgia, irritable bowel syndrome, and TMJ. One plausible explanation is that chronic pain of one type leads to an increased sensitivity of brain cells. This increased sensitivity is well documented and is called wind-up phenomenon. Fortunately, many treatments can address several pain syndromes at once. These include antidepressant drugs (amitriptyline, duloxetine, and other), cognitive-behavioral therapy, exercise, and other.

One possible explanation for the coexistence of psychiatric disorders is that 40-60% of people with chronic pain have a history of physical, emotional, or sexual abuse and may suffer from posttraumatic stress disorder (PTSD).  Another cause could be that they share serotonin and other neurochemical disturbances in the brain. Here too, antidepressants or certain epilepsy drugs may address both migraines and mood disorders.

Reflux (GERD) often seen in migraine sufferers could be the result of taking too many anti-inflammatory drugs such as ibuprofen, aspirin, and naproxen. Many patients will treat their heartburn with drugs such as omeprazole (Prilosec), which after prolonged use can cause multiple vitamin deficiencies, which in turn can worsen migraines and cause other symptoms.

Migraine has an inflammatory component and obesity is known to be pro-inflammatory, which could explain this connection. Diabetes drug, metformin could be a useful drug for patients who have difficulty losing weight with diet and exercise alone.

 

Read More

At the biennial International Headache Congress held last week in Dublin a group of Italian researchers presented a paper, Relationship between severity of migraine and vitamin D deficiency: a case-control study.

They examined 3 groups of subjects: 116 patients with chronic migraine, 44 patients with episodic migraine, and 100 non-headache controls. Ninety-two migraine patients had vitamin D insufficiency (borderline low levels), whereas 40 had a clear vitamin D deficiency. They found a strong inverse correlation between vitamin D levels and the severity of attacks as well as migraine-related disability.

This is only a correlational study, meaning that it does not prove that taking vitamin D will help relieve migraines. However, several neurological disorders seem to be associated with low vitamin D levels, suggesting that vitamin D is very important for the normal functioning of the nervous system. So it makes sense to keep your vitamin D levels at least in the middle of normal range.

Read More

Red wine is a common trigger for migraines, although we still don’t know the cause or why red wine is worse than white. I was just interviewed for this article in the WSJ along with my friend Mo Levin of the UCSF headache clinic.

Read More

A typical migraine aura consists of a visual disturbance (partial loss of vision, flickering lights, zigzags, etc) which lasts 15 to 60 minutes and precedes the headache. Auras can also occur without a headache. Auras occurs in 15 to 20% of migraine sufferers and those who experience them have a slightly higher risk of strokes. The reason for this increased risk has remained unclear.

A study just published in Neurology suggests a possible explanation. The study followed 11,939 participants, of whom 426 reported migraines with visual aura, 1,090 migraine without visual aura, 1,018 non-migraine headache, and 9,405 had no headache. Over a 20-year follow-up period, 232 (15%) of 1,516 with migraine developed atrial fibrillation, a type of cardiac arrhythmia (irregular heart beat). Migraine with visual aura was associated with 1.3 times higher risk of atrial fibrillation compared to no headache as well as 1.4 times higher when compared to migraine without visual aura.

Atrial fibrillation is very common and carries a fivefold increase in the risk of stroke compared to those with normal heart rhythm. This risk is even higher in those who are older than 65 years, in women, those who have congestive heart failure, had a prior stroke or transient ischemic attack, hypertension, diabetes and vascular disease. You can’t do anything about your age or being a woman, but good control of hypertension and diabetes (and exercise, weight control, and not smoking) can lower this risk. Patients with atrial fibrillation are usually treated with an anticoagulant (blood thinner), such as apixaban (Eliquis), which can prevent strokes.

Read More