Generic drugs should be cheap, but you still may be overpaying for them. I mentioned this problem in a previous post, but it bears repeating – your copay could be higher than an out-of-pocket price for some generic drugs. For example, 9 tablets of generic sumatriptan 100 mg can be purchased from a mail order pharmacy such as HealthWearhouse.com or a local pharmacy you can find on GoodRx.com for about $20. Your copay through your insurance plan could be $25 or much higher. Read more about this in a Bloomberg.com story.

We’ve adopted electronic medical records (EMR) over 10 years ago when the upfront costs were high and the training curve was steep. One of the reasons for our early adoption was that we were running out of space for paper charts in our small Manhattan office. We also knew that EMR would improve the quality of care and safety – it allows us to see the lists of problems, allergies, medications, and other information at a glance on one screen. Sending prescriptions electronically dramatically reduces errors and saves time. Being able to log onto our system from home improved the after-hours care of our patients. We’ve never regretted implementing EMR years before EMR was mandated by the government.

Now for the negatives. A recent study by Dr. Christine Sinsky and colleagues published in the Annals of Internal Medicine is entitled, Allocation of physician time in ambulatory practice: A time and motion study in 4 specialties.

For this study, fifty-seven ambulatory care physicians in four specialties (family medicine, internal medicine, cardiology, orthopedics) in four states were directly observed for 430 hours. Twenty of these physicians also completed after-hours diaries. The results were striking: physicians spent 27% of their time on direct clinical face time and 49% on electronic health records and deskwork, while the rest was spent on administrative and other tasks. Even in the exam room, physicians spent 53% of the time on direct clinical face time and 37% on electronic health records and deskwork. They also spent 1-2 hours each night after office hours devoted primarily to electronic health records completion. The authors determined that for every hour physicians spent in direct clinical face time with patients, they spent additional 2 hours on electronic health records and deskwork during the clinic day and 1-2 hours of personal time finishing up electronic health records and deskwork at night.

So, when you see a doctor or a nurse practitioner, keep in mind that in addition to the time he or she spends with you, they have to spend twice as much time typing information into the computer, completing disability, insurance, and other forms, speaking to doctors and pharmacists, answering emails, staying up-to-date with latest medical discoveries, and doing other work. Dr. Neil Busis, writing in Neurology Today comments that the study confirms what we already know, that EHR use adds considerable clerical burden to practice. The study authors found that the use of EMR have decreased satisfaction and increased the risk for professional burnout. Physicians who burn out are at a significantly greater risk for depression and are more likely than satisfied colleagues to provide lower-quality patient care and to leave clinical practice early. Dr. Busis also notes that for many years the Centers for Medicare and Medicaid Services were telling doctors that they are not interested in listening to complaints until doctors can demonstrate that their policies will adversely affect their beneficiaries by decreasing access to care. This study provides such information. The idea is not to stop using EMR, but to reduce the need for meaningless tasks and to provide adequate compensation which accounts for all of the tasks doctor completes and not only for the face to face encounters.

I want to stress that, at least in our office, replacing paper charts with EMR has improved care of our patients, which in turn made our work even more satisfying. However, we would also love to spend less time doing paperwork.

Vestibular migraine has been also called migraine-associated vertigo or dizziness and migrainous vertigo. Diagnostic criteria, according to the international headache classification, include a current or past history of migraine with or without aura, attacks lasting between 5 minutes and 72 hours, vestibular symptoms of moderate or severe intensity. These vestibular symptoms include spontaneous vertigo, positional vertigo occurring after a change of head position; vertigo triggered by a complex or large moving visual stimulus, head motion-induced vertigo occurring during head motion, head motion-induced dizziness with nausea. There is also a requirement for at least half of episodes to be associated with a typical migraine headache or visual aura.

These criteria are the result of a consensus arrived at by headache specialists, which makes them based on cases seen by these specialists, rather than large scientific studies. I’ve encountered some patients who do not have migraine headaches or visual auras, but probably still suffer from migraine-related dizziness or vertigo.

We also lack any studies of treatment for patients with vestibular migraine. My own observation is that vestibular symptoms improve with the treatment of migraine headaches. In patients who suffer from vestibular symptoms with few or no headaches we try similar treatments first – magnesium, CoQ10 and other supplements (we often check blood levels of RBC magnesium and CoQ10), regular aerobic exercise, and medications, such as gabapentin and nortiptyline. When headaches are very frequent we give Botox injections, which are not appropriate if headaches are infrequent.

The classification of headaches also lists benign paroxysmal vertigo as a condition which occurs in children and which may be associated with migraines. (This is different from benign positional vertigo which is triggered by a loose crystal in the inner ear and which can be cured with the Epley maneuver). This migraine-related vertigo usually occurs without a warning and resolves spontaneously after minutes to hours without loss of consciousness. Patients usually have one of the following features: nystagmus (beating movement of the eyes to one side), unsteadiness, vomiting, paleness, or fearfulness. The neurological examination, audiometry (hearing test) and vestibular functions (test also done by an ENT specialist) are normal between attacks.

An ENT colleague recently referred to me a patient with very persistent sensation of pressure in her sinuses. She’d had sinus surgery which relieved pain in one of her sinuses, but the pressure sensation persisted. She did not experience much pain, but the pressure was present constantly and was very distracting and upsetting. First we tried intravenous magnesium because her blood test showed a mild deficiency. This did not help and I gave her several acupuncture treatments, which helped only a little and the effect did not last. When she mentioned that sneezing helped for a brief period, I though that intranasal hot pepper extract, capsaicin could help, and in fact it did.

There are several over-the-counter nasal sprays containing capsaicin, but she found that only Ausanil brand was helpful. Other brands include Sinol and SInus Buster. Ausanil is being advertised for both sinus and migraine headaches. There only small studies showing that capsaicin applied into the nostril can relieve migraines and even cluster headaches. A small Italian study showed that if capsaicin is applied into the nostril on the side of the headache it helped, but when applied on the opposite side, it did not.

This is not an easy treatment because it causes severe burning and some people tolerate it well, while other do not. It is certainly safe and inexpensive.

Chronic migraine afflicts more than 4 million Americans, but shockingly less than 5% of them receive appropriate care, according to a new study just published in the journal Headache.

Chronic migraine sufferers experience headaches on more than half of the days and some, every day. These headaches are much more disabling than episodic migraines (those occurring on less than half of the days).

The study established three barriers to an effective treatment of this very common and very disabling condition. The first barrier was being able to see a specialist for a consultation. Those patients who were more likely to get a consultation were older, had more severe migraine symptoms, more disability, and had health insurance.

The second barrier is getting a correct diagnosis. Consulting a specialist rather than a primary care provider, being a female and having more severe migraines increased the odds of a correct diagnosis.

The third barrier was getting proper treatment with preventive medications and Botox injections and acute treatment with triptans and prescription nonsteroidal anti-inflammatory drugs (NSAIDs).

Only 56 (4.5%) out of the 1254 patients evaluated in the study overcame all three barriers and were given appropriate treatment. In a previous study, the same authors found that 26% of patients with episodic migraines traversed all three barriers, which means that only one of of four of more then 30 million Americans with episodic migraines received proper treatment.

The first barrier is possibly the most difficult to eliminate. Despite the fact that the Obamacare provided millions of people with insurance, access to doctors has improved only marginally. A sudden increase in the number of insured was not matched by an increase in the number of doctors. The main bottleneck is not the number of doctors who graduate from medical schools, but the number of residency training positions. Residency training is subsidized by Medicare, which has not increased the number of residencies. We do have a growing number of nurse practitioners and other non-physician healthcare providers who will hopefully make the shortage of doctors less acute. However, this study suggests that migraine sufferers need to see a specialist to receive a correct diagnosis. This does not necessarily mean a physician – we have three nurse practitioners who specialize in treating headaches and who are highly qualified to diagnose and treat various headache disorders.

Zecuity, a transdermal sumatriptan patch has been reported to cause skin burns and scarring, according to the FDA. The FDA has started an investigation, but the manufacturer, Teva Pharmaceuticals has decided to pull the product off the market.

This is not a major loss for migraine sufferers since we now have four other ways to deliver sumatriptan (Imitrex) – tablet, injection, nasal spray, and nasal powder.

Dr. Leo Galland, whom I’ve known professionally for many years, has written (with his son) another outstanding book, The Allergy Solution. Sometimes I see a patient, who in addition to migraine headaches, suffers from a variety of other ailments. These patients usually see an allergist, an ENT doctor, an infectious disease specialist, and several other physicians, all without answers or relief. In most cases, Dr. Galland is the one who can figure out what’s wrong and how to fix it.

Dr. Galland’s new book, which I just read cover-to-cover, presents scientific research that explains hidden causes of unexplained symptoms such as migraines, fatigue, weight gain, chronic pain, poor sleep, allergies, and reflux. The book describes the role of immune function, stress, nutrition, inflammation, environmental health, leaky gut, and the microbiome.

Most importantly, The Allergy Solution gives people practical solutions to relieve their symptoms, which are very often caused by allergies. Dr. Galland convincingly shows that allergies are aggravated by stress, abnormal gut bacteria, specific vitamin and mineral deficiencies, and other factors. He writes about scientific studies that show the effect of meditation on inflammation and how taking probiotics can improve not only your digestive problems but also migraines and many other symptoms. From this book you will learn the role of vitamin D, zinc, magnesium and a variety of other minerals and vitamins in returning you to health. One of the things I learned is that a combination of vitamin B12 and a mineral called molybdenum can reduce the amount of sulfites in your body. Sulfites, which often trigger migraines are used as a preservative and also occur naturally in wine.

To tell you more about what’s in the book, here is a series of questions answered by Dr. Galland:

Q: What have you discovered about the surprising hidden truths behind chronic symptoms?
A: You may not think of yourself as allergic. Your nose may not run, and your skin doesn’t itch. But you have common complaints that just won’t go away.
Do you suffer from:
•Weight gain?
•Stomachaches?
•Insomnia?
•Headaches?
•Fatigue?
•Depression or anxiety?
•Brain fog?

A hidden allergy is often the culprit. Chronic conditions that were previously diagnosed as autoimmune diseases, psychiatric disorders, or many others, wind up being allergic in origin.

Our search for answers to common mystery conditions, and the source of the allergy epidemic inspired us to write our new book, The Allergy Solution: Unlock the Surprising, Hidden Truth about Why You Are Sick and How to Get Well.

We reveal the proven role of allergy in causing weight gain, fatigue, headache, joint and muscle pain, a range of digestive symptoms from heartburn to diarrhea, mood problems, poor mental focus, and more. A step-by-step method for determining if you have hidden allergies is provided. And if you suffer from classic allergies like rhinitis, eczema or have asthma, our program addresses these issues from a nutritional and lifestyle perspective.

Q: Why are we seeing an epidemic of allergy today?
A: Allergies were once rare. Today they affect over a billion people. Environmental toxicity, depletion of beneficial intestinal bacteria and fast food all contribute to allergies.
Pollen counts are going up and up. A big cause? Air pollution, the kind generated by cars, buses and trucks. Scientists at the US Department of Agriculture investigated how air pollution affects ragweed. They discovered that pollution makes the plants grow twice as large and produce 5 times as much pollen. Many types of pollen, especially ragweed, are actually toxic. They contain an enzyme that damages the lining of your nose and lungs when you breathe them in. This sets the stage for rising allergies.

Driving While Allergic: Dutch scientists tested driving skills in people with allergies and discovered that Pollen exposure impaired the operation of an automobile to the same extent as drinking two cocktails.
Air fresheners increase the risk of allergies and asthma, mostly because of the chemical fragrances they contain, reports a study from the University of California. So what’s alternative? We can’t think of a better way to freshen your air than with ventilation. If the air outside your home is actually worse than the air inside, then try a commercial air purifier.

Cleaning sprays are also hazardous to your health. Using a household cleaning spray just once a week elevates your risk of developing asthma by 30 to 50 per cent, reports a study from Europe. But true clean doesn’t come from a cleaning spray. The Allergy Solution contains a program for freeing your home from these toxins. We call it Mission Detoxable. Step one is easy: ditch the chemical sprays and use water and baking soda for most cleaning jobs. Vinegar in water is great for glass and tile.
Q: How does nutrition impact allergies?
A: Research shows that people with allergies often suffer from nutritional deficiencies and may need nutritional enrichment of protective factors like selenium, magnesium, vitamins C and D, and omega-3 fats. In The Allergy Solution we provide a nutritional approach to overcoming allergy through food and supplements.
All of us need concentrated nutritional support for T-regs, which comes from natural folates found in vegetables such as leafy greens; carotenoids found in orange and yellow vegetables; the bioflavonoids found in things like parsley, strawberries and oolong tea; and detoxifying compounds found in broccoli.

Q: What are the most important nutritional factors for reversing allergy?
A: It is vital that the food you eat supply the nutrients you need to help your body remove toxins and establish healthy immune balance. To accomplish this, we include a simple program in The Allergy Solution called the Power Wash. It’s like hitting the re-set button on your computer. You can get started over a 3-day weekend.
With the Power Wash you eliminate the major problem foods like wheat, dairy, soy, corn, yeast, eggs and you nourish your body with a specially designed combination of vegetables, fruits, spices, herbs, and teas. They’ve been chosen because they support the function of a critical part of your immune system: regulatory T-lymphocytes. We call them T-regs. Their role is to turn off the unwanted immune reactions that create allergies. If you have allergies, you suffer from defective function of T-regs.
Q: How does allergy cause weight gain and prevent weight loss?
A: What happens is a vicious cycle driven by the effects of allergy on your metabolism. Clinical research reveals a strong link between allergy and weight gain. People with allergies are more likely to become overweight. People who are overweight are more likely to develop allergies.
Laboratory research shows that allergic reactions actually make fat cells grow larger and larger. Fat cells create a type of inflammation that unleashes stronger allergic reactions. Balancing immunity is essential for healthy weight loss.

Q: How does your program affect the skin?
A: Your skin is your most visible barrier against a toxic environment and a key target for allergic reactions. Allergy rapidly ages the skin and reversing allergy is essential to restoring its vitality.
The nutrients that nourish your immune cells are also essential for nourishing your skin. In addition, Mission Detoxable helps you decrease the stress placed on your skin by avoiding toxins in your home.

Q: What’s the role of your gut in creating or defending against allergy?
A: Two-thirds of your immune system is located in your intestinal tract. The gut is like a boot camp for training your immune cells. The drill sergeants are the bacteria living in your intestines. Biodiversity of these bacteria is essential for immune health and protects against allergy.
Antibiotics, pesticides, herbicides, disinfectants and the modern diet all destroy this diversity and contribute to the allergy epidemic. Our book contains a program for overcoming allergies by healing your gut. It’s called ARC, for Avoidance, Reflorastation and Cultivation.

Q: How does your book address the environmental challenges facing the world?
A: We wrote The Allergy Solution to change how the world thinks about allergy, health, and our relationship with the environment. We reveal the science that says allergies are not just annoying symptoms to be covered over by medications, and the environment is not just a convenient place to put our car exhaust, toss our garbage, and spray our pesticides. In the chapter “How Did We Get So Sick” we bring to light the astonishing research that connects pollution, global warming and toxins to rising allergies and asthma.

The environment is all around us and within us, inside our digestive tract, respiratory system, and whole body. we have exposed the truth that just as the earth’s environment is out of balance, our bodies have become out of balance. Now the environment we all depend on is threatened as never before.

Q: Can We Be Part of the Solution?
A: Absolutely. A community effort is needed to protect the environment and our health. Let’s all work together to turn around air pollution, giving those with asthma—and those without—a better chance to breathe free? Reductions in air pollution could also curb the rising levels of pollen, helping those with hay fever feel more comfortable. Using fewer toxic chemicals would reduce the burden on the environment.

Allergies are connected to the food we eat, the air we breathe, and the environment we live in. Join us and be part of the solution. Learn more about natural health by joining our community at drgalland.com Follow Dr. Galland on facebook.com/leogallandmd and Twitter (@leogallandmd), and follow Jonathan Galland at facebook.com/jonathangallandjd and on Twitter @JonathanGalland.

Richard Wenzel PharmD of the Diamond Headache Clinic in the latest issue of the leading medical journal, Headache writes about the shocking fact that this country’s pharmaceutical industry cannot reliably supply medications for patients. He also talks about a connected, also undeniable development: “generic drugs currently push the boundaries of affordability”.

Drug shortages involve easily replaceable drugs, but also many life-saving cancer medications. Headache sufferers have not been spared, especially those with severe illness requiring injectable products; droperidol has been unavailable since 2013, various haloperidol and magnesium products are currently on backorder, and the availability of ketorolac, diphenhydramine, and valproic acid has recently been sporadic.

Dr. Wenzel writes that as of July, 2015, the American Society of Health Systems Pharmacists (ASHP) cited 265 active drug shortages. There’s also a “drugs no longer available” list of 57 medications unlikely to ever be commercially manufactured again, including ergotamine.

In the past two years, injections of dihydroergotamine, an irreplaceable migraine drug developed in 1940s, had been unavailable for two periods of lasting several months. The cost of this generic drug skyrocketed from 10 to up to $130 for a single dose.

Scarcities of raw materials, disruptions to manufacturing plants (eg, hurricane damage), insufficient FDA staff to provide prompt approval for production facilities, industry consolidation, and decisions to stop producing a marginally profitable or unprofitable product have all been cited as shortage reasons.

According to the Healthcare Supply Chain Association the costs of 10 drugs widely prescribed among the general public have jumped up to 8000% in as little as one year (2013–2014). For example, a single tablet of an antibiotic doxycycline went from $0.04 to over $3.60 and the new cost of Isuprel, a heart medication went from $180 to $2700 for a single ampule.

The medical community has been trying to address the problem of shortages and high costs through various organizations and the congress, but to no avail. Actually, the government is to blame in some cases. Besides the FDA staff shortages, low payments by the government (and insurers) that do not cover the cost of production is another common reason. When all pharmaceutical companies stop manufacturing a non-profitable or money-losing drug, one company jumps back in and because it is the only one making this medicine, they can charge exorbitant amounts for a generic drug.

Looking for health advice is one of the most common reason people search the web. Many websites provide health information and some even offer self-diagnosis using a symptom checker. After entering all of the symptoms the website suggests a possible diagnosis and advises to take some home remedies or see a doctor. A study recently mentioned on this blog showed that Wikipedia had errors in 9 out of 10 articles on different medical conditions.

Another recent study by Harvard researchers examined the accuracy of the sites that offer self-diagnosis. Not surprisingly, this study also found that the online programs are often wrong. The results were published in the British Medical Journal.

The lead author Ateev Mehrotra, commented that “These tools may be useful in patients who are trying to decide whether they should get to a doctor quickly, but in many cases, users should be cautious and not take the information they receive from online symptom checkers as gospel.”

Some of these symptom checkers were developed by prestigious institutions, including Harvard and other medical schools, major hospital groups, insurance companies, and some government agencies (including the United Kingdom’s National Health Service).

The researchers presented 45 hypothetical cases (including headaches) to test 23 different symptom checkers. Only 34% listed the correct diagnosis first and the correct diagnosis was in the top three possibilities in 51% of cases.

Dr. Mehrotra said that “It’s not nearly as important for a patient with fever, headache, stiff neck, and confusion to know whether they have meningitis or encephalitis as it is for them to know that they should get to an ER quickly.”

Of the 23 symptom checkers 58% provided correct advice and in more serious conditions, it correctly recommended emergency room visit in 80 percent of cases.

To complicate matters, the checkers with the most accurate diagnoses (Isabel, iTriage, Mayo Clinic, and Symcat) were not the ones that were best at recommending the appropriate level of care (Healthychildren.org, Steps2Care, and Symptify).

The researchers compared the online symptom checkers with a live telephone triage nurse offered by many insurance companies. The accuracy of live nurses is between 61% and 69%, so these are more accurate accurate, but also leave a lot of room for improvement. Hopefully, these online programs will continue to evolve, but at this point, you should not rely on them.

Germany was just voted world’s favorite country, according to a report in the USA Today. It also may be the most advanced country in the area of medical rehabilitation. I just came back from Germany where I was invited to give lectures at two prominent clinics. Doctors from both institutions had visited our New York Headache Center to learn about our approach to the treatment of migraines and to learn Botox injection techniques.

My first stop was at the Berolina Klinik, a 280-bed rehabilitation hospital located 80 miles west of Hanover. This hospital provides rehabilitation for a variety of conditions, including orthopedic problems, depression, and chronic headaches. Patients are admitted for a period of 4 to 5 weeks. Treatments available at this institution include physical therapy, biofeedback, individual and group psychotherapy, art therapy, and other. All patient rooms are private. There is a 25-meter (82 feet) swimming pool, gym, inviting dining rooms (with excellent food – I sampled it), green lawns with reclining chairs, and all of it immaculately clean and well-maintained. Staying in such a facility for 4 to 5 weeks is a luxury not available to most Americans. The hospital welcomes patients from abroad and the cost is surprisingly low – about $9,000 for a month of stay, which is less than a third of the cost in the US. They will even pick you up at the Frankfurt airport (third busiest in Europe), which is only 3 hours’ drive. Most of the German patients treated at the Berolina Klinik are covered by insurance, mostly by the German pension fund. The pension fund annually evaluates every facility using strict outcome measures, including the percentage of patients employed two years after being treated at a rehabilitation facility. Berolina Klinik consistently rates among the top German rehabilitation clinics. Dr. Zoltan Medgyessy is the main headache specialist at the clinic and is considered to be one of the leading headache experts in Germany.

The second stop was in Kiel at one of the best German headache and pain clinics, Schmerzklinik Kiel, which is directed by Dr. Hartmut Göbel. This clinic is also an in-patient facility (unlike in the US, where the word clinic implies an office setting). Approximately 70% of patients treated at the Schmerzklinik suffer from headaches and 30% from chronic pain. The clinic is housed in a beautiful building located on the Kiel fjord. Dr. Göbel is one of the top headache researchers and he and I have collaborated on the study of butterbur for the treatment of migraines, which was published in 2004. On this trip I had the honor of speaking in Dr. Göbel’s Master Class – an annual training course for German headache specialists. While I would refer patients who need longer-term rehabilitation (or detox from opioid and other headache drugs) to the Berolina Klinik, Schmerzklinik is where I refer European patients with complicated headache problems and those needing shorter hospital stays.

Don’t use Wikipedia for medical information and tell your doctor not to either. It is the most popular reference site not only for the lay public, but also for doctors – anywhere from 47% to 70% of physicians and medical students admit to using it as a reference.

A study just published in a medical journal shows that Wikipedia very often offers erroneous information.The researchers looked at articles on 10 common conditions: coronary artery disease, lung cancer, major depression, concussion, osteoarthritis, chronic obstructive lung disease, hypertension,diabetes, back pain, and hyperlipidemia.

Articles on each condition were evaluated independently by two physicians to make sure that the evaluations were not biased and were consistent between two doctors. The information on Wikipedia was compared to the up-to-date information on these diseases published in scientific medical journals. Shockingly, only information on concussion was accurate, while information on the other nine conditions contained serious errors. This study did not include migraines or other headaches, but it is very likely that at least some information on these conditions are also incorrect.

Tell your doctor about this study, just to make sure that he or she knows about it. For consumers, the best sources of information are medlineplus.com, mayoclinic.org/diseases-conditions, and WebMD.com.