We always try to use one preventive drug or Botox for the treatment of frequent or very severe migraine headaches. However, it is not unusual to go through several drugs and not find one which works well and does not cause side effects. Under those circumstances combining two drugs or Botox injections with a daily drug with is the next step. A study to be presented at the 62nd annual meeting of the American Academy of Neurology looked at 92 migraine patients who did not respond to a single drug. 86 of these patients found relief from a combination of either topiramate (Topamax) with verapamil (Calan, Verelan), or amitriptyline (Elavil) and a beta blocker (such as Inderal or propranolol, or atenolol). Combining two medications makes sense is they have different mechanism of action. For example topiramate is an epilepsy drug, while verapamil is a blood pressure medicine in the category of calcium channel blockers. Amitriptyline is an antidepressant with pain-relieving properties, while beta-blockers are blood pressure drugs. At times we combine two epilepsy drugs or two anti-depressants if they work in two distinct ways.
Read MoreMany migraine sufferers complain of dizziness, fatigue, exercise intolerance, blurred or tunnel vision, diminished concentration, tremulousness, nausea and recurrent syncope (fainting). These symptoms are often attributed to anxiety or panic attacks. A study to be presented later this month by Dr. Mark Stillman of Cleveland Clinic at the 62nd annual meeting of the American Academy of Neurology in Toronto reveals that the true cause of these symptoms in many migraine patients is POTS. Postural tachycardia syndrome, or POTS is a pronounced increase in heart rate (by at least 30 beats per minute) on standing up. Most of these patients do not suffer from a more familiar condition, orthostatic hypotension, which is a drop in blood pressure on sanding up. Treatment of POTS is difficult and usually involves increasing salt and water intake, aerobic exercise, and small doses of beta blockers (a type of blood pressure medicine also used for prevention of migraines).
Read MoreAlcohol can trigger a headache immediately or soon after it is consumed or the next morning. Some people develop a headache only from a particular type of alcohol, such as red wine, rum, or beer, while others cannot drink any form of alcohol without getting a headache. It seems that vodka is least likely to cause a headache, because it is possible that it is not alcohol that is causing headaches, but rather preservatives, such as sulfites, fermentation products, and natural colors. Some people are exquisitely sensitive – a small sip of wine can trigger a headache within minutes, and some can drink two glasses of wine without a headache, while the third glass will always result in a headache. If you’ve found a medicine that works for your headaches, have it handy since the sooner you take it the better it will work. However, check with your doctor to see if your medicine can be taken with alcohol (none of them should be mixed with alcohol, but some are more dangerous than other). Headaches that occur the day after drinking are usually due to overindulgence and are thought to be in part due to dehydration and in part due to magnesium depletion by alcohol.
Read MoreMigralex is finally available to all headache sufferers. This is the first new brand of headache medicine in 15 years. After years of painstaking research, complicated development work, and manufacturing setup it is very gratifying to see Migralex available at www.Migralex.com and independent pharmacies. If you know someone who suffers from headaches, please tell them about Dr. Mauskop’s Migralex. Migralex works quickly, has few side effects, and works for many different types of headaches. Please go to www.Migralex.com for more information.
Read MoreHeadache Relief is a new iPhone app which I developed to help patients better manage their headaches. The main feature of the app is a headache diary. A summary of all your diary entries can be emailed to yourself or your doctor in an Excel spreadsheet form. I find that patients who keep a diary benefit from it in many ways. The diary makes it easier to figure out what may be causing your headaches, how well the treatment works, and allows you to better control your headaches. The potential triggers that are recorded in the diary include stress, menstrual cycle, food, sleep, and other. Weather can be a major contributor and the three most common weather-related triggers are temperature, humidity and barometric pressure. A unique (and very neat) feature of this app is that if you to enter your zip code these three weather parameters will be downloaded into your diary. The app also contains an e-book with a wealth of information on headaches, natural and pharmacological therapies. And the price is right – it’s free. Please let me know what you think or better still, post your evaluations on the iTunes store.
Read MoreNeedle-free injection of sumatriptan (Imitrex) was tested for its ease of use and for its bioequivalence in a study led by Dr. Jan Brandes. The new device that provides needle-free subcutaneous injections was easy to use and if injected into the thigh or abdomen (but not the upper arm) delivered the same amount of medicine as an injection with a needle. Unfortunately, needle-free does not mean pain-free, so the injection still hurts. This device, when it is approved by the FDA, may be useful for those patients who are afraid of needles. Many migraine sufferers still do not know that injections of sumatriptan can be easily self-administered using a pen-like device that does contain a needle. Many doctors do not offer this option because they do not think that patients will readily accept an injection or because they don’t realize how severe the migraines are. I see many migraine sufferers who gladly take an injection over the tablet. It is particularly effective for people who have severe nausea and vomiting with their migraine. The speed of relief is another reason to take an injection – some patients wake up with a migraine and have to go to work or take care of their children and cannot wait for 1-2 hours before the tablet provides relief. I have taken sumatriptan injection many times myself. Usually the tablet works for me, but if before going to bed I have a headache from the wine I had with dinner, I will often opt for a shot. The shot works within 10-15 minutes and allows me to fall asleep right after that, while a tablet may take an hour or longer.
Read MoreA new treatment for migraines is very effective and well tolerated, according to a paper published in Neurology. Two years ago I mentioned on this blog that this new migraine drug did well in Phase II trial and now the results of Phase III also appear to be very positive. The study was double-blind and placebo-controlled and involved more than 1,200 patients. The drug’s chemical name is telcagepant and it belongs to a new family of migraine drugs, CGRP antagonists. They work on a different receptor than the triptans (sumatriptan or Imitrex and similar drugs) and appear to be as effective. Possible advantages of this drug are that it may work when triptans are ineffective and it does not appear to constrict coronary blood vessels, which can happen, albeit rarely, with triptans.
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.
Smoking marijuana and taking its legal medicinal derivative, dronabinol helped one patient with cluster headaches, according to a report from the Montefiore Headache Clinic. Dronabinol is approved for the treatment of nausea and loss of appetite. The effectiveness of smoking marijuana or taking dronabinol for the relief of pain has been reported by many patients, but never proven in large trials. I generally discourage patients trying marijuana for the relief of any symptoms, unless they have tried and failed traditional medications and they have already tried marijuana and it did help. Marijuana not only has many negative effects on the body, but can be also contaminated by other harmful substances. Cluster headaches can be extremely intense and at times lead patients to thoughts of suicide. In view of this report it seems reasonable to try dronabinol in patients who failed Imitrex injections, oxygen and preventive drugs, such as high dose of verapamil, lithium, and topiramate.
Read MoreDoxycycline has been reported to relieve treatment-resistant new daily persistent headache in four patients. The dose was 100 mg twice a day and was given for 3 months. One of the patients responded after two weeks, but the average response time was 2 months. The lead author of the study, Dr. Todd Rozen speculated that the reason for improvement is the fact that doxycycline is not only an antimicrobial drug, but also acts as an anti-inflammatory agent.
Read MoreMindfulness meditation has been shown to produce numerous benefits in older adults with chronic low back pain. These benefits included less pain, improved attention, better sleep, enhanced well-being, and improved quality of life. One patient reported: “I felt like a new person”. The subjects attended a weekly 90-minute class and practiced for 45 minutes every day for 8 weeks. The study was conducted at the University of Pittsburgh by Natalia Morone and her colleagues, who speculated that this approach might help with other chronic conditions. And we can speculate that if the elderly, who are often regarded to have a less adaptable nervous system, responded so well, then younger patients may do even better.
Read MoreChronic migraine is very disabling and is poorly treated according to a study by Dr. Marcelo Bigal and his colleagues published in the current issue of journal Neurology. The study looked at 520 patients with chronic migraine (those who had more than 15 days with headaches a month) and 9,424 with episodic. More than half of the patients with chronic migraines missed at least five days of household work, compared 24% of patients with episodic migraine. The majority of chronic migraine sufferers (88%) had previously soguht care, but most of them did not receive specific acute or preventive medications. Only 33% of these patients were on preventive medications at the time of the study. Millions of Americans who suffer from migraines do not receive appropriate treatment, but those with chronic migraines are particularly under-treated and suffer needlessly.
Chronic migraine is a common conditions
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