I’ve previously written about the benefits of meditation and how it has helped alleviate my migraines. I recommend it to all of my patients.

A recent study published in the Journal of Headache and Pain by Chinese researchers examined changes in resting-state functional networks in the brain and their correlation with clinical traits in migraine patients.

The study used EEG and fMRI to compare 24 migraine patients with 26 healthy controls. The subjects were evaluated for migraine-related disability using the MIDAS score, cognitive functioning, anxiety, and depression.

The researchers found that the decrease of functional connectivity within the default mode network (DMN) and between DMN and executive control network (ECN) in migraine patients was negatively correlated with MIDAS score.

They also found differences in various other functional networks, but the difference in DMN connectivity caught my attention because of its association with meditation. Studies using fMRI have shown that engaging in meditation leads to a decrease in DMN activity and an increase in the activation of brain regions responsible for cognitive and emotional regulation.

Altered connectivity in the DMN has been associated with a range of neuropsychiatric conditions such as depression, anxiety, post-traumatic stress disorder, attention deficit hyperactive disorder, and obsessive-compulsive disorder. Psychedelics are also thought to produce their effect, at least in part, by acting on the DMN.

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The second updated and expanded edition of The End of Migraines, 150 Ways to Stop Your Pain is now available on Amazon.com. The book is available as an ebook, paperback and hardcover. I would recommend getting the Kindle or ebook version as it has over 100 hyperlinks to original articles and other resources.

Thank you to all of my colleagues who gave a rousing endorsement for the first edition. This a self-published book without the marketing force of a major publisher. If you read it, please post a review on Amazon and spread the word about it.

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Botox is one of the most effective and safest treatments for frequent and chronic migraines. One of the potential side effects of Botox is droopy eyelids. When injections are done correctly this happens in a very small percentage of patients. This is more common in older people partly because with age eyelids tend to sag naturally and partly because relaxing wrinkles makes the skin of the forehead relax down. Sometimes, what droops are not the eyelids (ptosis) but the eyebrows (brow ptosis). In either case, it can cause not only a cosmetic problem but can also interfere with vision.

If this happens, two types of eye drops can help lift the eyelids. Apraclonidine (Iopidine) is an old medicine for the treatment of glaucoma. It tightens the eyelid muscle and makes the eylid move up. Oxymetazoline (Upneeq) was approved by the FDA in 2020 to lift droopy eyelids that occur with age (acquired blepharoptosis). Although oxymetazoline is specifically approved for droopy eyelids, I mostly prescribe apraclonidine because of a large cost differential. Oxymetazoline is a branded product protected by a patent, while apraclonidine is an inexpensive generic drug.

Another way to provide temporary relief is to use double-sided eyelid tape.

For one of my patients, none of these methods worked. She developed droopy eyelids every time she had Botox injections even when injections were given high up in the forehead. And she needed those areas injected because her migraine pain was localized to the forhead. She solved this problem by having a plastic surgeon perform a surgical eye lift. This allowed her to continue Botox injections without any side effects.

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Patients with chronic pain, including those with migraines, have been shown to benefit from psychological interventions. There is a wide variety of such treatments – biofeedback, meditation, acceptance-commitment, dialectical behavioral, and other types of therapy. These treatments improve the frequency and the severity of migraine attacks, as well as other types of pain which in turn leads to improved mood, sleep, and physical function. What we don’t know is which treatment is the most effective.

In a study just published in Pain, the journal of the International Association for the Study of Pain, researchers compared cognitive therapy (CT), mindfulness-based stress reduction, and behavioral therapy (BT) with treatment as usual (TAU).

This was a randomized controlled study of 521 patients with chronic low back pain. Each person underwent eight weekly individual treatment sessions. The primary outcome measure was pain interference, which assessed interference with general functioning due to pain. Secondary outcome measures were pain intensity, depressive symptoms, physical function, and sleep disturbance.

All three interventions produced similar improvement on all five outcome measures. And on all five measures, all three interventions produced better results than TAU. The difference with TAU was noted after the 6th treatment session and this improvement was still present six months later.

These findings are not surprising. The authors mentioned that three recent comparative outcome studies with fairly large samples also found similar efficacy of different psychosocial approaches. One study compared cognitive-behavioral therapy (CBT) with MBSR with usual care. Another compared CBT with pain education with usual care, And the third one compared CBT with emotional awareness and expression therapy with pain education.

The authors discussed the possibility that all psychological interventions produce similar results. However, it is more likely that the individual psychosocial characteristics of each patient is what determines the response. So it is possible that different patients may respond to different treatments and some will not respond to any. The researchers are planning to look at various patient characteristics that they’ve collected to see if any were predictive of a positive response to various treatments.

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Two large studies have established that if you have diabetes you are less likely to suffer from migraines.

The first study was done on the entire population of Norway. The authors concluded that both type 1 and type 2 diabetes are significantly associated with a decreased risk of migraine.

The second study involved 74,247 French women. The researchers discovered that there was a lower risk of developing type 2 diabetes in women with active migraine. They also found that migraine was less common even prior to the development of diabetes.

Being overweight increases the frequency of migraines. Losing weight by any method, including bariatric surgery, improves migraines. There have been no studies of diabetes drugs in the treatment of migraines.

However, I do prescribe a diabetes drug metformin to migraine patients who are overweight or develop migraines when they are hungry. Metformin helps lose weight by maintaining a steady level of blood sugar. It does this by regulating the release of glucose from the liver. It also has anti-inflammatory properties.

Another diabetes drug, semaglutide in injections (Wegovy and Ozempic) and tablets (Rybelsus) is even more effective for weight reduction than metformin. Semaglutide, unlike metformin, is approved by the FDA for weight loss even in the absence of diabetes.

It is possible that the treatment of diabetes reduces the risk of developing migraines. The French study, however, suggests that other factors could play a role as well.

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The evidence is growing that those with low vitamin D levels are at a higher risk for respiratory infections, including COVID-19. However, purists argue that we need more evidence and better evidence from randomized trials. This is quite irresponsible considering that we have so much correlational data and that the risk of taking vitamin D is minuscule. You can read some of the debates on this question in the recent issue of the Irish Medical Journal.

As I mentioned in a recent post, it is important to keep your vitamin D level not only in the normal range, which in most laboratories is between 30 and 100, but at least in the middle of this range.

One piece of supporting evidence is the fact that patients with multiple sclerosis (MS) whose vitamin D level is in the bottom quartile of the normal range are four times more likely to have a flare-up of their MS than those in the top quartile. Another MS study showed “…profound association of 25(OH)D levels with MRI measures of disease activity and progression” Those with vitamin D deficiency were also found to have higher risk of developing Alzheimer’s disease.

The above-mentioned evidence is not necessarily transferable to respiratory infections, however, multiple sclerosis is an autoimmune inflammatory condition, while Alzheimer’s has an inflammatory component and it is possible that inflammation could be where vitamin D exerts its beneficial effect.

So the debates need to end and everyone should take at least 50 mcg (2,000 units) of vitamin D. An important fact to keep in mind is that some people do not absorb vitamin D well so if you were found to be deficient, it is a good idea to recheck your level since you may need to increase the dose.

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Drs. Lisa Yablon, Sara Crystal, and Alexander Mauskop are included in yesterday’s New York Times Magazine supplement, SuperDoctors. According to this publication, “Physicians are selected using a patented multiphase selection process, combining peer nominations and evaluations with independent research.” We thank all of our colleagues who nominated us. We will continue to strive to provide the best care for all headache sufferers who come to see us. Read More

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Yesterday the FDA approved the long-awaited breakthrough drug for the prevention of migraines. It promises to provide relief to two out of three migraine sufferers with minimal side effects.

It should become available in a couple of weeks. The cost of the monthly injection is $575, but hopefully most insurance plans will cover it. The insurance companies are likely to require that the patient first try and fail a couple of inexpensive drugs before paying for Aimovig, as they do with Botox.

The medicine comes in a simple-to-use auto-injector and after the initial injection patients will be able to self-administer it.

To patients of the New York Headache Center – please call the office and schedule an appointment.

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We are in great need of better preventive treatments for migraines. CGRP monoclonal antibodies appear to fulfil their early promise. At the recent annual meeting of the American Headache Society four companies presented their data and it looks very good. The drugs are very effective and are likely to help about 60% of patients and what continues to surprise is their safety. Three of the four companies have completed their final, phase 3 trials and in a few months will submit their data to the FDA. The FDA has a year to decide whether to approve them, but considering their demonstrated safety and efficacy, there is no reason why they should not be approved.

Once they are approved, one issue that may pose a problem is the cost. I mentioned this in a previous post.

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