# LLMs.txt - Sitemap for AI content discovery # Headache NewsBlog > The New York Headache Center is a headache clinic --- ## Pages ## ## Posts - [Flossing teeth: a surprising link to fewer strokes and migraines](https://www.nyheadache.com/blog/flossing-teeth-a-surprising-link-to-fewer-strokes-and-migraines/): You may think of flossing as a way to keep your teeth and gums healthy, but new research shows that... - [fMRI changes in kids after a concussion; could TMS help?](https://www.nyheadache.com/blog/fmri-changes-in-kids-after-a-concussion-could-tms-help/): Concussions in children are far more than just a bump on the head—they can trigger subtle yet significant changes in... - [Zonisamide Shows Promise as a Preventive Migraine Treatment for Kids and Teens ](https://www.nyheadache.com/blog/zonisamide-shows-promise-as-a-preventive-migraine-treatment-for-kids-and-teens/): A new study suggests that zonisamide (Zonegran), a medication traditionally used to treat seizures, may help reduce migraine days in... - [My book, The End of Migraines: 150 Ways to Stop Your Pain, just became available as an audiobook on Amazon.](https://www.nyheadache.com/blog/my-book-the-end-of-migraines-150-ways-to-stop-your-pain-just-became-available-as-an-audiobook-on-amazon/): Check it out https://a. co/d/gwB2xEw - [Medical Cannabis vs. Prescription Medications for Chronic Pain](https://www.nyheadache.com/blog/medical-cannabis-vs-prescription-medications-for-chronic-pain/): In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared... - [The Right Tempo in Music May Help Reduce Pain](https://www.nyheadache.com/blog/the-right-tempo-in-music-may-help-reduce-pain/): New research from McGill University published in the journal Pain suggests that the tempo—or speed—of music plays a crucial role... - [Meeting of the Headache Cooperative of the Northeast](https://www.nyheadache.com/blog/meeting-of-the-headache-cooperative-of-the-northeast/): It was an honor to participate in the 35th Annual Winter Symposium of the Headache Cooperative of the Northeast, held... - [Vitamin B12: "Normal" blood Levels are often not normal](https://www.nyheadache.com/blog/vitamin-b12-normal-blood-levels-are-often-not-normal/): A new study published in the Annals of Neurology by researchers at UCSF challenges our current understanding of what constitutes... - [A Breakthrough in Migraine Diagnosis](https://www.nyheadache.com/blog/a-breakthrough-in-migraine-diagnosis/): Recent advances in neuroimaging are bringing us closer to an objective diagnosis of migraines. Korean researchers have published groundbreaking findings... - [Suzetrigine: A Promising New Treatment for Pain](https://www.nyheadache.com/blog/suzetrigine-a-promising-new-treatment-for-pain/): FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be... - [Magnesium given in pregnancy reduces the risk of cerebral palsy](https://www.nyheadache.com/blog/magnesium-given-in-pregnancy-reduces-the-risk-of-cerebral-palsy/): A new Cochrane meta-analysis has reaffirmed the significant role of magnesium sulfate in reducing the risk of cerebral palsy (CP)... - [A new device to treat chronic migraines](https://www.nyheadache.com/blog/a-new-device-to-treat-chronic-migraines/): The Chordate System, using a technique called Kinetic Oscillation Stimulation (K. O. S), has shown promising results in reducing monthly... - [Why I Take These Supplements - A Doctor's Personal Perspective](https://www.nyheadache.com/blog/the-supplements-i-take/): As a 68-year-old physician, I’m often asked about my own supplement regimen. Here is my approach to supplementation. The uncomfortable... - [Can Magnetic Brain Stimulation (rTMS) Prevent Pain?](https://www.nyheadache.com/blog/can-magnetic-brain-stimulation-rtms-prevent-pain/): Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of... - [A new textbook on headaches and facial pain.](https://www.nyheadache.com/blog/a-new-textbook-on-headaches-and-facial-pain/): It’s an honor to have contributed, alongside Andrew Blumenfeld and Sait Ashina, a chapter on Botox injections to the upcoming... - [It's good to see the lasting impact of our research](https://www.nyheadache.com/blog/its-good-to-see-the-lasting-impact-of-our-research/): “Dr. Mauskop, Congratulations on hitting a new milestone – over 3800 citations of your articles! This places you in the... - [Hemicrania continua is a very disabling headache and it is often misdiagnosed](https://www.nyheadache.com/blog/hemicrania-continua-is-a-very-disabling-headache-and-it-is-often-misdiagnosed/): Hemicrania continua, a rare but severe headache condition, literally means “continuous one-sided headache” in Latin. This chronic condition manifests as... - [Having migraines does not lead to brain damage with age](https://www.nyheadache.com/blog/having-migraines-does-not-lead-to-brain-damage-with-age/): If you’re one of the millions of people who suffer from migraines, you might be worried about the long-term effects... - [Severe vitamin B12 deficiency can occur with normal blood levels of B12](https://www.nyheadache.com/blog/severe-vitamin-b12-deficiency-with-a-normal-blood-level-of-b12/): Vitamin B12 deficiency is common in the elderly, vegetarians, people with diabetes, and other chronic conditions. This deficiency can cause... - [New Daily Persistent Headache may respond to TMS](https://www.nyheadache.com/blog/new-daily-persistent-headache-may-respond-to-tms/): Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial... - [The best drug to treat an acute migraine is eletriptan](https://www.nyheadache.com/blog/the-best-drug-to-treat-an-acute-migraine-is-eletriptan/): Dr. Messoud Ashina of the Danish Headache Center led a group of European researchers in analyzing the efficacy of migraine... - [A novel migraine drug shows promise](https://www.nyheadache.com/blog/a-novel-migraine-drug-shows-promise/): Two sets of “designer drugs” have been developed based on our understanding of the neurobiology of migraines. The first, sumatriptan... - [What can you do about long COVID](https://www.nyheadache.com/blog/what-can-you-do-about-long-covid/): Long COVID, also known as post-COVID conditions, can present with a wide range of symptoms that persist for weeks or... - [Disruption of brain networks by chronic pain can be prevented.](https://www.nyheadache.com/blog/disruption-of-brain-networks-by-chronic-pain-can-be-prevented/): Chronic pain is known to alter the brain’s default mode network (DMN). The DMN is a group of interconnected brain... - [If two antidepressants fail, TMS may offer relief.](https://www.nyheadache.com/blog/if-two-antidepressants-fail-tms-may-offer-relief/): The FDA approved transcranial magnetic stimulation (TMS) to treat anxiety, depression, and OCD about 15 years ago. Most insurers cover... - [Focused ultrasound to specific brain regions relieves pain](https://www.nyheadache.com/blog/focused-ultrasound-to-specific-brain-regions-relieves-pain/): The use of focused ultrasound to treat brain disorders was one of the topics discussed at the 2024 NYC Neuromodulation... - [Another MRI study attempts to diagnose migraine](https://www.nyheadache.com/blog/another-mri-study-attempts-to-diagnose-migraine/): The diagnosis of migraine still relies on the patient’s description of symptoms. We do not have an objective test to... - [Some people's genes prevent them from having migraines](https://www.nyheadache.com/blog/some-peoples-gene-prevent-them-from-having-migraines/): Given enough triggers, almost anyone can develop a migraine. There is a very good chance that even someone who has... - [Creatine is good for your brain, not just muscles](https://www.nyheadache.com/blog/creatine-is-good-for-your-brain-not-just-muscles/): Athletes have been using creatine supplementation for over 30 years. It seems to improve the energy supply to muscle tissues... - [Another study confirms that candesartan relieves migraines](https://www.nyheadache.com/blog/another-study-confirms-that-candesartan-relieves-migraines/): Candesartan ((Atacand) is a blood pressure medication in the class of angiotensin receptor blockers (ARBs). A recently published study involving... - [Abnormal functional connectivity in patients with post-traumatic headaches](https://www.nyheadache.com/blog/abnormal-functional-connectivity-in-patients-with-post-traumatic-headaches/): A new study from Mayo Clinic researchers, published in The Journal of Headache and Pain, has examined the brain changes... - [Abnormal functional connectivity in brains of patients with vestibular migraine](https://www.nyheadache.com/blog/abnormal-functional-connectivity-in-brains-of-patients-with-vestibular-migraine/): Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain... - [Our brains are getting bigger, and hopefully, we are getting smarter.](https://www.nyheadache.com/blog/our-brains-are-getting-bigger-and-hopefully-we-are-getting-smarter/): The famous Framingham Heart Study, spanning over 80 years from 1902 to 1985, looked at brain volumes across multiple generations... - [EPA in fish oil prevents migraines](https://www.nyheadache.com/blog/epa-in-fish-oil-prevents-migraines/): Several studies have suggested that fish oil helps prevent migraine headaches. A new clinical trial by Taiwanese doctors provides the... - [PPIs are the worst, but all heartburn drugs increase the risk of severe headaches](https://www.nyheadache.com/blog/ppis-are-the-worst-but-all-heartburn-drugs-increase-the-risk-of-severe-headaches/): A new study just published in Neurology showed that people taking proton pump inhibitors (PPIs) such as omeprazole (Prilosec) and... - [Visit with the Nolan Williams' TMS team at Stanford](https://www.nyheadache.com/blog/visit-with-the-nolan-williams-tms-team-at-stanford/): Nolan Williams has been at the forefront of developing breakthrough TMS protocols for the treatment of depression and other psychiatric... - [I am honored to speak at the 2024 China Headache Conference](https://www.nyheadache.com/blog/i-am-honored-to-speak-at-the-2024-china-headache-conference/): I will be speaking on nutritional supplements for migraines and an update on triptans on April 20, 2024. - [Pain relief from transcranial magnetic stimulation is possibly opioid-mediated](https://www.nyheadache.com/blog/pain-relief-from-transcranial-magnetic-stimulation-is-possibly-opioid-mediated/): Repetitive transcranial magnetic stimulation (rTMS) is approved by the FDA for the treatment of depression and anxiety. We have been... - [New Survey Sheds Light on High Migraine Burden and the Unhelpful Label of “Acute Medication Overuse”](https://www.nyheadache.com/blog/new-survey-sheds-light-on-high-migraine-burden-and-the-unhelpful-label-of-acute-medication-overuse/): A recent national survey called the “Harris Poll Migraine Report Card” provides insight into the profound impact migraine has on... - [Another study on triptan safety](https://www.nyheadache.com/blog/another-study-on-triptan-safety/): A study published in the current issue of JAMA Neurology examined the risk of stroke and myocardial infarction (heart attack)... - [CGRP drugs in pregnancy](https://www.nyheadache.com/blog/cgrp-drugs-in-pregnancy/): A new report suggests that CGRP-blocking drugs (CGRP-A) are safe in pregnancy. In the latest study, Swiss doctors examined the... - [Caffeine and headaches](https://www.nyheadache.com/blog/caffeine-and-headaches/): A new study by Harvard researchers suggests that there is no connection between caffeine consumption and migraine headaches. I am... - [Monitoring your blood sugar levels](https://www.nyheadache.com/blog/monitoring-your-blood-sugar-levels/): Because of my research and publications on magnesium, I was contacted by Nutrisense. This company helps people without diabetes improve... - [If you are healthcare provider, attend the annual meeting of the Headache Cooperative of the Northeast](https://www.nyheadache.com/blog/if-you-are-healthcare-provider-attend-the-annual-meeting-of-the-headache-cooperative-of-the-northeast/): I am once again honored to participate in the annual meeting of the Headache Cooperative of the Northeast to be... - [More on TMS](https://www.nyheadache.com/blog/more-on-tms/): We use a neuronavigation system from Soterix (on the left) for precise targeting of transcranial magnetic stimulation (TMS). And we... - [TMS for medication overuse (rebound) headaches](https://www.nyheadache.com/blog/tms-for-medication-overuse-rebound-headaches/): Medication overuse or rebound headaches can occur as the result of excessive intake of caffeine, opioid analgesics, and short-acting barbiturate... - [We now offer transcranial magnetic stimulation (TMS) for migraines and other neurological conditions](https://www.nyheadache.com/blog/we-now-offer-transcranial-magnetic-stimulation-tms-for-migraines-and-other-neurological-conditions/): Neurologists frequently find themselves managing patients resistant to standard treatments due to limited proven therapies for many neurological conditions. Some... - [More on the dangers of PPIs such as Prilosec, Nexium, Dexilant, et al.](https://www.nyheadache.com/blog/more-on-the-dangers-of-ppis-such-as-prilosec-nexium-dexilant-et-al/): Proton Pump Inhibitors (PPIs) are a class of medications commonly used to treat conditions such as acid reflux, ulcers, and... - [Attend the Diamond Research & Educational Foundation's course](https://www.nyheadache.com/blog/attend-the-diamond-research-educational-foundations-course/): The annual course, “The Shifting Migraine Paradigm 2024” will be held February 15-17, 2024 at the Plaza San Antonio Hotel... - [Have your homocysteine level checked](https://www.nyheadache.com/blog/have-your-homocysteine-level-checked/): Homocysteine, an amino acid crucial for cellular metabolism and protein synthesis, is naturally produced by the body. However, either too... - [Why sleep regularity is important](https://www.nyheadache.com/blog/why-sleep-regularity-is-important/): Lack of sleep is a common migraine trigger. A less common trigger is getting too much sleep. I always recommend... - [More on combination supplements](https://www.nyheadache.com/blog/more-on-combination-supplements/): My recent blog post on supplement combinations mentioned one that contains magnesium, riboflavin, and feverfew. I did not mention its... - [Migraine and thyroid disease](https://www.nyheadache.com/blog/migraine-and-thyroid-disease/): The thyroid function test is in the initial battery of blood tests we order on all our headache patients (along... - [fMRI scan can establish the diagnosis of migraine](https://www.nyheadache.com/blog/fmri-scan-can-establish-the-diagnosis-of-migraine/): Neurologists diagnose migraine by the description of symptoms provided by the patient. We have not had an objective test to... - [Meditation can be harmful](https://www.nyheadache.com/blog/meditation-can-be-harmful/): I tell most of my patients that after physical exercise, meditation is the second-best preventive treatment for migraine headaches. It... - [Combining supplements](https://www.nyheadache.com/blog/combining-supplements/): Every patient visiting our clinic undergoes a routine blood test, which includes an assessment for magnesium and vitamin deficiencies. We... - [Shingles vaccine for the prevention of cluster headaches](https://www.nyheadache.com/blog/shingles-vaccine-for-the-prevention-of-cluster-headaches/): Cluster headaches arguably cause the worst imaginable pain, hence the moniker, suicide headaches.   Fortunately, there are many treatments for... - [More research on vitamin D and migraine](https://www.nyheadache.com/blog/more-research-on-vitamin-d-and-migraine/): There is growing evidence that vitamin D is important in the development and treatment of migraines. In the past 15... - [A double-blind study of cannabis for the acute treatment of migraine](https://www.nyheadache.com/blog/a-double-blind-study-of-cannabis-for-the-acute-treatment-of-migraine/): Since the legalization of medical marijuana in New York in 2014, I have prescribed it to several hundred patients. My... - [Another report on triptan safety](https://www.nyheadache.com/blog/another-report-on-triptan-safety/): A presentation by Jing Jie Yu, Joshua E. Levine, and others from U. of Florida at the last meeting of... - [Magnificent Magnesium and Movement Disorders](https://www.nyheadache.com/blog/magnificent-magnesium-and-movement-disorders/): Magnificent Magnesium is the title of a book my colleague and friend, cardiologist Dr. Dennis Goodman wrote about this underappreciated... - [New Daily Persistent Headache is very treatable](https://www.nyheadache.com/blog/new-daily-persistent-headache-is-very-treatable/): New daily persistent headache (NDPH) is condition that is defined solely by the fact that the headache begins suddenly one... - [Gut bacteria and migraine](https://www.nyheadache.com/blog/gut-bacteria-and-migraine/): Most people have heard about the gut-brain connection.  Research published in The Journal of Headache and Pain examined this connection... - [Anxiety may facilitate transformation of pain from acute to chronic](https://www.nyheadache.com/blog/anxiety-may-facilitate-transformation-of-pain-from-acute-to-chronic/): Our thoughts and emotions can impact the development of chronic pain. However, there haven’t been many studies exploring what causes... - [A better fix for Benign Paroxysmal Positional Vertigo](https://www.nyheadache.com/blog/a-better-fix-for-benign-paroxysmal-positional-vertigo/): People who suffer from migraines are twice as likely to develop benign paroxysmal positional vertigo (BPPV) than individuals without a... - [The role of a physical therapist in treating migraines](https://www.nyheadache.com/blog/the-role-of-a-physical-therapist-in-treating-migraines/): Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their... - [Depakote, oral and infusion, for migraines in children](https://www.nyheadache.com/blog/depakote-oral-and-infusion-for-migraines-in-children/): A recently published study suggests that valproic acid (Depakene) given intravenously in an emergency room can relieve migraine headaches in... - [Botox in pregnancy](https://www.nyheadache.com/blog/botox-in-pregnancy/): Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant... - [Controlled trial of meditation for migraines](https://www.nyheadache.com/blog/controlled-trial-of-meditation-for-migraines/): Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to... - [Zavegepant, a new abortive migraine drug, is now available](https://www.nyheadache.com/blog/zavegepant-a-new-abortive-migraine-drug-is-now-available/): Zavegepant (Zavzpret), the first CGRP nasal spray for the treatment of acute migraine attacks, was approved by the FDA in... - [Effects of observational learning on placebo responses, or why sham remedies seem to work so well](https://www.nyheadache.com/blog/effects-of-observational-learning-on-placebo-responses-or-why-sham-remedies-seem-to-work-so-well/): Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied... - [PTSD biomarkers](https://www.nyheadache.com/blog/ptsd-biomarkers/): Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder... - [Weather and headaches – AI confirms the connection](https://www.nyheadache.com/blog/weather-and-headaches-ai-confirms-the-connection/): The fact that certain types of weather can trigger headaches is not news to many migraine sufferers. Many researchers have... - [Structural brain connectivity predicts pain](https://www.nyheadache.com/blog/structural-brain-connectivity-predicts-pain/): In a recent post, I mentioned a study in which researchers using functional MRI (fMRI) were able to link functional... - [Migraine, strokes, and oral contraceptives](https://www.nyheadache.com/blog/migraine-strokes-and-oral-contraceptives/): Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for... - [Avoid screen time after a concussion](https://www.nyheadache.com/blog/avoid-screen-time-after-a-concussion/): A new study published in JAMA Pediatrics found that engaging in screen time within the first 48 hours after concussion... - [Magnesium makes your brain bigger, according to a 6,000 person study.](https://www.nyheadache.com/blog/magnesium-makes-your-brain-bigger-according-to-a-6000-person-study/): Our research at the New York Headache Center and that of many of our colleagues, as well as the clinical... - [Antidepressant use during pregnancy](https://www.nyheadache.com/blog/antidepressant-use-during-pregnancy/): Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of... - [How to reduce pain recollection](https://www.nyheadache.com/blog/how-to-reduce-pain-recollection/): A recent study published in the journal Pain showed that adding a non-painful stimulus at the end of a Pap... - [Using AI to predict who will respond to placebo](https://www.nyheadache.com/blog/using-ai-to-predict-who-will-respond-to-placebo/): Placebo response is a bane of clinical trials but it can be very helpful in practice. A team of American... - [Functional brain networks in migraine and meditation](https://www.nyheadache.com/blog/functional-brain-networks-in-migraine-and-meditation/): I’ve previously written about the benefits of meditation and how it has helped alleviate my migraines. I recommend it to... - [How long to rest after a concussion](https://www.nyheadache.com/blog/how-long-to-rest-after-a-concussion/): The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate... - [The top 10 non-drug therapies for migraines](https://www.nyheadache.com/blog/the-top-10-non-drug-therapies-for-migraines/): Most people are right in not wanting to take medications. They can have serious or just very bothersome side effects,... - [The Top 10 Prophylactic Treatments for Migraines](https://www.nyheadache.com/blog/the-top-10-prophylactic-treatments-for-migraines/): In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book,... - [Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases](https://www.nyheadache.com/blog/thank-you-for-making-the-end-of-migraines-1-bestseller-in-nervous-system-diseases/): - [A new migraine drug and my top 10 acute treatments for migraines](https://www.nyheadache.com/blog/a-new-migraine-drug-and-my-top-10-acute-treatments-for-migraines/): Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the... - [Attend the Migraine World Summit!](https://www.nyheadache.com/blog/attend-the-migraine-world-summit/): I am honored to speak at this year’s Migraine World Summit on Sunday, March 12. My topic is Safety Update:... - [Predicting response to migraine treatment](https://www.nyheadache.com/blog/predicting-response-to-migraine-treatment/): Updated on 3/5/23 Even the best migraine medications work for only about half of the people who try them. In... - [An instructive case of dramatic relief of migraines](https://www.nyheadache.com/blog/an-instructive-case-of-dramatic-relief-of-migraines/): On March 10, I will be speaking on the Treatment of a Refractory Headache Patient at the annual meeting of... - [More on exercise - timing matters](https://www.nyheadache.com/blog/more-on-exercise-timing-matters/): In a recent blog post, I wrote about the benefit of different types of exercises for the relief of migraines... - [More on Zinc - could help migraines](https://www.nyheadache.com/blog/more-on-zinc-could-help-migraines/): In a post last August, I mentioned that zinc could possibly extend the duration of the effect of Botox. A... - [GABA supplement for anxiety and insomnia](https://www.nyheadache.com/blog/gaba-supplement-for-anxiety-and-insomnia/): GABA, or gamma-aminobutyric acid, is a popular supplement for the relief of anxiety and insomnia. Until recently, I was not... - [The review of my book, "The End of Migraines: 150 Ways to Stop Your Pain" by Lisa Robin Benson](https://www.nyheadache.com/blog/the-review-of-my-book-the-end-of-migraines-150-ways-to-stop-your-pain-by-lisa-robin-benson/): Thank you, Lisa Robin Benson for a kind review of my book. This is a video review on the Migraine.... - [If you can't fall asleep, try this!](https://www.nyheadache.com/blog/if-you-cant-fall-asleep-try-this/): Insomnia is a very common problem. Sleep aids, over-the-counter and prescription have been proven to be harmful if taken long-term.... - [I am speaking on refractory migraines at the Winter HCNE Headache Symposium](https://www.nyheadache.com/blog/i-am-speaking-on-refractory-migraines-at-the-winter-hcne-headache-symposium/): Another excellent educational course for healthcare professionals will be held on March 10th and 11th in Greenwich, CT. The Headache... - [Dr. Lisa Gfrerer to speak on migraine surgery at the NY Headache Club meeting on January 25](https://www.nyheadache.com/blog/dr-lisa-gfrerer-to-speak-on-migraine-surgery-at-the-ny-headache-club-meeting-on-january-25/): Migraine surgery is controversial. I would not consider it until most of the less invasive options have been tried. In... - [Multivitamins proven to improve brain health!](https://www.nyheadache.com/blog/multivitamins-proven-to-improve-brain-health/): Daily multivitamin use was compared to cocoa extract in more than 2,200 people over 65. After three years, taking a... - [Attend an excellent headache course for health care providers in San Diego](https://www.nyheadache.com/blog/attend-an-excellent-headache-course-for-health-care-providers-in-san-diego/): Opportunities & Challenges in the Management of Headache is one of the two annual courses organized by the Diamond Headache... - [Botox for trigeminal neuralgia due to multiple sclerosis](https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia-due-to-multiple-sclerosis/): Botox has been shown to relieve the pain of trigeminal neuralgia (TN). TN is an excruciatingly painful and debilitating condition.... - [Go ahead, have a drink. Science proves that it won't give you a migraine.](https://www.nyheadache.com/blog/go-ahead-have-a-drink-science-proves-that-it-wont-give-you-a-migraine/): Holidays are again upon us. There are many reasons why people experience more migraines this time of year. Family drama,... - [Strength training vs aerobic exercise for migraine](https://www.nyheadache.com/blog/strength-training-vs-aerobic-exercise-for-migraine/): Multiple posts on this blog have described clinical trials that prove the benefit of exercise for the prevention of migraine... - [Cognitive impairment due to migraine](https://www.nyheadache.com/blog/cognitive-impairment-due-to-migraine/): According to a new report by Spanish researchers published in The Journal of Headaches and Pain, effective preventive treatment of... - [Thiamine (vitamin B1) may be more effective for migraines than riboflavin (vitamin B2)](https://www.nyheadache.com/blog/thiamine-vitamin-b1-may-be-more-effective-for-migraines-than-riboflavin-vitamin-b2/): Riboflavin (vitamin B2) has been a popular supplement for the prevention of migraine headaches. The evidence for its efficacy is... - [Microdosing for chronic pain](https://www.nyheadache.com/blog/microdosing-for-chronic-pain/): Psychedelics are being actively studied for depression and post-traumatic stress disorder (PTSD). These trials usually involve hallucinogenic doses. Microdosing psychedelic... - [Acupuncture relieves chronic tension-type headaches](https://www.nyheadache.com/blog/acupuncture-relieves-chronic-tension-type-headaches/): A recent study by Chinese researchers showed that acupuncture is an effective treatment for tension-type headaches. The results were published... - [The 6th Annual International Headache Symposium in Israel](https://www.nyheadache.com/blog/the-6th-annual-international-headache-symposium-in-israel-2/): It was an honor to speak in Israel at the 6th Annual International Headache Symposium along with past presidents of... - [The 2nd edition of The End of Migraines, 150 Ways to Stop Your Pain was just published](https://www.nyheadache.com/blog/the-2nd-edition-of-the-end-of-migraines-150-ways-to-stop-your-pain-was-just-published/): The second updated and expanded edition of The End of Migraines, 150 Ways to Stop Your Pain is now available... - [How to treat nummular headache](https://www.nyheadache.com/blog/how-to-treat-nummular-headache/): Nummular (coin-shaped) headache is an uncommon condition.   It is defined as intermittent or continuous pain in a small circumscribed... - [Exercise prevents not only migraines but also shrinkage of the brain](https://www.nyheadache.com/blog/exercise-prevents-not-only-migraines-but-also-shrinkage-of-the-brain/): Regular exercise has been proven to prevent migraine headaches in many studies. A Swedish study of 91 patients established that exercising... - [Daxxify, a new Botox competitor](https://www.nyheadache.com/blog/doxxify-a-new-botox-competitor/): No, Daxxify is not really a competitor in the treatment of chronic migraines or any other medical condition. Daxxify, a... - [Post-COVID headaches](https://www.nyheadache.com/blog/post-covid-headaches/): Headache is a common symptom of any infectious illness, including COVID. A group of Spanish researchers analyzed six published studies... - [If the effect of Botox does not last 3 months, taking a zinc supplement might help.](https://www.nyheadache.com/blog/if-the-effect-of-botox-does-not-last-3-months-taking-a-zinc-supplement-might-help/): Dr. Brian Loftus, a Texas neurologist, alerted me to the possibility that the shortening of the effect of Botox can... - [Migraine patients stick with Botox longer than with injections of CGRP mAbs](https://www.nyheadache.com/blog/migraine-patients-stick-with-botox-longer-than-with-injections-of-cgrp-mabs/): Patients with chronic migraine who were started on Botox were significantly more likely to continue to be treated with Botox... - [Rimegepant for trigeminal neuralgia: a case report](https://www.nyheadache.com/blog/rimegepant-for-trigeminal-neuralgia-a-case-report/): A case report presented at the annual meeting of the American Headache Society described a patient with trigeminal neuralgia (TN)... - [Magnesium and migraines - an interview with Dr. Amelia Scott Barrett](https://www.nyheadache.com/blog/magnesium-and-migraines-an-interview-with-dr-amelia-scott-barrett/): Last week I spoke to Dr. Amelia Scott Barrett, a neurologist and headache specialist based in Denver. She shares my... - [The 6th Annual International Headache Symposium in Israel](https://www.nyheadache.com/blog/the-6th-annual-international-headache-symposium-in-israel/): The 6th Annual International Headache Symposium in Israel will be held at Daniel Hotel, Herzliya (8 miles from Tel Aviv),... - [Intravenous magnesium prevents migraines in children](https://www.nyheadache.com/blog/intravenous-magnesium-prevents-migraines-in-children/): Regular intravenous infusions of magnesium prevented migraines in five children, according to a report presented at the annual meeting of... - [Acute migraine therapy in pregnancy - triptan is the safest choice.](https://www.nyheadache.com/blog/acute-migraine-therapy-in-pregnancy-triptan-is-the-safest-choice/): Two out of three women stop having migraines during pregnancy, especially in the second and third trimester. The difficult question... - [Cove presents its data on the efficacy of telemedicine in treating migraines](https://www.nyheadache.com/blog/cove-presents-its-data-on-the-efficacy-of-telemedicine-in-treating-migraines/): With tens of millions of Americans suffering from migraines, access to care is a major problem. Cove, a telemedicine startup,... - [Triptans are safe even in those with cardiovascular conditions - a new report](https://www.nyheadache.com/blog/triptans-are-safe-even-in-those-with-cardiovascular-conditions-a-new-report/): A paper presented at the annual meeting of the American Headache Society that is taking place this weekend examined the... - [Another study confirms vascular safety of triptans](https://www.nyheadache.com/blog/another-study-confirms-vascular-safety-of-triptans/): Sumatriptan (Imitrex) and other triptans have been available without a prescription in all European countries for over a decade. A... - [Primary stabbing headache](https://www.nyheadache.com/blog/primary-stabbing-headache/): Primary stabbing headache is a rare disorder. Because it is rare, it is often misdiagnosed and not treated properly. This... - [CGRP monoclonal antibodies in pregnancy](https://www.nyheadache.com/blog/cgrp-monoclonal-antibodies-in-pregnancy/): Not surprisingly, none of the new migraine drugs have been tested in pregnant women. No new drug for any indication... - [Rimegepant (Nurtec) is now approved in Europe](https://www.nyheadache.com/blog/rimegepant-nurtec-is-now-approved-in-europe/): Rimegepant (Nurtec ODT) was just approved by the European Medicines Agency for marketing in 27 EU countries as well as... - [Treating so-called medication overuse headache](https://www.nyheadache.com/blog/treating-so-called-medication-overuse-headache/): If you are “overusing” acute migraine medications, preventive migraine treatments still work very well. This was the conclusion of a... - [What to do if Emgality, Aimovig, and Ajovy do not last a full month](https://www.nyheadache.com/blog/what-to-do-if-emgality-aimovig-and-ajovy-do-not-last-a-full-month/): Yesterday I saw a 48-year-old man who has been suffering from migraine headaches since his teens. He did not respond... - [Headache after COVID vaccination](https://www.nyheadache.com/blog/headache-after-covid-vaccination/): I recently saw a 32-year-old woman who never suffered from headaches until a year ago when she was given an... - [Chiropractic for migraine](https://www.nyheadache.com/blog/chiropractic-for-migraine/): A patient recently asked me about trying chiropractic treatment for her migraines. This is a chapter on chiropractic from my... - [Attend RetreatMigraine, online or in person](https://www.nyheadache.com/blog/attend-retreatmigraine-online-or-in-person/): I am honored to speak (in person) at this patient advocacy event. My topic will be, When treatments stop working,... - [Julie Mauskop at Shrine.nyc](https://www.nyheadache.com/blog/julie-mauskop-at-shrine-nyc/): See Julie’s solo show at Shrine. nyc, 179 East Broadway, New York, NY - [Relief for droopy eyelids caused by Botox](https://www.nyheadache.com/blog/relief-for-droopy-eyelids-caused-by-botox/): Botox is one of the most effective and safest treatments for frequent and chronic migraines. One of the potential side... - [Migraine World Summit is on again and it offers a wealth of information](https://www.nyheadache.com/blog/migraine-world-summit-is-on-again-and-it-offers-a-wealth-of-information/): I am happy to announce that you can attend the Migraine World Summit free of charge. It is back on... - [Combining peripheral electrical stimulation with relaxation training to treat migraine headaches](https://www.nyheadache.com/blog/combining-peripheral-electrical-stimulation-with-relaxation-training-to-treat-migraine-headaches/): Nerivio, an electrical stimulation device was cleared by the FDA to treat acute migraine attacks in adults almost three years... - [Internet-delivered cognitive and behavioral interventions help chronic pain](https://www.nyheadache.com/blog/internet-delivered-cognitive-and-behavioral-interventions-help-chronic-pain/): My previous post described a study that found no difference in efficacy among different types of psychosocial interventions for the... - [What is best - cognitive therapy, mindfulness-based stress reduction, or behavioral therapy?](https://www.nyheadache.com/blog/what-is-best-cognitive-therapy-mindfulness-based-stress-reduction-or-behavioral-therapy/): Patients with chronic pain, including those with migraines, have been shown to benefit from psychological interventions. There is a wide... - [Intranasal ketamine for cluster headaches](https://www.nyheadache.com/blog/intranasal-ketamine-for-cluster-headaches/): Cluster headaches are considered to cause the worst pain imaginable. We have a variety of medications – both acute and... - [Marijuana increases the risk of car accidents](https://www.nyheadache.com/blog/marijuana-increases-the-risk-of-car-accidents/): I’ve been prescribing medical marijuana (MM) since 2016 when it became legal in New York. We still lack controlled clinical... - [Pandemic worsens headaches in children](https://www.nyheadache.com/blog/pandemic-worsens-headaches-in-children/): Worsening of headaches in children is one of many deleterious effects of the pandemic and measures to control it. A... - [If you are having surgery and have had migraines, read this!](https://www.nyheadache.com/blog/if-you-are-having-surgery-and-have-had-migraines-read-this/): There is a new and surprising connection between postoperative nausea and vomiting (PONV) and migraines. It offers a very effective... - [Repetitive transcranial magnetic stimulation relieves migraines](https://www.nyheadache.com/blog/repetitive-transcranial-magnetic-stimulation-relieves-migraines/): Magnetic stimulation with a single pulse has been shown to be effective in aborting a migraine attack with the eNeura... - [Sublingual ketamine for pain](https://www.nyheadache.com/blog/sublingual-ketamine-for-pain/): Ketamine was approved by the FDA in 1970 and was originally used for the induction of anesthesia. It has been... - [Zürich headache conference](https://www.nyheadache.com/blog/zurich-headache-conference/): With Swiss colleagues Drs. Caterina Podella, Livia Granata, and Reto Agosti at the headache conference held on November 4, 2021,... - [Men with migraine and cluster headaches can also have hormonal issues](https://www.nyheadache.com/blog/men-with-migraine-and-cluster-headaches-can-also-have-hormonal-issues/): The influence of estrogen on migraines in women is well established – women often experience migraines before or during menstruation... - [If you see a friend respond to treatment, you are more likely to respond as well](https://www.nyheadache.com/blog/if-you-see-a-friend-responds-to-treatment-you-are-more-likely-to-respond-as-well/): The placebo effect is a bane of clinical trials. It is, however, a great tool in clinical practice. It is... - [Dr. Mauskop to speak on refractory migraines in Zurich, Switzerland](https://www.nyheadache.com/blog/6358-2/): I am honored to participate in a symposium on headache management, “THE CHALLENGE OF MIGRAINE AND CLUSTER HEADACHES”. The title... - [Response to drugs is influenced by psychological factors](https://www.nyheadache.com/blog/response-to-drugs-is-influenced-by-psychological-factors/): To gain FDA approval a drug has to be shown to be better than a placebo. The placebo effect is... - [FDA approves Qulipta (atogepant), a new preventive migraine drug](https://www.nyheadache.com/blog/fda-approves-qulipta-atogepant-a-new-preventive-migraine-drug/): Atogepant (Qulipta) is a new migraine drug that was just approved by the FDA for the preventive treatment of migraines.... - [A large study shows that the weather affects pain](https://www.nyheadache.com/blog/a-large-study-shows-that-the-weather-affects-pain/): Many migraine sufferers report that their migraines are brought on by the weather. High humidity, high temperatures, and changes in... - [Migraines are less common in people with diabetes](https://www.nyheadache.com/blog/migraines-are-less-common-in-people-with-diabetes/): Two large studies have established that if you have diabetes you are less likely to suffer from migraines. The first... - [Julie Mauskop on David Zwirner’s Platform](https://www.nyheadache.com/blog/julie-mauskop-on-david-zwirners-platform/): Patients coming to the New York Headache Center have enjoyed seeing my daughter Julie’s artwork since she was 11. This... - [A new, better DHE nasal spray is approved for acute migraines](https://www.nyheadache.com/blog/a-new-better-dhe-nasal-spray-is-approved-for-acute-migraines/): Trudhesa is a new formulation of dihydroergotamine (DHE) nasal spray just approved by the FDA. It appears to be more... - [Placebo really works, even if you know it's placebo](https://www.nyheadache.com/blog/placebo-really-works-even-if-you-know-its-placebo/): The placebo effect is a bane of clinical trials. A drug is considered ineffective if it is only as good... - [Another review of The End of Migraines: 150 Ways to Stop Your Pain](https://www.nyheadache.com/blog/another-review-of-the-end-of-migraines-150-ways-to-stop-your-pain/): It is gratifying to know that my colleagues consider my new book, The End of Migraines: 150 Ways to Stop... - [More of the omega-3 and less of omega-6 fatty acids helps migraines](https://www.nyheadache.com/blog/more-of-the-omega-3-and-less-of-omega-6-fatty-acids-helps-migraines/): Migraine can be triggered by many foods, including sugar, chocolate, smoked, pickled, cured, dried, and fermented foods. There are also... - [Magnesium can reduce the risk of aneurysm formation and rupture](https://www.nyheadache.com/blog/magnesium-can-reduce-the-risk-of-aneurysm-formation-and-rupture/): Many patients with headaches are concerned about having a brain aneurysm. It is rare for an aneurysm to cause ongoing... - [Naratriptan is the most effective triptan?](https://www.nyheadache.com/blog/naratriptan-is-the-most-effective-triptan/): In the US, we are lucky to have seven different triptans available in the pharmacies. Five of them – sumatriptan,... - [Chronic pain causes cognitive decline](https://www.nyheadache.com/blog/chronic-pain-causes-cognitive-decline/): Many patients with chronic migraines complain of memory, word-finding, and other cognitive difficulties. I tell them that once we find... - [Occipital nerve stimulation relieves chronic cluster headaches](https://www.nyheadache.com/blog/occipital-nerve-stimulation-relieves-chronic-cluster-headaches/): The pain of cluster headaches is considered to be the worst of all headaches. Hence the moniker, suicide headaches. Thankfully,... - [Mindfulness-based stress reduction helps migraines](https://www.nyheadache.com/blog/mindfulness-based-stress-reduction-helps-migraines/): It’s been a few years since I wrote about meditation. There is little doubt that it helps migraine sufferers. Unlike... - [Dividing migraines into chronic and episodic was a costly mistake](https://www.nyheadache.com/blog/dividing-migraines-into-chronic-and-episodic-was-a-costly-mistake/): The international classification of headache disorders lists many different types of migraines – migraine with aura, hemiplegic, retinal, chronic, and... - [Erenumab relieves trigeminal neuralgia - another case series](https://www.nyheadache.com/blog/erenumab-relieves-trigeminal-neuralgia-another-case-series/): Trigeminal neuralgia (TN) is an extremely painful and often debilitating condition. Many people respond to the standard therapy with epilepsy... - [Dr. Allan Purdy's review of my new book](https://www.nyheadache.com/blog/dr-allan-purdys-review-of-my-new-book/): A publication of the American Headache Society, Headache, The Journal of Head and Face Pain, has just published Dr. Allan... - [Nurtec is the first drug approved for acute and preventive treatment of migraines.](https://www.nyheadache.com/blog/nurtec-is-the-first-drug-approved-for-acute-and-preventive-treatment-of-migraines/): Biohaven, the manufacturer of rimegepant (Nurtec ODT) just received FDA approval to market this drug for the prevention of migraines.... - [Predicting success of surgery for trigeminal neuralgia.](https://www.nyheadache.com/blog/predicting-success-of-surgery-for-trigeminal-neuralgia/): Trigeminal neuralgia (TN) is an extremely painful condition. Patients describe the pain as electric shocks going through the face. The... - [The pendulum swings and hits hard patients on opioid drugs](https://www.nyheadache.com/blog/the-pendulum-swings-and-hits-hard-patients-on-opioid-drugs/): The opioid epidemic has claimed many lives. Overprescribing by doctors has certainly played a role. The push to use opioids... - [ER treatment of posttraumatic headaches](https://www.nyheadache.com/blog/er-treatment-of-posttraumatic-headaches/): Almost 1. 5 million Americans visit emergency rooms every year for the treatment of head trauma. Headache, not surprisingly, is... - [Skipping breakfast, lack of greenery, and other factors that may predispose kids to headaches.](https://www.nyheadache.com/blog/skipping-breakfast-lack-of-greenery-and-other-factors-that-may-predispose-kids-to-headaches/): We know that physical emotional, and sexual abuse in childhood increases the risk of developing chronic pain and migraines later... - [Post-traumatic headaches are mostly migraines](https://www.nyheadache.com/blog/post-traumatic-headaches-are-mostly-migraines/): Post-traumatic headaches (PTH) are classified as a distinct category of headaches. There is growing evidence, however, that headaches that develop... - [The description of neuropathic pain predicts response to Botox](https://www.nyheadache.com/blog/the-description-of-neuropathic-pain-predicts-response-to-botox/): The goal of personalized medicine will be achieved through the exponential growth of computing power. Epigenetics, pharmacogenomics, and machine learning... - [Magnesium enhances the migraine prevention effect of valproate](https://www.nyheadache.com/blog/magnesium-enhances-the-migraine-prevention-effect-of-valproate/): This blog has many posts about the role of magnesium in the prevention of migraines and clinical trials of magnesium.... - [Dramatic weight loss with a diabetes drug; may help migraines and other neurological problems](https://www.nyheadache.com/blog/dramatic-weight-loss-with-a-diabetes-drug-may-help-migraines-and-other-neurological-problems/): Weight loss in overweight migraine sufferers – including that produced by bariatric surgery – leads to a reduction in the... - [Bidirectional association between loneliness and pain](https://www.nyheadache.com/blog/bidirectional-association-between-loneliness-and-pain/): COVID-related lockdowns have saved many lives. We don’t yet fully appreciate, however, the other side of the ledger – the... - [Low cerebrospinal fluid pressure headache](https://www.nyheadache.com/blog/low-cerebrospinal-fluid-pressure-headache/): The headache of low cerebrospinal fluid (CSF) pressure can be very severe. Its main feature is that it gets worse... - [Postural orthostatic tachycardia syndrome (POTS) and migraine](https://www.nyheadache.com/blog/postural-orthostatic-tachycardia-syndrome-pots-and-migraine/): The term postural orthostatic tachycardia means that the heart rate becomes very fast upon standing up. POTS is a disorder... - [Cyclic vomiting, a migraine variant](https://www.nyheadache.com/blog/cyclic-vomiting-a-migraine-variant/): Cyclic vomiting is considered to be a form of migraine. It is most common in children. Surveys indicate that 2%... - [Low dietary intake of magnesium increases the risk of migraines](https://www.nyheadache.com/blog/low-dietary-intake-of-magnesium-increases-the-risk-of-migraines/): Magnesium supplementation for the prevention of migraine headaches has been gaining wider acceptance. Dozens of studies, including several of our... - [Transient global amnesia and migraines](https://www.nyheadache.com/blog/transient-global-amnesia-and-migraines/): Transient global amnesia (TGA) is a very frightening condition. Suddenly, you feel confused and disoriented. You don’t know where you... - [In a new study prednisone relieves cluster headaches](https://www.nyheadache.com/blog/in-a-new-study-prednisone-relieves-cluster-headaches/): Cluster headaches are considered to cause the most severe pain of any type of headache. Once the cluster period begins,... - [Just published - The End of Migraines: 150 Ways to Stop Your Pain](https://www.nyheadache.com/blog/just-published-the-end-of-migraines-150-ways-to-stop-your-pain/): My new book, The End of Migraines: 150 Ways to Stop Your Pain, was just published by Amazon. It is... - [Prompt treatment could restore the loss of smell due to COVID](https://www.nyheadache.com/blog/prompt-treatment-could-restore-the-loss-of-smell-due-to-covid/): The loss of the sense of smell is the second most common presenting symptom of COVID. It occurs in 65%... - [Prolonged postconcussion headaches after mild head injury](https://www.nyheadache.com/blog/prolonged-postconcussion-headaches-after-mild-head-injury/): Persistent post-traumatic headache (PTH), paradoxically, is more common after a mild traumatic brain injury (TBI) than after a severe one.... - [Nerivio relieves migraine in adolescents](https://www.nyheadache.com/blog/nerivio-relieves-migraine-in-adolescents/): Nerivio device is approved by the FDA for the acute treatment of migraine attacks in adults. A study just published... - [New daily persistent headache (NDPH) is an unhelpful myth](https://www.nyheadache.com/blog/new-daily-persistent-headache-ndph-is-an-unhelpful-myth/): Researchers in Cincinnati, OH led by Dr. Andrew Hershey reviewed information about the diagnosis, headache features, medication overuse, functional disability... - [Stiff from too much time at a computer? Feldenkrais to the rescue.](https://www.nyheadache.com/blog/stiff-from-too-much-time-at-a-computer-feldenkrais-to-the-rescue/): Feldenkrais method can appear magical but it is rooted in good science. It has withstood the test of time. Moshe... - [What to try first, Botox or CGRP mAbs?](https://www.nyheadache.com/blog/what-to-try-first-botox-or-cgrp-mabs/): This is a common question I get from patients. Botox was first approved by the FDA in 1989. The CGRP... - [100 Migraine Drugs, A to Z: zonisamide](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-zonisamide/): Zonisamide (Zonegran) is an epilepsy drug similar to topiramate in its mechanism of action. Unfortunately, it shares its side effects... - [Migraine device, Cefaly no longer requires a prescription](https://www.nyheadache.com/blog/migraine-device-cefaly-no-longer-requires-a-prescription/): Cefaly is a neurostimulation device that was approved by the FDA in 2014. Until October of this year, it required... - [100 Migraine Drugs, A to Z: zolmitriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-zolmitriptan/): Zolmitriptan (Zomig, Zomig ZMT, Zomig NS) is one of seven triptans sold in the US. It is available in tablets,... - [Virtual reality for pain relief](https://www.nyheadache.com/blog/virtual-reality-for-pain-relief/): Many studies have shown that virtual reality experience can relieve pain. The first such study in burn patients was published... - [100 Migraine Drugs, A to Z: verapamil](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-verapamil/): Verapamil (Calan, Isoptin) is an effective drug for the prevention of cluster headaches. It is sometimes used for migraines as... - [Botox for migraines in pregnancy](https://www.nyheadache.com/blog/botox-for-migraines-in-pregnancy/): Fortunately, migraines improve during pregnancy in the majority of women. None of the preventive drugs for migraine are approved by... - [Dry eyes and migraine](https://www.nyheadache.com/blog/dry-eyes-and-migraine/): People who suffer from migraines often have a variety of visual symptoms. These include seeing an aura prior to the... - [100 Migraine Drugs, A to Z: venlafaxine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-venlafaxine/): Venlafaxine (Effexor) is the first drug in the serotonin-norepinephrine reuptake inhibitors (SNRI) class. It was approved by the FDA for... - [Find out what a hangover headache feels like](https://www.nyheadache.com/blog/find-out-what-a-hangover-headache-feels-like/): If you’ve never experienced a hangover headache, a group of Spanish researchers can tell you what it feels like. They... - [100 Migraine Drugs, A to Z: tramadol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-tramadol/): Tramadol (Ultram) is a mild narcotic (opioid) pain killer. Just like other opioids it is not a good choice to... - [Marijuana protects brain in trauma](https://www.nyheadache.com/blog/marijuana-protects-brain-in-trauma/): Frequent use of marijuana has a negative effect on the developing brain. Researchers at Tulane and Dartmouth medical schools looked... - [Anti-inflammatory effect of cannabis](https://www.nyheadache.com/blog/anti-inflammatory-effect-of-cannabis/): Cannabis has known anti-inflammatory properties. A group of researchers from UCSD published a study, Recent cannabis use in HIV is... - [100 Migraine Drugs, A to Z: topiramate](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-topiramate/): Topiramate (Topamax) is one of the most popular preventive drugs for migraine. This is not because it is more effective... - [An update on the Nerivio device](https://www.nyheadache.com/blog/an-update-on-the-nerivio-device/): It’s been a year since the introduction of Nerivio, an electrical stimulation device for the acute treatment of migraines. One... - [Benign paroxysmal positional vertigo - another benefit of vitamin D](https://www.nyheadache.com/blog/benign-paroxysmal-positional-vertigo-another-benefit-of-vitamin-d/): Vitamin D deficiency predisposes to or worsens many different medical problems. I’ve written at least a dozen blog posts on... - [Melatonin for migraines](https://www.nyheadache.com/blog/melatonin-for-migraines/): Melatonin is a hormone produced by the pineal gland located in the brain. The release of melatonin helps us fall... - [100 Migraine Drugs, A to Z: tizanidine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-tizanidine/): Tizanidine (Zanaflex) is a muscle relaxant that has been shown to relieve chronic migraines in a 200-patient double-blind study by... - [Oxygen for migraines](https://www.nyheadache.com/blog/oxygen-for-migraines/): People who live at high altitudes tend to have lower oxygen levels in their blood. A higher percentage of them... - [100 Migraine Drugs, A to Z: timolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-timolol/): Timolol (Blocadren), is the second of the two beta-blockers approved by the FDA for both hypertension and the prevention of... - [Histamine and migraine](https://www.nyheadache.com/blog/histamine-and-migraine/): Histamine is best known as a part of the defense against allergies. But it is also an important neurotransmitter –... - [Acetyl-leucine may help dizziness, vertigo and migraines](https://www.nyheadache.com/blog/acetyl-leucine/): Acetyl-leucine (Tanganil) is an amino acid that has been available in France for over 60 years as a prescription drug.... - [100 Migraine Drugs, A to Z: Low-dose naltrexone](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-low-dose-naltrexone/): Naltrexone is similar to naloxone, a drug used to reverse the effect of narcotic (opioid) overdose. Naltrexone is not used... - [100 Migraine Drugs, A to Z: sumatriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-sumatriptan/): Sumatriptan (Imitrex, Imigran) is by far the most popular triptan because it was the first one on the market. Because... - [WTF? Do we need another study of swearing for the relief of pain?](https://www.nyheadache.com/blog/wtf-do-we-need-another-study-of-swearing-for-the-relief-of-pain/): Having given Botox injections to thousands of patients, I know that some patients tolerate pain better if they curse during... - [100 Migraine Drugs, A to Z: rizatriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-rizatriptan/): Rizatriptan (Maxalt, Maxalt MLT) is one of the seven triptans approved in the US. Along with zolmitriptan, it is one... - [100 Migraine Drugs, A to Z: lisinopril](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lisinopril/): Lisinopril (Prinivil, Zestril) is a blood pressure medicine in the family of angiotensin-converting enzyme inhibitors (ACEI). At 20 mg a... - [Botox for brain tumor headaches?](https://www.nyheadache.com/blog/botox-for-brain-tumor-headaches/): Two patients treated at MD Anderson Cancer Center for brain tumors were given Botox injections for their tumor-related headaches. The... - [100 MIgraine drugs, A to Z: lamotrigine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lamotrigine/): Lamotrigine (Lamictal) is an epilepsy drug that is also approved as a mood stabilizer in bipolar disorders. Its exact mechanism... - [100 Migraine Drugs, A to Z: promethazine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-promethazine/): Promethazine (Phenergan) is a phenothiazine drug that can be very effective for the treatment of migraine-induced nausea and vomiting. Like... - [100 Migraine Drugs, A to Z: prochlorperazine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-prochlorperazine/): Prochlorperazine (Compazine) belongs to the category of phenothiazine drugs. Chlorpromazine (Thorazine) was the first drug in this family and it... - [100 Migraine Drugs, A to Z: protriptyline](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-protriptyline/): Protriptyline (Vivactil) is one of the tricyclic antidepressants (TCAs). It is rarely used, compared to amitriptyline and nortriptyline. This is... - [100 Migraine Drugs, A to Z: pregabalin](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-pregabalin/): Pregabalin (Lyrica) is an epilepsy drug that is also approved by the FDA for the treatment of neuropathic (nerve) pain... - [High CRP level is a modifiable risk factor for chronic migraine](https://www.nyheadache.com/blog/high-crp-level-is-a-modifiable-risk-factor-for-chronic-migraine/): A large population-based 11-year long study just published by Norwegian researchers confirmed that an elevated level of an inflammatory marker... - [100 Migraine Drugs, A to Z: propranolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-propranolol/): Propranolol (Inderal) belongs to the beta-blocker family of medications and it was approved by the FDA in 1967 for the... - [A large study confirms that yoga helps migraines](https://www.nyheadache.com/blog/a-large-study-confirms-that-yoga-helps-migraines/): If you’ve ever tried doing yoga as I have (I love hot yoga, but it’s not for everyone), you will... - [100 Migraine Drugs A to Z: propofol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-propofol/): Propofol (Diprivan) was originally developed for general anesthesia during surgery. Smaller amounts were found to work well for “conscious sedation”... - [I've tried Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant)](https://www.nyheadache.com/blog/ive-tried-ubrelvy-ubrogepant-and-nurtec-odt-rimegepant/): My migraines respond very well to sumatriptan, but I do like to try new treatments that I recommend to my... - [Eye exercises for head trauma and headaches](https://www.nyheadache.com/blog/eye-exercises-for-head-trauma-and-headaches/): We recently started using RightEye eye-tracking equipment which can help our patients who are suffering from visual difficulties due to... - [More on vitamin D and COVID-19](https://www.nyheadache.com/blog/more-on-vitamin-d-and-covid-19/): The evidence is growing that those with low vitamin D levels are at a higher risk for respiratory infections, including... - [100 Migraine Drugs, A to Z: phenelzine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-phenelzine/): Phenelzine (Nardil) is an antidepressant which was approved by the FDA for the treatment of depression in 1961. It belongs... - [100 Migraine Drugs, A to Z: ondansetron](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ondansetron/): Ondansetron (Zofran) is not a migraine drug per se, but it is used for the treatment of nausea that often... - [Tonight you can watch a live Facebook event on exercise and migraines](https://www.nyheadache.com/blog/tonight-you-can-watch-a-live-facebook-event-on-exercise-and-migraines/): Tonight at 6 PM (EST), Dr. Mauskop will speak at the Weekly Wellness with the American Migraine Foundation. He will... - [100 Migraine Drugs, A to Z: metoclopramide](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metoclopramide/): Metoclopramide (Reglan) is an anti-nausea drug that has been in use since 1979. Controlled studies have shown that metoclopramide stops... - [Covid-19 and headaches](https://www.nyheadache.com/blog/covid-19-and-headaches/): It is hard to think or write about anything other than Covid-19, so here is some information on Covid-19 and... - [Nerivio, a drug-free treatment for acute migraines](https://www.nyheadache.com/blog/nerivio-a-drug-free-treatment-for-acute-migraines/): Nerivio is a smartphone-controlled wireless device that provides electrical stimulation of the type that is similar to TENS units widely... - [Vitamin C is another supplement to consider for pain, immune system (Covid?), connective tissue](https://www.nyheadache.com/blog/vitamin-c-is-another-supplement-to-consider-for-pain-immune-system-covid-connective-tissue/): Vitamin C or ascorbic acid (AA) was discovered by Albert von Szent-Györgyi for which he received the 1937 Nobel Prize... - [Vitamin D is good for pain, immune system (think Coronavirus), brain, and body](https://www.nyheadache.com/blog/vitamin-d-is-good-for-pain-immune-system-think-coronavirus-brain-and-body/): Vitamin D level testing is no longer covered by many insurers and many doctors, NY Times, and other media consider... - [100 Migraine Drugs, A to Z: onabotulinumtoxinA](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-onabotulinumtoxina/): OnabotulinumtoxinA (Botox) is a most remarkable medicine. It was first approved by the FDA in 1989 for two eye conditions... - [Listen to podcast by Bottom Line - 7 New Treatments for Migraines](https://www.nyheadache.com/blog/listen-to-podcast-by-bottom-line-7-new-treatments-for-migraines/): Sarah Hiner, President of BottomLineInc interviews me for The Bottom Line Advocator podcast – 7 New Treatments for Migraines Just... - [Galcanezumab can start to improve migraines within a day](https://www.nyheadache.com/blog/galcanezumab-can-start-to-improve-migraines-within-a-day/): Galcanezumab (Emgality) is one of the three injectable monoclonal antibodies approved for the prevention of migraines. Pharmacological studies show that... - [Rimegepant, another very safe and effective drug receives FDA approval for the acute treatment of migraine headaches](https://www.nyheadache.com/blog/rimegepant-another-very-safe-and-effective-drug-receives-fda-approval-for-the-acute-treatment-of-migraine-headaches/): Rimegepant (NURTEC ODT) is the second gepant approved for the acute treatment of migraine headaches. It blocks the same CGRP... - [100 Migraine Drugs, A to Z: nortriptyline](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-nortriptyline/): Nortriptyline (Pamelor) is a tricyclic antidepressant approved by the FDA only for the treatment of depression. However, with the introduction... - [Vyepti - Another breakthrough in the prevention of migraines](https://www.nyheadache.com/blog/vyepti-another-breakthrough-in-the-prevention-of-migraines/): Eptienzumab (Vyepti) was just approved by the FDA for the preventive treatment of migraine headaches. Eptinezumab is another monoclonal antibody... - [fMRI may offer the first accurate and objective way to diagnose migraines](https://www.nyheadache.com/blog/fmri-may-offer-the-first-accurate-and-objective-way-to-diagnose-migraines/): A group of American and Chinese researchers reported an objective way to diagnose migraine headaches using functional magnetic resonance imaging... - [Acupuncture for migraines - worth a try](https://www.nyheadache.com/blog/acupuncture-for-migraines-worth-a-try/): Acupuncture has been subjected to a very large number of clinical trials for a variety of conditions, including migraine headaches.... - [100 Migraine Drugs, A to Z: nebivolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-nebivolol/): Nebivolol (Bystolic) is one of the newer, third generation beta-blockers, drugs used for the treatment of high blood pressure as... - [Lasmiditan - another new drug for acute treatment of migraines.](https://www.nyheadache.com/blog/lasmiditan-another-new-drug-for-acute-treatment-of-migraines/): Lasmiditan (Rayvow) is the first (and probably the last) drug in the class of ditans. Just like the triptans (sumatriptan... - [100 Migraine Drugs, A to Z: naratriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-naratriptan/): Naratriptan (Amerge, Naramig) is a triptan with a longer duration of action of 6 hours, compared to sumatriptan, rizatirptan, zolmitriptan,... - [Light therapy with Allay lamp](https://www.nyheadache.com/blog/light-therapy-with-allay-lamp/): Light sensitivity is a common feature of migraine headaches and during an attack most people prefer being in the dark.... - [100 Migraine Drugs, A to Z: naproxen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-naproxen/): Naproxen (Aleve, Anaprox, Naprosyn) is a popular over-the-counter and prescription non-steroidal anti-inflammatory drug (NSAID), which is often used for the... - [Migraine comorbidities](https://www.nyheadache.com/blog/migraine-comorbidities/): If you suffer from migraines you are at a higher risk of having certain other medical problems, or comorbidities. They... - [100 Migraine Drugs, A to Z: mirtazapine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-mirtazapine/): Mirtazapine (Remeron) is a tetracyclic antidepressant similar to tricyclic antidepressants and like tricyclics may have pain-relieving properties. The three and... - [Ubrogepant (Ubrelvy), a new type of drug to treat acute migraines is approved by the FDA](https://www.nyheadache.com/blog/ubrogepant-ubrelvy-a-new-type-of-drug-to-treat-acute-migraines-is-approved-by-the-fda/): Ubrogepant (Ubrelvy) is the first oral anti-CGRP drug to be approved by the FDA for the acute treatment of migraine... - [100 Migraine Drugs, A to Z: milnacipran](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-milnacipran/): Milnacipran (Savella) is a drug that is approved by the FDA for the treatment of fibromyalgia. Fibromyalgia is a chronic... - [100 Migraine Drugs, A to Z: metoprolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metoprolol/): Metoprolol (Toprol) is one of the beta-blockers, drugs used for the treatment of hypertension and other heart conditions. It is... - [Triptans are woefully underutilized](https://www.nyheadache.com/blog/triptans-are-woefully-underutilized/): When sumatriptan (Imitrex) was introduced in 1992 it was truly a breakthrough drug – the first drug specifically developed for... - [100 Migraine Drugs, A to Z: methylergonovine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-methylergonovine/): Methylergonovine (Methergine) is used intravenously or in a tablet form after childbirth to help stop bleeding from the uterus. Methylergonovine... - [Vitamin B12 and migraines](https://www.nyheadache.com/blog/vitamin-b12-and-migraines/): Vitamin B12 (cyanocobalamin) deficiency has been long suspected to play a role in the development of migraines, but so far... - [100 MIgraine Drugs, A to Z: metformin](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metformin/): Metformin (Glucophage, Glumetza) is a drug for the treatment of diabetes and you will not find any scientific articles if... - [100 Migraine Drugs, A to Z: clopidogrel](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clopidogrel/): Clopidogrel (Plavix) was not on my original list of 100 migraine drugs, but I decided to add it after another... - [100 Migraine Drugs, A to Z: memantine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-memantine/): Memantine (Namenda) is an Alzheimer’s drug that has been used for the treatment of pain and migraine headaches. This drug... - [Cove, a telemedicine startup for migraine sufferers](https://www.nyheadache.com/blog/cove-a-telemedicine-startup-for-migraine-sufferers/): Cove, a telemedicine startup provides medical care to people suffering from migraines. There are 40 million migraine sufferers in the... - [100 Migraine Drugs, A to Z: meloxicam](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-meloxicam/): Meloxicam (Mobic) is a non-steroidal anti-inflammatory drug (NSAID) which is approved for the treatment of rheumatoid arthritis and osteoarthritis in... - [Thinking fast and slow when prescribing opioids](https://www.nyheadache.com/blog/thinking-fast-and-slow-when-prescribing-opioids/): It is not surprising that when a doctor is tired or hurried he or she is more likely to make... - [More evidence that Botox relieves not only migraines, but also depression](https://www.nyheadache.com/blog/more-evidence-that-botox-relieves-not-only-migraines-but-also-depression/): A large study confirms previous reports of the beneficial effect of onabotulinumtoxinA (Botox) injections on depression as well as anxiety.... - [100 Migraine Drugs, A to Z: mefenamic acid](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-mefenamic-acid/): Mefenamic acid (Ponstel) is one the nonsteroidal antiinflammatory drugs (NSAIDs) and like all other NSAIDs it is being used for... - [Caffeine and migraine headaches](https://www.nyheadache.com/blog/caffeine-and-migraine-headaches/): Medication overuse headache (MOH) is not proven to occur from the frequent intake of triptans (Imitrex, or sumatriptan and other)... - [100 Migraine Drugs, A to Z: lidocaine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lidocaine/): Lidocaine (Xylocaine) is an old local anesthetic used by surgeons, dentists, and other doctors to numb parts of the body.... - [](https://www.nyheadache.com/blog/3362-2/): On September 12, 2019, Dr. Mauskop spoke on Advances and Controversies in Migraine at Charité – Universitätsmedizin Berlin, Europe’s largest... - [Vitamin D and migraine](https://www.nyheadache.com/blog/vitamin-d-and-migraine/): At the biennial International Headache Congress held last week in Dublin a group of Italian researchers presented a paper, Relationship... - [100 Migraine Drugs, A to Z: levetiracetam](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-levetiracetam/): Levetiracetam (Keppra) is an epilepsy drug that has been reported to help some patients with migraines. However, unlike divalproex sodium... - [Migraine Associated With Dementia, Alzheimer’s in Women](https://www.nyheadache.com/blog/migraine-associated-with-dementia-alzheimers-in-women/): An alarming study entitled Association Between Migraine Headaches and Dementia in More than 7,400 Patients Followed in General Practices in... - [100 Migraine Drugs, A to Z: ketorolac](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketorolac/): Ketorolac (Toradol) is one of many nonsteroidal anti-inflammatory (NSAID) pain medications used to treat migraine headaches. In a tablet form... - [tDCS, which we are testing for migraines, may relieve depression](https://www.nyheadache.com/blog/tdcs-which-we-are-testing-for-migraines-may-relieve-depression/): Transcranial direct current stimulation (tDCS) has been definitively shown to alter brain connectivity and function. We are still enrolling patients... - [Migraine does not increase the risk of strokes in postmenopausal women](https://www.nyheadache.com/blog/migraine-does-not-increase-the-risk-of-strokes-in-postmenopausal-women/): Migraine with and without aura carries an increased risk of strokes and heart attacks, according to several large studies. Most... - [Probiotics for migraine](https://www.nyheadache.com/blog/probiotics-for-migraine/): Many migraine sufferers have gastro-intestinal problems, such as irritable bowel syndrome, constipation, sensitivity to gluten, dairy, and other types of... - [100 Migraine Drugs, A to Z: ketoprofen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketoprofen/): Ketoprofen (Orudis, the branded version, is no longer available) is a prescription nonsteroidal antiinflammatory drug (NSAID) without any outstanding features.... - [Another promising acute therapy for migraines](https://www.nyheadache.com/blog/another-promising-acute-therapy-for-migraines/): Dihydroergotamine (DHE-45) is a very old migraine drug in the family of ergot alkaloids. It is one of the most... - [Erenumab for trigeminal neuralgia and other news from the American Headache Society meeting](https://www.nyheadache.com/blog/erenumab-for-trigeminal-neuralgia-and-other-news-from-the-american-headache-society-meeting/): The annual scientific meeting was held last weekend in Philadelphia. The largest number of presentations was about the CGRP drugs,... - [100 Migraine Drugs, A to Z: ketamine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketamine/): Ketamine (Ketalar) was officially approved for human use by Food and Drug Administration (FDA) in 1970 and, because of its... - [100 Migraine Drugs, A to Z: indomethacin](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-indomethacin/): Indomethacin (Indocin) is one of the strongest non-steroidal anti-inflammatory drugs (NSAIDs), but unfortunately it is rarely used for the treatment... - [100 Migraine Drugs, A to Z: ibuprofen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ibuprofen/): Ibuprofen (Advil, Motrin, Nuprin, Nurofen, etc) is a very effective migraine drug. Of course, patients with severe migraines tell me... - [First drug approved for the prevention of cluster headaches](https://www.nyheadache.com/blog/first-drug-approved-for-the-prevention-of-cluster-headaches/): Galcanezumab (Emgality) was just approved by the FDA for the prevention of episodic cluster headaches. Galcanezumab is one of the... - [A case against migraine headache diary](https://www.nyheadache.com/blog/a-case-against-migraine-headache-diary/): Keeping a diary of symptoms has long been considered a part of a successful approach to managing migraine headaches. The... - [100 Migraine Drugs, A to Z: hydroxyzine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-hydroxyzine/): Hydroxyzine (Vistaril) is an underutilized old anti-histamine drug with some unique properties. Just like diphenhydramine (Benadryl) and other older anti-histamine... - [Exercise speeds recovery from a concussion](https://www.nyheadache.com/blog/exercise-speeds-recovery-from-a-concussion/): Researchers at SUNY Buffalo and University of Manitoba studied the effect of exercise on recovery from a sports-related concussion in... - [All 3 NYHC docs are SuperDoctors!](https://www.nyheadache.com/blog/all-3-nyhc-docs-are-superdoctors/): Drs. Lisa Yablon, Sara Crystal, and Alexander Mauskop are included in yesterday’s New York Times Magazine supplement, SuperDoctors. According to... - [100 Migraine Drugs, A to Z: hydrocodone](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-hydrocodone/): Hydrocodone (Vicodin, Lortab, Norco) is an opioid or narcotic pain killer, which should not have much of a role to... - [Vitamin B12 deficiency, "A Problem That's Easy to Miss"](https://www.nyheadache.com/blog/vitamin-b12-deficiency-a-problem-thats-easy-to-miss/): The role of vitamin B12 is underappreciated by many doctors. This week, The Wall Street Journal published a full-page article... - [Men have migraines too.](https://www.nyheadache.com/blog/men-have-migraines-too/): Migraine is rightfully considered a women’s health issue since of the more than 39 million Americans with migraines, 28 million... - [100 Migraine drugs, A to Z: haloperidol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-haloperidol/): Haloperidol (Haldol) is a psychiatric drug prescribed  for the treatment of schizophrenia, tics in Tourette syndrome, mania in bipolar disorder, nausea and vomiting, delirium, agitation,... - [100 MIgraine Drugs, A to Z: granisetron](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-granisetron/): Granisetron (Kytril, Sancuso) is one of the anti-nausea medications in the family of setrons. Ondansetron (Zofran) and palonosetron (Aloxi) are... - [The NY Headache Center is featured in this great new video](https://www.nyheadache.com/blog/the-ny-headache-center-is-featured-in-this-great-new-video/): by Molly Rubin, a video journalist at Quartz.  Quartz is a digital news site founded by the Atlantic. This is... - [Migraine raises the risk of stroke if it begins after 50](https://www.nyheadache.com/blog/migraine-raises-the-risk-of-stroke-if-it-begins-after-50/): Patients suffering from migraine with aura (MA) are at a higher risk of strokes. It is not clear what leads... - [This is a cluster season, again](https://www.nyheadache.com/blog/this-is-a-cluster-season-again/): Cluster headaches derive their name from the fact that they occur daily for a period of one to several months.... - [100 Migraine Drugs, A to Z: galcanezumab](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-galcanezumab/): Galcanezumab (Emgality) was the third drug in the family of CGRP monoclonal antibodies (mAbs) to become approved by the FDA... - [Your brain needs vitamin D - keep your level up](https://www.nyheadache.com/blog/your-brain-needs-vitamin-d-keep-your-level-up/): Yet another study shows that low vitamin D level predisposes to neurological problems. A report just published in a leading... - [Ginger improves emergency room treatment of migraine](https://www.nyheadache.com/blog/ginger-improves-emergency-room-treatment-of-migraine/): Ginger is not only a popular spice, but a truly remarkable medicinal plant. Ginger’s proven anti-inflammatory properties may be responsible... - [100 Migraine Drugs, A to Z: gabapentin](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-gabapentin/): Gabapentin (Neurontin) is a drug that was originally developed for the treatment of epilepsy but now it is used for... - [More about our new study of tDCS for the prevention of migraines](https://www.nyheadache.com/blog/more-about-our-new-study-of-tdcs-for-the-prevention-of-migraines/): To be eligible for this study you have to live in NYC or its suburbs and cannot be currently receiving... - [A new study of Cefaly to treat acute migraines](https://www.nyheadache.com/blog/a-new-study-of-cefaly-to-treat-acute-migraines/): Cefaly is a transcutaneous electrical nerve stimulation (TENS) device designed to treat migraine headaches by stimulating supraorbital nerves. The device... - [Sign up for our trial of tDCS for the prevention of migraines!](https://www.nyheadache.com/blog/sign-up-for-our-trial-of-tdcs-for-the-prevention-of-migraines/): Advertising flyer - [Migraines and dry eyes](https://www.nyheadache.com/blog/migraines-and-dry-eyes/): Several older reports have suggested an association between dry eye disease (DED) and migraine headaches. Researchers at the Univercity of... - [100 Migraine Drugs from A to Z: frovatriptan](https://www.nyheadache.com/blog/100-migraine-drugs-from-a-to-z-frovatriptan/): Frovatriptan (Frova) is one of seven drugs in the family of triptans, drugs used to abort a migraine attack. The... - [Must read! A very important new study of magnesium.](https://www.nyheadache.com/blog/must-read-a-very-important-new-study-of-magnesium/): A study just published in Neurology by the MEGASTROKE project of the International Stroke Genetics Consortium found that “genetically higher serum... - [100 Migraine Drugs, A to Z: fremanezumab](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fremanezumab/): Fremanezumab (Ajovy) is one of the three drugs in the family of CGRP monoclonal antibodies that have been approved for... - [More magnesium, fewer migraines](https://www.nyheadache.com/blog/more-magnesium-fewer-migraines/): Having conducted and published research on magnesium and seeing dramatic improvement from magnesium in many of my patients, I try... - [100 Migraine Drugs, A to Z: flurbiprofen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-flurbiprofen/): Flurbiprofen is just another nonsteroidal antiinflammatory drug (NSAID), which is reflected in the name of its branded version – Ansaid.... - [TOSYMRA, a new migraine product was just approved by the FDA](https://www.nyheadache.com/blog/tosymra-a-new-migraine-product-was-just-approved-by-the-fda/): Tosymra is a product that uses a novel way to deliver sumatriptan through the nasal passages. Unlike other nasal formulations... - [100 Migraine Drugs, A to Z: fluvoxamine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fluvoxamine/): Fluvoxamine (Luvox) is one of the drugs in the selective serotonin reuptake inhibitor (SSRI) class. Unlike other SSRIs, which are... - [100 Migraine drugs, A to Z: flunarizine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-flunarizine/): Flunarizine (Sibelium) is a calcium channel blocker approved for the preventive treatment of migraines in most countries, except for the... - [I decided to stop Ajovy too](https://www.nyheadache.com/blog/i-decided-to-stop-ajovy-too/): I’ve given myself an injection of Ajovy in November and December with some improvement and without constipation which I had... - [100 Migraine Drugs, A to Z: fluoxetine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fluoxetine/): Antidepressants are widely used for the preventive treatment of migraine headaches. However, some types of antidepressants are better for this... - [Red wine and headaches in the WSJ](https://www.nyheadache.com/blog/red-wine-and-headaches-in-the-wsj/): Red wine is a common trigger for migraines, although we still don’t know the cause or why red wine is... - [100 Migraine Drugs, A to Z: estrogen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-estrogen/): Estrogen can be an effective agent for the treatment of menstrual migraines. Many women report that their migraines tend to... - [100 Migraine Drugs, A to Z: erenumab](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-erenumab/): Erenumab (Aimovig) was the first drug in the family of monoclonal antibodies (mAbs) against calcitonin gene-related peptide (CGRP) approved for... - [Migraine aura increases the risk of atrial fibrillation, which may lead to a stroke](https://www.nyheadache.com/blog/migraine-aura-increases-the-risk-of-atrial-fibrillation-which-may-lead-to-a-stroke/): A typical migraine aura consists of a visual disturbance (partial loss of vision, flickering lights, zigzags, etc) which lasts 15... - [Now I've tried Ajovy too](https://www.nyheadache.com/blog/now-ive-tried-ajovy-too/): Fremanezumab (Ajovy) is the second CGRP monoclonal antibody to become after the introduction of erenumab (Aimovig) and it has some... - [100 Migraine Drugs, A to Z: eletriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-eletriptan/): Eletriptan (Relpax) is one of seven triptans approved for the treatment of an acute migraine. While all triptans are similar... - [100 Migraine Drugs, A to Z: duloxetine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-duloxetine/): Duloxetine (Cymbalta) is an antidepressant in the family of serotonin-norepinephrine reuptake inhibitors (SNRIs). Unlike the selective serotonin reuptake inhibitors (SSRIs)... - [100 Migraine Drugs, A to Z: droperidol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-droperidol/): Droperidol (Inapsine) is not a phenothiazine, but is structurally very similar to this class of anti-nausea and anti-psychotic drugs. It... - [100 Migraine Drugs, A to Z: Doxepine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-doxepine/): Doxepin (Sinequan) is a tricyclic antidepressant and all drugs in this category (amitriptyline, nortriptyline, desipramine, protriptyline) appear to be effective... - [100 Migraine Drugs, A to Z: domperidone](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-domperidone/): Domperidone (Motilium) is not a champagne (that would be Dom Perignon and it can give you a headache) but an... - [100 Migraine Drugs, A to Z: divalproex sodium](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-divalproex-sodium/): Divalproex sodium (Depakote) is one of two epilepsy drugs that are also approved by the FDA for the preventive treatment... - [100 Migraine Drugs, A to Z: dihydroergotamine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dihydroergotamine/): Dihydroergotamine (DHE-45) when given intravenously (IV) is considered to be the most effective migraine medication. It was introduced in 1943... - [100 Migraine Drugs, A to Z: diclofenac](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-diclofenac/): Diclofenac (Cambia, Voltaren) is one of the nonsteroidal anti-inflammatory drugs (NSAIDs) used for the treatment of migraine headaches. Cambia, which... - [100 Migraine Drugs, A to Z: dichloralphenazone](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dichloralphenazone/): Dichloralphenazone is one of three ingredients in the headache drug, Midrin. The other two ingredients are isometheptene, a drug that... - [100 Migraine Drugs, A to Z: desvenlafaxine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-desvenlafaxine/): Desvenlafaxine (Pristiq) is an antidepressant in the family of serotonin and norepinephrine reuptake inhibitors (SNRIs). Selective serotonin reuptake inhibitors (SSRIs)... - [100 Migraine Drugs, A to Z: desipramine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-desipramine/): Desipramine (Norpramin) belongs to the family of tricyclic antidepressants which have been proven to be effective for the treatment of... - [100 Migraine Drugs, A to Z: celecoxib](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-celecoxib/): Celecoxib (Celebrex) is a non-steroidal anti-inflammatory drug (NSAID) that belongs to a subclass of selective COX-2 inhibitors. This subclass of... - [More science to support the use of cannabis for pain](https://www.nyheadache.com/blog/more-science-to-support-the-use-of-cannabis-for-pain/): We’ve been prescribing medical marijuana for migraines and other painful conditions since it was legalized in the state of New... - [Galcanezumab, the third CGRP monoclonal antibody for migraine is approved](https://www.nyheadache.com/blog/galcanezumab-the-third-cgrp-monoclonal-antibody-for-migraine-is-approved/): The FDA has just approved galcanezumab (Emgality), the third CGRP monoclonal antibody for the prophylactic treatment of migraines. It follows... - [100 Migraine Drugs, A to Z: bisoprolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-bisoprolol/): Bisoprolol (Zebeta) is one of about a dozen drugs in the beta-blocker family, medications that were developed for the treatment... - [Botox relieves hemiplegic migraine and migraine with aura](https://www.nyheadache.com/blog/botox-relieves-hemiplegic-migraine-and-migraine-with-aura/): A recent report by neurologists from the Mayo Clinic suggests that onabotulinumtoxinA (Botox) injections can relieve not only headache pain,... - [Fremanezumab (Ajovy), a second CGRP monoclonal antibody for migraines is approved](https://www.nyheadache.com/blog/fremanezumab-ajovy-a-second-cgrp-monoclonal-antibody-for-migraines-is-approved/): Fremanezumab (Ajovy) was just approved by the FDA for the preventive treatment of migraine headaches. It is the second drug,... - [100 Migraine Drugs, A to Z: bupivacaine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-bupivacaine/): Bupivacaine (Marcaine, Sensorcaine) is a numbing agent (local anesthetic) similar to lidocaine (Xylocaine), but with a longer duration of effect.... - [100 Migraine Drugs, A to Z: dexamethasone](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dexamethasone/): Dexamethasone (Decadron) is a strong corticosteroid (steroid) anti-inflammatory medication similar to prednisone and methylprednisolone (Medrol). Considering that inflammation occurs during... - [100 Migraine Drugs, A to Z: codeine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-codeine/): Codeine is a mild opioid (narcotic) pain killer, which has less of an addiction potential of butorphanol, described in the... - [100 Migraine Drugs, A to Z: butorphanol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butorphanol/): Butorphanol nasal spray (Stadol NS) is approved by the FDA for the treatment of acute migraine attacks. It belongs to... - [Botox for migraines in children](https://www.nyheadache.com/blog/botox-for-migraines-in-children/): Injections of onabotulinumtoxinA (Botox) are approved for the treatment of chronic migraine headaches in adults. Botox is also widely used... - [100 Migraine Drugs, A to Z: cyproheptadine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-cyproheptadine/): Cyproheptadine (Periactin) is one of the most popular drugs for the prevention of migraine headaches in children. Unfortunately, there is... - [100 Migraine Drugs, A to Z: clonidine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clonidine/): Blood pressure medication propranolol was the first preventive drug approved for the treatment of migraine headaches over 50 years ago.... - [100 Migraine Drugs, A to Z: clonazepam](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clonazepam/): Clonazepam (Klonopin) is a drug approved for the treatment of panic attacks and certain types of seizures. It is also... - [100 Migraine Drugs, A to Z: chlorpromazine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-chlorpromazine/): Chlorpromazine (Thorazine) belongs to the phenothiazine family, which includes prochlorperazine (Compazine) and promethazine (Phenergan), drugs used to treat nausea and... - [100 Migraine Drugs, A to Z: cannabidiol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-cannabidiol/): Medical marijuana (MM) is now legal in 30 states. Most states approve its use for specific medical conditions and severe... - [How to quickly relieve painful knots in the shoulders](https://www.nyheadache.com/blog/how-to-quickly-relieve-painful-knots-in-the-shoulders/): Almost everyone has an occasional pain in the upper back and shoulders, often caused by prolonged sitting in front of... - [100 Migraine Drugs, A to Z: candesartan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-candesartan/): Candesartan (Atacand) is a blood pressure medication in the class of ACE receptor blockers (ARBs), none of which are approved... - [100 Migraine Drugs, A to Z: butterbur](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butterbur/): The New York Headache Center participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg... - [100 Migraine Drugs, A to Z: caffeine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-caffeine/): Caffeine can be considered a drug since it is available in a pure form in tablets and injections. It is... - [100 Migraine Drugs, A to Z: Boswellia](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-boswellia/): Boswellia serrata is not a drug, but a plant, but I am including herbal products as well if a serious... - [A new book on headaches that is worth reading](https://www.nyheadache.com/blog/a-new-book-on-headaches-that-is-worth-reading/): Jan Mundo, who is a Somatic and Headache Coach, and Bodyworker just wrote a book, The Headache Healer’s Handbook, which... - [100 Migraine Drugs, A to Z: baclofen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-baclofen/): Baclofen (Lioresal) is one of several muscle relaxants that have been tested for the treatment of migraine headaches. The testing... - [100 Migraine drugs, A to Z: butalbital](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butalbital/): Butalbital, a short-acting barbiturate, is one of the three ingredients in headache drugs such as Fioricet, Fiorinal, Esgic and their... - [Orgasmic headaches](https://www.nyheadache.com/blog/orgasmic-headaches/): Headaches that occur during sexual activity tend to elicit fear and embarrassment. Embarrassment is why most people are not aware... - [100 Drugs for Migraine, A to Z: buspirone](https://www.nyheadache.com/blog/100-drugs-for-migraine-a-to-z-buspirone/): Anxiety is one of the conditions comorbid with migraines – if you have migraines you are 2-3 times more likely... - [Update: I injected myself with Aimovig (erenumab) and here's what happened so far](https://www.nyheadache.com/blog/update-i-injected-myself-with-aimovig-erenumab-and-heres-what-happened-so-far/): On June 1, I injected myself with erenumab (Aimovig). I still had to take sumatriptan for an incipient migraine on... - [100 Migraine Drugs, A to Z: botulinum toxin](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-botulinum-toxin/): The FDA has approved 4 different types of botulinum toxin for various therapeutic indications. The oldest, the most popular and... - [100 Migraine drugs, A to Z: Atenolol](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-atenolol/): Atenolol (Tenormin) is a blood pressure medicine in the beta blocker family. Atenolol is considered to be equally effective in... - [I just injected myself with erenumab (Aimovig)](https://www.nyheadache.com/blog/i-just-injected-myself-with-erenumab-aimovig/): As expected, we’ve been overwhelmed by the demand for the new preventive therapy for migrianes, erenumab (Aimovig). It offers a... - [Cannabis relieves pain in the elderly](https://www.nyheadache.com/blog/cannabis-relieves-pain-in-the-elderly/): Medical marijuana appears to be very effective for the treatment of pain, according to a new study just published in... - [A very promising new treatment for cluster headaches](https://www.nyheadache.com/blog/a-very-promising-new-treatment-for-cluster-headaches/): A new and very promising preventive treatment for cluster headaches being developed by Eli Lilly may become available in the... - [Migraine drugs, A to Z: timolol eye drops](https://www.nyheadache.com/blog/migraine-drugs-a-to-z-timolol-eye-drops/): Propranolol (Inderal) and other blood pressure medications in the beta blocker family are effective for the prevention of migraines. In... - [Aimovig (CGRP monoclonal antibody) is approved by the FDA!](https://www.nyheadache.com/blog/aimovig-cgrp-monoclonal-antibody-is-approved-by-the-fda/): Yesterday the FDA approved the long-awaited breakthrough drug for the prevention of migraines. It promises to provide relief to two... - [100 Migraine drugs, A to Z: Amlodipine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amlodipine/): Calcium channel blockers, a family of drugs used to treat hypertension, are sometimes used for the prevention of migraine headaches.... - [100 Migraine drugs, A to Z: Amitriptyline](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amitriptyline/): Amitriptyline (Elavil) and other drugs in the family of tricyclic antidepressants have been proven to be very effective in the... - [100 Migraine drugs, A to Z: amiloride](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amiloride/): Only about 20% of migraine sufferers experience an aura. The most common type of aura is visual and it typically... - [100 Migraine drugs, A to Z: Alpha-lipoic acid](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-alpha-lipoic-acid/): Alpha-lipoic acid is one of the natural supplements included in this list of 100 migraine drugs. According to a study... - [Brain is damaged by repeated head trauma, even without a concussion](https://www.nyheadache.com/blog/brain-is-damaged-by-repeated-head-trauma-even-without-a-concussion/): A group of American and Israeli researchers published a study in the journal Brain, suggesting that hits to the head,... - [100 Migraine drugs, A to Z: Acetylsalicylic acid](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-acetylsalicylic-acid/): Acetylsalicylic acid, also known as aspirin, is a truly miracle drug. It is an excellent pain and fever-reducing medicine and... - [100 Migraine drugs, A to Z: Amantadine](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amantadine/): Amantadine (Symmetrel) is a medication that has U. S. Food and Drug Administration (FDA) approval for use both as an... - [100 Migraine drugs, A to Z: Abobotulinumtoxin A](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-abobotulinumtoxin-a/): AbobotulinumtoxinA (Dysport) is a product that is very similar to OnabotulinumtoxinA (Botox), but only Botox is approved by the FDA... - [100 Migraine drugs, A to Z: Acetaminophen](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-acetaminophen/): Many migraine sufferers do not find acetaminophen (Tylenol) to be strong enough to treat migraine headaches and it does not... - [100 Migraine drugs, A to Z: Almotriptan](https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-almotriptan/): Almotriptan (Axert) belongs to the family of triptans, which are, by far, the most effective drugs for the acute treatment... - [100 Migraine drugs, A to Z: acetazolamide](https://www.nyheadache.com/blog/migraine-drugs-a-to-z-acetazolamide/): This is the first in a 100-part series of blogs on various migraine drugs. Yes, we do use that many... - [Certain drugs do not help concussion recovery, but other can](https://www.nyheadache.com/blog/certain-drugs-do-not-help-concussion-recovery-but-other-can/): Several drugs are often used to treat symptoms of concussion, including an epilepsy drug, gabapentin (Neurontin), amitriptyline (Elavil) and other... - [Biohaven Follows Allergan in Announcing Positive Results for Rimegepant - an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine](https://www.nyheadache.com/blog/biohaven-follows-allergan-in-announcing-positive-results-for-rimegepant-an-oral-cgrp-receptor-antagonist-for-the-acute-treatment-of-migraine/): Last month Allergan reported that their oral CGRP receptor antagonist, ubrogepant was safe and effective in the acute treatment of... - [Allergan Announces Positive Results for Ubrogepant - an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine](https://www.nyheadache.com/blog/allergan-announces-positive-results-for-ubrogepant-an-oral-cgrp-receptor-antagonist-for-the-acute-treatment-of-migraine/): The first of the four CGRP monoclonal antibodies developed for the prevention of migraines is expected to be approved by... - [FDA approves the first blood test to diagnose concussion](https://www.nyheadache.com/blog/fda-approves-the-first-blood-test-to-diagnose-concussion/): The news headlines are filled with stories of professional football players suffering from brain damage, but you do not to... - [Intravenous lidocaine for pain (and headaches)](https://www.nyheadache.com/blog/intravenous-lidocaine-for-pain-and-headaches/): Lidocaine is an effective local anesthetic that is injected for dental procedures, minor surgeries, as well as nerve blocks, including... - [Botox for TMJ; the effect on clenching and grinding of teeth](https://www.nyheadache.com/blog/botox-for-tmj-the-effect-on-clenching-and-grinding-of-teeth/): TMJ syndrome is a disorder which often coexists with migraine and tension-type headaches and is characterized by pain in the... - [gammaCore for migraine](https://www.nyheadache.com/blog/gammacore-for-migraine/): An electric stimulation device, gammaCore has received clearance from the U. S. Food and Drug Administration (FDA) as an acute... - [The Feldenkrais method](https://www.nyheadache.com/blog/the-feldenkrais-method/): A recent article in the New York Times by the health columnist, Jane Brody, Trying the Feldenkrais Method for Chronic... - [Feverfew for migraines](https://www.nyheadache.com/blog/feverfew-for-migraines/): Feverfew (tanacetum parthenium) is one of the oldest herbal remedies for the treatment of migraine headaches. It was first mentioned... - [Terrorism and headaches](https://www.nyheadache.com/blog/terrorism-and-headaches/): Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer... - [Migraines can be prevented with CoQ10 supplementation](https://www.nyheadache.com/blog/migraines-can-be-prevented-with-coq10-supplementation/): Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of... - [Dementia and magnesium levels](https://www.nyheadache.com/blog/dementia-and-magnesium-levels/): Magnesium deficiency is found in up to 50% of migraine sufferers, 40% of those with cluster headaches, 45% of the... - [Botox for kids with chronic migraines](https://www.nyheadache.com/blog/botox-for-kids-with-chronic-migraines/): A new report by doctors at UC Irvine describes successful treatment of 9 children aged 8 to 17 with migraine... - [Ignore fearmongering: triptans still do not increase the risk of strokes and heart attacks](https://www.nyheadache.com/blog/ignore-fearmongering-triptans-still-do-not-increase-the-risk-of-strokes-and-heart-attacks/): A group of highly respected researchers at the Albert Einstein College of Medicine just published their second article in the... - [Breakthrough in the treatment of migraines](https://www.nyheadache.com/blog/breakthrough-in-the-treatment-of-migraines/): Two landmark studies on an entirely new type of treatment for migraines have been just published in the New England... - [Vomiting from too much pot is similar to cyclic vomiting syndrome](https://www.nyheadache.com/blog/vomiting-from-too-much-pot-is-similar-to-cyclic-vomiting-syndrome/): Excessive consumption of marijuana can lead to bouts of severe nausea and vomiting, which in medicalese is called cannabinoid hyperemesis... - [Psychological factors in chronic migraine](https://www.nyheadache.com/blog/psychological-factors-in-chronic-migraine/): Psychological factors play a major role in migraines. This is not to say that migraine is a psychological disorder –... - [Visual snow is related to migraines, can be disabling](https://www.nyheadache.com/blog/visual-snow-is-related-to-migraines-can-be-disabling/): People who have experienced “visual snow” know what it means. Their vision tends to be distorted by white spots that... - [Curcumin helps improve memory, possibly migraines.](https://www.nyheadache.com/blog/curcumin-helps-improve-memory-possibly-migraines/): Curcumin, which is one of the ingredients in turmeric, has long been touted for many of its anti-inflammatory and anti-cancer... - [More on intravenous ketamine for migraines](https://www.nyheadache.com/blog/more-on-intravenous-ketamine-for-migraines/): Ketamine is a medicine that is sometimes given intravenously for anesthesia. It is a controlled drug because it can induce... - [Stem cells help stroke victims, will revolutionize medicine](https://www.nyheadache.com/blog/stem-cells-help-stroke-victims-will-revolutionize-medicine/): There is little doubt that stem cells, along with genetics and computer science will revolutionize medicine. There are more than... - [The effect of post-traumatic headaches on the brain](https://www.nyheadache.com/blog/the-effect-of-post-traumatic-headaches-on-the-brain/): Chronic pain is known to alter the structure of the brain. Mayo Clinic researchers used MRI scans to examine brains... - [Gut bacteria can cause big holes in the brain](https://www.nyheadache.com/blog/gut-bacteria-can-cause-big-holes-in-the-brain/): Biome, or the collection of bacteria living in our bodies has been receiving belated and well deserved attention. The discovery... - [Two different types of exercise prevent migraines](https://www.nyheadache.com/blog/two-different-types-of-exercise-prevent-migraines/): A new study by Swiss researchers compared the effect of high intensity interval training (HIT) with moderate intensity continuous training... - [What to do when Botox stops working](https://www.nyheadache.com/blog/what-to-do-when-botox-stops-working/): Botox is the most effective and the safest preventive treatment for migraine headaches. However, in a very small number of... - [Color of the ambient light can help or worsen migraines](https://www.nyheadache.com/blog/color-of-the-ambient-light-can-help-or-worsen-migraines/): Bright light bothers many migraine sufferers and in some, a flash of bright light, such as sun reflecting off a... - [Medication overuse (rebound) headache is a myth](https://www.nyheadache.com/blog/medication-overuse-rebound-headache-is-a-myth/): Caffeine and opioid (narcotic) drugs, if taken regularly, are proven to worsen headaches. This will not come as a surprise... - [Triptans (like Imitrex) mix well with antidepressants](https://www.nyheadache.com/blog/triptans-like-imitrex-mix-well-with-antidepressants/): Sumatriptan (Imitrex), rizatriptan (Maxalt) and the other 5 triptans work on serotonin receptors to stop a migraine attack. Many antidepressants,... - [Magnesium reduces the size of hemorrhagic strokes](https://www.nyheadache.com/blog/magnesium-reduces-the-size-of-hemorrhagic-strokes/): Researchers at Northwestern University in Chicago examined possible correlation between magnesium level on admission to the hospital with the size... - [Another study shows benefits of fish oil](https://www.nyheadache.com/blog/another-study-shows-benefits-of-fish-oil/): Omega-3 polyunsaturated fatty acids (PUFA) which are found in fish oil, have been studied in a wide variety of diseases,... - [Botox injections improve not only migraine symptoms, but also sleep and fatigue](https://www.nyheadache.com/blog/botox-injections-improve-not-only-migraine-symptoms-but-also-sleep-and-fatigue/): Sleep disturbances and fatigue are more common in patients with chronic migraine headaches than in people without migraines. Sometimes it... - [Anxiety contributes to disability in kids with headaches](https://www.nyheadache.com/blog/anxiety-contributes-to-disability-in-kids-with-headaches/): Anxiety is at least twice as common in both children and adults with migraine headaches compared to people without migraines.... - [Occipital (back of the head) headaches in children](https://www.nyheadache.com/blog/occipital-back-of-the-head-headaches-in-children/): Most children who complain of headaches report pain in the forehead and/or temples. Doctors and parents tend to get more... - [Sumatriptan injections still underutilized. New lower dose, easy-to-use device could help](https://www.nyheadache.com/blog/sumatriptan-injections-still-underutilized-new-lower-dose-easy-to-use-device-could-help/): Sumatriptan (Imitrex) injection was introduced 25 years ago, but it remains extremely underutilized. Of course, why would you inject yourself... - [Migraine increases the risk of stroke during and after surgery](https://www.nyheadache.com/blog/migraine-increases-the-risk-of-stroke-during-and-after-surgery/): It is an established fact that migraine, and especially migraine with aura increases the risk of strokes. The increase in... - [Telemedicine is effective to treat headache patients](https://www.nyheadache.com/blog/telemedicine-is-effective-to-treat-headache-patients/): We often get requests for a telephone consultation from patients who live too far to come in for a visit.... - [New information on cluster headaches](https://www.nyheadache.com/blog/new-information-on-cluster-headaches/): Cluster headache is one of the most painful conditions that has lead some patients call it a suicide headache. A... - [Another report on Botox for trigeminal neuralgia](https://www.nyheadache.com/blog/another-report-on-botox-for-trigeminal-neuralgia/): Trigeminal neuralgia is a rare, but an extremely painful conditions. Patients compare the quality and the severity of pain to... - [More support for the use of Botox in posttraumatic headaches](https://www.nyheadache.com/blog/more-support-for-the-use-of-botox-in-posttraumatic-headaches/): Concussion, even when it is mild, can result in a post-concussion syndrome. The main symptom is a headache and it... - [Our report on stem cells for migraines is published](https://www.nyheadache.com/blog/our-report-on-stem-cells-for-migraines-is-published/): Stem cells hold great promise in the treatment of many conditions, possibly including migraines. In a post from 3 years... - [Opioid hydromorphone (Dilaudid) does not help migraine](https://www.nyheadache.com/blog/opioid-hydromorphone-dilaudid-does-not-help-migraine/): Unfortunately, opioid hydromorphone (Dilaudid) is still administered to 25% of patients with an acute migraine visiting an ER. Benjamin Friedman... - [A migraine vaccine should be out next year](https://www.nyheadache.com/blog/a-migraine-vaccine-should-be-out-next-year/): We are in great need of better preventive treatments for migraines. CGRP monoclonal antibodies appear to fulfil their early promise.... - [Living at high altitudes leads to more migraines](https://www.nyheadache.com/blog/living-at-high-altitudes-leads-to-more-migraines/): Many migraine sufferers complain about worsening of their migraines when they travel to high altitudes. But do people who permanently... - [New research on cannabis for migraines](https://www.nyheadache.com/blog/new-research-on-cannabis-for-migraines/): Medical marijuana has been legalized in NY and more than 20 other states. It is approved in NY for several... - [A new book for migraine sufferers and their families](https://www.nyheadache.com/blog/a-new-book-for-migraine-sufferers-and-their-families/): Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the... - [When nothing relieves your migraines, rehabilitation might](https://www.nyheadache.com/blog/when-nothing-relieves-your-migraines-rehabilitation-might/): The most satisfying part of our work is that we can help more than 95% of our patients. However, a... - [A new drug is approved for temporal arteritis, cause of headaches in those over 50](https://www.nyheadache.com/blog/a-new-drug-is-approved-for-temporal-arteritis-cause-of-headaches-in-those-over-50/): Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected.... - [Preeclampsia can have lasting effects on the brain](https://www.nyheadache.com/blog/preeclampsia-can-have-lasting-effects-on-the-brain/): Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated,... - [Hyperbaric oxygen for traumatic brain injury and postconcussion syndrome](https://www.nyheadache.com/blog/hyperbaric-oxygen-for-traumatic-brain-injury/): Inhalation of pure oxygen under high flow is an effective treatment for an acute cluster headache, although not migraines. Headache... - [Update on medical marijuana from the founder of the field](https://www.nyheadache.com/blog/update-on-medical-marijuana-from-the-founder-of-the-field/): The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other... - [Non-drug treatment of insomnia helps headaches](https://www.nyheadache.com/blog/non-drug-treatment-of-insomnia-helps-headaches/): Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in... - [Learn from The Migraine World Summit](https://www.nyheadache.com/blog/learn-from-the-migraine-world-summit/): I am certain that you will learn a lot of useful information from listening to the top headache experts in... - [Blood vessels, stroke and migraine](https://www.nyheadache.com/blog/blood-vessels-stroke-and-migraine/): Stroke is slightly more common in migraine sufferers. There are two main types of stroke: hemorrhagic, which results from a... - [Sensitivity to light (photophobia) and migraine](https://www.nyheadache.com/blog/sensitivity-to-light-photophobia-and-migraine/): Photophobia, or sensitivity to light is one of the most common symptoms that accompany a migraine attack. Many patients remains... - [Postconcussion symptoms in teens are relieved by CBT](https://www.nyheadache.com/blog/postconcussion-symptoms-in-teens-are-relieved-by-cbt/): Postconcussion symptoms can be debilitating and can persist for long periods of time, both in kids and adults. Persistence of... - [Beta-blockers (e.g. propranolol) prevent migraines, but could also help other pains](https://www.nyheadache.com/blog/beta-blockers-e-g-propranolol-prevent-migraines-but-could-also-help-other-pains/): Beta-blocker propranolol (Inderal) was first approved over 50 years ago for the treatment of hypertension and 10 years later became... - [Wireless electric patch for migraines](https://www.nyheadache.com/blog/wireless-electric-patch-for-migraines/): A new electric device is being tested for the treatment of migraine by an Israeli company, Theranica. Transcutaneous electric nerve... - [Cluster headaches are more often misdiagnosed in women](https://www.nyheadache.com/blog/cluster-headaches-are-more-often-misdiagnosed-in-women/): Cluster headaches are much less common than migraines (less than a million vs 36 million sufferers), but are arguably the... - [Soccer is not good for your brain, at any age and whether you head the ball or not](https://www.nyheadache.com/blog/soccer-is-not-good-for-your-brain-at-any-age-and-whether-you-head-the-ball-or-not/): With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250... - [Low dose naltrexone (LDN) for pain](https://www.nyheadache.com/blog/low-dose-naltrexone-ldn-for-pain/): Naltrexone, along with naloxone are narcotic (opioid) antidotes, that is they counteract the effect of narcotics and are used to... - [You’re Overpaying for Drugs and Your Pharmacist Can’t Tell You](https://www.nyheadache.com/blog/youre-overpaying-for-drugs-and-your-pharmacist-cant-tell-you/): Generic drugs should be cheap, but you still may be overpaying for them. I mentioned this problem in a previous... - [Electronic medical records is a blessing and a curse](https://www.nyheadache.com/blog/electronic-medical-records-is-a-blessing-and-a-curse/): We’ve adopted electronic medical records (EMR) over 10 years ago when the upfront costs were high and the training curve... - [An update on contraceptives in migraine with aura](https://www.nyheadache.com/blog/an-update-on-contraceptives-in-migraine-with-aura/): Estrogen-based oral contraceptives are usually contraindicated for women who have migraines with aura. In the latest issue of the journal... - [Early return to physical activity after concussion may reduce post-concussive symptoms](https://www.nyheadache.com/blog/early-return-to-physical-activity-after-concussion-may-reduce-post-concussive-symptoms/): Physical and mental symptoms can persist after a concussion and strangely, mild concussions are more likely to cause persistent symptoms... - [Attachment style correlates with headache features and psychological symptoms in children and adolescents with migraines](https://www.nyheadache.com/blog/attachment-style-correlates-with-headache-features-and-psychological-symptoms-in-children-and-adolescents-with-migraines/): Italian researchers published a study in the journal Headache that attempted to correlate the attachment style in children with migraines... - [How to reduce the cost of Botox for migraines](https://www.nyheadache.com/blog/how-to-reduce-the-cost-of-botox-for-migraines/): Botox is by far the safest and the most effective preventive treatment for chronic and frequent episodic migraine headaches. The... - [A brilliant writer on how we take care of people with difficult-to-treat migraines](https://www.nyheadache.com/blog/a-brilliant-writer-on-how-we-take-care-of-people-with-difficult-to-treat-migraines/): Atul Gawande is a surgeon at the Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School.... - [Vestibular migraine](https://www.nyheadache.com/blog/vestibular-migraine/): Vestibular migraine has been also called migraine-associated vertigo or dizziness and migrainous vertigo. Diagnostic criteria, according to the international headache... - [Glaucoma and migraines](https://www.nyheadache.com/blog/glaucoma-and-migraines/): Severe headache is a common symptom of acute glaucoma. It comes from a sudden increase in the intra-ocular pressure caused... - [Placebo effect is how chiropractic relieves migraines](https://www.nyheadache.com/blog/placebo-effect-is-how-chiropractic-relieves-migraines/): Many chiropractors advertise their success in treating migraine headaches. Norwegian researchers conducted a scientific study of chiropractic manipulation for migraine... - [Vitamin C deficiency is associated with neck and back pain, and possibly headaches](https://www.nyheadache.com/blog/vitamin-c-deficiency-is-associated-with-neck-and-back-pain-perhaps-migraine-too/): Vitamin C deficiency appears to be more common in people with back pain, according to a study just published in... - [Women living together have a higher frequency of menstrual migraine](https://www.nyheadache.com/blog/women-living-together-have-a-higher-frequency-of-menstrual-migraine/): Many women are more likely to have migraines around the time of their menstrual period and in some, those migraines... - [Restless leg syndrome and migraine](https://www.nyheadache.com/blog/restless-leg-syndrome-and-migraine/): Restless leg syndrome (RLS) has been reported to be more common in patients with migraines. I wrote about this association... - [Functional MRI may be less than meets the eye](https://www.nyheadache.com/blog/functional-mri-may-be-less-than-meets-the-eye/): Functional MRI (fMRI) imaging has been a powerful tool for visualizing processing of information in the brain. This technique is... - [Experts' comments on the recent acupuncture report](https://www.nyheadache.com/blog/experts-comments-on-the-recent-acupuncture-report/): Two leading headache experts, Drs. Richard Lipton and Dawn Buse of the Montefiore Headache clinic gave positive comments on the... - [Blood pressure drugs prevent migraines but may cause depression](https://www.nyheadache.com/blog/blood-pressure-drugs-prevent-migraines-but-may-cause-depression/): Beta blockers, such as propranolol (Inderal) and timolol (Blocadren) are the oldest drugs for the prevention of migraine headaches. They’ve... - [Cluster headaches, sleep disturbance, and depression](https://www.nyheadache.com/blog/cluster-headaches-sleep-disturbance-and-depression/): According to large epidemiological studies, migraine sufferers are 2-3 times more likely to develop depression, anxiety and other psychiatric disorders... - [Acupuncture provides long-term relief](https://www.nyheadache.com/blog/acupuncture-provides-long-term-relief/): Acupuncture for the treatment of migraines has been studied in dozens of clinical trials. A 2012 study mentioned in a... - [Do migraine drugs work in kids?](https://www.nyheadache.com/blog/do-migraine-drugs-work-in-kids/): About 6% of young children suffer from migraine headaches. After puberty, this number triples to 18% in girls and remains... - [Guidelines for the use of medical marijuana](https://www.nyheadache.com/blog/guidelines-for-the-use-of-medical-marijuana/): Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30... - [Liver damage is often caused by supplements](https://www.nyheadache.com/blog/liver-damage-is-often-caused-by-supplements/): We are big proponents of non-drug treatments, including a variety of vitamins, minerals, and herbal supplements. However, potential liver damage... - [Another option for the treatment of nausea](https://www.nyheadache.com/blog/another-option-for-the-treatment-of-nausea/): Nausea is a very common symptom that accompanies migraine attacks. Effective treatment of migraine with a drug like sumatriptan often... - [Thyroid disease and headaches](https://www.nyheadache.com/blog/thyroid-disease-and-headaches/): Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as... - [Migraine and blood clots in veins (thrombosis)](https://www.nyheadache.com/blog/migraine-and-blood-clots-in-veins-thrombosis/): Migraine with aura is known to be associated with an increased risk of diseases of arteries, such as strokes, heart... - [Common avoidable problems with Botox injections](https://www.nyheadache.com/blog/common-avoidable-problems-with-botox-injections/): One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol... - [Medical marijuana reduces prescription costs](https://www.nyheadache.com/blog/medical-marijuana-reduces-prescription-costs/): Medical marijuana reduces the number of prescriptions written by doctors, according to a recent study published in Health Affairs. The... - [CGRP drugs remain highly promising.](https://www.nyheadache.com/blog/cgrp-drugs-remain-highly-promising/): CGRP migraine drugs remain on track to get an approval from the FDA within two years. My first post on... - [Vitamin B12 is in the news](https://www.nyheadache.com/blog/vitamin-b12-is-in-the-news/): Vitamin B12 was the subject of an article in the New York Times by Jane Brody entitled, Vitamin B12 as... - [Fracking and Migraines](https://www.nyheadache.com/blog/fracking-and-migraines/): Living in areas where fracking takes place doubles the risk of having migraines, as well as fatigue and sinus symptoms.... - [Men suffer from migraines too, but are often not diagnosed](https://www.nyheadache.com/blog/men-suffer-from-migraines-too-but-are-often-not-diagnosed/): Three times as many women are afflicted by migraines as men, according to many large studies. However, 6% of men... - [More on intravenous magnesium for migraines, muscle cramps, PMS, and other symptoms](https://www.nyheadache.com/blog/more-on-intravenous-magnesium-for-migraines-muscle-cramps-pms-and-other-symptoms/): Intravenous magnesium relieves acute migraine attacks in patients with magnesium deficiency, which is present in half of migraine sufferers, according... - [Cramp Bark - another herb for migraines](https://www.nyheadache.com/blog/cramp-bark-another-herb-for-migraines/): Recently, a patient of mine reported that cramp bark has significantly improved her menstrual migraines. Cramp bark is a common... - [Vagus nerve stimulation for migraines](https://www.nyheadache.com/blog/vagus-nerve-stimulation-for-migraines/): Vagus nerve stimulation (VNS) with an electrode implanted in the neck is an FDA-approved treatment for depression and epilepsy, when... - [Migraines worsen in perimenopause](https://www.nyheadache.com/blog/migraines-worsen-in-perimenopause/): Menopause often brings relief to female migraine sufferers. However, many women have worsening of their migraines during the transition. This... - [Botox for trigeminal neuralgia: additional case reports](https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia-additional-case-reports/): Several of my patients with trigeminal neuralgia (TN) responded to Botox injection (although some have not). My previous post on... - [Capsaicin (hot pepper ingredient) for sinus pain and headaches](https://www.nyheadache.com/blog/capsaicin-hot-pepper-ingredient-for-sinus-pain-and-headaches/): An ENT colleague recently referred to me a patient with very persistent sensation of pressure in her sinuses. She’d had... - [Learn to meditate with Tara Brach](https://www.nyheadache.com/blog/learn-to-meditate-with-tara-brach/): If you are interested in learning to meditate, but don’t know how to get started, go to Dr. Tara Brach’s... - [Elie Wiesel, Holocaust survivor, Nobel Prize winner and chronic migraine sufferer, dies](https://www.nyheadache.com/blog/elie-wiesel-holocaust-survivor-nobel-prize-winner-and-chronic-migraine-sufferer-dies/): It was a great privilege to know Elie Wiesel, survivor of Auschwitz, Nobel Peace Prize winner, author of 40 books,... - [Tremor can affect not only hands, but voice too](https://www.nyheadache.com/blog/tremor-can-affect-not-only-hands-but-voice-too/): Tremor of the hands is usually a benign condition. It is even called, benign essential tremor or, if it runs... - [Post-concussion syndrome responds to intravenous magnesium](https://www.nyheadache.com/blog/post-concussion-syndrome-responds-to-intravenous-magnesium/): A new report presented at the last annual scientific meeting of the American Headache Society in San Diego showed that... - [What position to sleep in?](https://www.nyheadache.com/blog/what-position-to-sleep-in/): Should you sleep on the right or on the left side? Researchers led by Dr. Helene Benveniste of Stony Brook... - [The existence of medication overuse headache is debated](https://www.nyheadache.com/blog/the-existence-of-medication-overuse-headache-is-debated/): Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However,... - [Why millions of chronic migraine sufferers go untreated](https://www.nyheadache.com/blog/why-millions-of-chronic-migraine-sufferers-go-untreated/): Chronic migraine afflicts more than 4 million Americans, but shockingly less than 5% of them receive appropriate care, according to... - [Zecuity, sumatriptan skin patch can cause burns, is pulled off the market](https://www.nyheadache.com/blog/zecuity-sumatriptan-skin-patch-can-cause-burns-is-pulled-off-the-market/): Zecuity, a transdermal sumatriptan patch has been reported to cause skin burns and scarring, according to the FDA. The FDA... - [Triptans may be safe in basilar and hemiplegic migraine](https://www.nyheadache.com/blog/triptans-may-be-safe-in-basilar-and-hemiplegic-migraine/): Hemiplegic and basilar migraine are rare types of migraine. Hemiplegic migraine is accompanied by a paralysis of one side of... - [Pre-Concussion Psychological Symptoms Can Delay Recovery from a Concussion](https://www.nyheadache.com/blog/pre-concussion-psychological-symptoms-can-delay-recovery-from-a-concussion/): Post-concussion symptoms have long been thought to be more severe and prolonged in people who have pre-existing psychological problems. This... - [Magnesium in pregnancy](https://www.nyheadache.com/blog/magnesium-in-pregnancy/): Intravenous magnesium infusions may not be as safe in pregnant women as it has been always thought. The FDA recently... - [The Allergy Solution - a new book you should read](https://www.nyheadache.com/blog/the-allergy-solution-a-new-book-you-should-read/): Dr. Leo Galland, whom I’ve known professionally for many years, has written (with his son) another outstanding book, The Allergy... - [Intranasal ketorolac is as good as intranasal sumatriptan (Imitrex)](https://www.nyheadache.com/blog/intranasal-ketorolac-is-as-good-as-intranasal-sumatriptan-imitrex/): Sumatriptan (Imitrex) and similar drugs (so called triptans) are “designer” drugs that were specifically developed for the treatment of migraine... - [Botox is woefully underused in the treatment of chronic migraines](https://www.nyheadache.com/blog/botox-is-woefully-underused-in-the-treatment-of-chronic-migraines/): The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered... - [Yoga, chiropractic and my neck](https://www.nyheadache.com/blog/yoga-chiropractic-and-my-neck/): Yoga is the most impactful import from India to the US. Yoga has many documented health benefits, including relief of... - [Sodium intake and migraines](https://www.nyheadache.com/blog/sodium-intake-and-migraines/): I have not been aware of any research indicating a link between salt intake and migraines. A study just published... - [Caffeine and miscarriages](https://www.nyheadache.com/blog/caffeine-and-miscarriages/): Caffeine is a well-know trigger of migraine headaches and I regularly write on this topic (my last post on this... - [Ketamine for migraine](https://www.nyheadache.com/blog/ketamine-for-migraine/): Ketamine is a sedating agent used to induce anesthesia. It is also a drug of abuse with street names such... - [Low magnesium and growth factor are found in fibromyalgia](https://www.nyheadache.com/blog/low-magnesium-and-growth-factor-are-found-in-fibromyalgia/): Fibromyalgia is a condition comorbid with migraine, which means that migraine sufferers are more likely to have fibromyalgia and those... - [Nose surgery relieves migraines?](https://www.nyheadache.com/blog/nose-surgery-relieves-migraines/): A patient of mine just emailed me about a recent segment of the TV show, The Doctors, which featured a... - [Medical marijuana relieves migraines, epileptic seizures](https://www.nyheadache.com/blog/medical-marijuana-relieves-migraines-epileptic-seizures/): Marijuana has been tried for a variety of medical conditions, including migraines, and in one of my previous post I... - [More science about meditation](https://www.nyheadache.com/blog/more-science-about-meditation/): There has been some backlash against meditation with newspapers publishing articles claiming that meditation is overrated. Fortunately, serious scientists continue... - [More on dangers of Prilosec and other PPIs](https://www.nyheadache.com/blog/more-on-dangers-of-prilosec-and-other-ppis/): Prilosec (omeprazole), Nexium, Prevacid, and other similar drugs in the family of proton pump inhibitors (PPIs) can cause headaches directly,... - [Electric current treats not only migraines, but also malignant brain tumors.](https://www.nyheadache.com/blog/electric-current-treats-malignant-brain-tumors-what-about-migraines/): Treatment of medical conditions with electricity was first used by the ancient Romans who used electric eels to treat headaches,... - [Pituitary adenoma and headache](https://www.nyheadache.com/blog/pituitary-adenoma-and-headache/): Pituitary gland which is located inside the skull and underneath the brain is responsible for secreting various hormones. Pituitary adenoma... - [Daily long-term use of sumatriptan injections in cluster headaches](https://www.nyheadache.com/blog/daily-long-term-use-of-sumatriptan-injections-in-cluster-headaches/): My most commented on blog post (over 150 comments) is on the daily use of triptans. A new report confirms... - [Another way to administer sumatriptan (Imitrex) was just approved by the FDA](https://www.nyheadache.com/blog/another-way-to-administer-sumatriptan-imitrex-was-just-approved-by-the-fda/): Sumatriptan is now available in a nasal powder form. We already have sumatriptan in a tablet, injection, nasal spray, and... - [Temporal arteritis may be due to shingles virus](https://www.nyheadache.com/blog/temporal-arteritis-may-be-due-to-shingles-virus/): Headache is usually the main presenting symptom of temporal arteritis (also known as giant cell arteritis, or GCA), which is... - [Radiosurgery for trigeminal neuralgia](https://www.nyheadache.com/blog/radiosurgery-for-trigeminal-neuralgia/): Trigeminal neuralgia is an extremely painful condition which causes jolts of very intense electric-like pains in the face. Fortunately, many... - [White matter lesions and stroke](https://www.nyheadache.com/blog/white-matter-lesions-and-stroke/): The little white spots seen on brain MRI scans have long been thought to be benign. A nagging concern has... - [Asthma and chronic migraine](https://www.nyheadache.com/blog/asthma-and-chronic-migraine/): Asthma is more common in migraine sufferers and migraine is more common in those who suffer from asthma (the medical... - [Blood thinner for migraine?](https://www.nyheadache.com/blog/blood-thinner-for-migraine/): A hole between the left and the right side of the heart has been suspected to be the cause of... - [PMS, high blood pressure and magnesium](https://www.nyheadache.com/blog/pms-high-blood-pressure-and-magnesium/): Magnesium deficiency is a regular topic on this blog. Up to half of migraine sufferers are deficient in magnesium, but... - [Meditation is more effective than placebo](https://www.nyheadache.com/blog/meditation-is-more-effective-than-placebo/): Meditation is growing in popularity and deservedly so. Several of my previous posts mentioned the benefit of meditation in migraine... - [Update on Berolina KliniK](https://www.nyheadache.com/blog/update-on-berolina-klinik/): Inpatient migraine headache treatment in the US is usually limited to a five-day course of intravenous DHE and other medications.... - [23andme studies migraine using the power of crowds](https://www.nyheadache.com/blog/23andme-studies-migraine-using-the-power-of-crowds/): 23andMe offers direct-to-consumer genetic testing by analyzing a saliva sample. It provides information on predisposition for more than 90 traits and conditions ranging... - [IV magnesium reduces post-operative pain and opioid use](https://www.nyheadache.com/blog/iv-magnesium-reduces-post-operative-pain-and-opioid-use/): Magnesium infusion given before or during surgery reduces the amount of opioid analgesics (narcotics) needed in the 24 hours following... - [Sphenopalatine galnglion block for migraine and cluster headaches](https://www.nyheadache.com/blog/sphenopalatine-galnglion-block-for-migraine-and-cluster-headaches/): Sphenopalatine ganglion (SPG) block has been used for the treatment of headaches and other pain conditions for over 100 years.... - [About my migraines](https://www.nyheadache.com/blog/about-my-migraines/): Since my early 20s I’ve been getting visual auras without a headache several times a year. I still get them... - [Acupuncture and Alexander technique relieve neck pain](https://www.nyheadache.com/blog/acupuncture-and-alexander-technique-relieve-neck-pain/): Acupuncture and Alexander technique appear to be equally effective and significantly more effective for the treatment of chronic neck pain... - [Shortage of drugs is a growing problem](https://www.nyheadache.com/blog/shortage-of-drugs-is-a-growing-problem/): Richard Wenzel PharmD of the Diamond Headache Clinic in the latest issue of the leading medical journal, Headache writes about... - [Cluster headaches are on an upsurge in the past 2 weeks. Is sun to blame?](https://www.nyheadache.com/blog/many-more-cluster-patients-in-the-past-2-weeks-is-sun-to-blame/): Solar activity is high again – NASA’s Solar Dynamics Observatory reported a flare on October 1. And in the past... - [You can't get magnesium through the skin](https://www.nyheadache.com/blog/you-cant-get-magnesium-through-the-skin/): A report describing delivery of magnesium through the skin for the treatment of fibromyalgia has just appeared in the Journal... - [Zecuity, a transdermal migraine patch is now available](https://www.nyheadache.com/blog/zecuity-a-transdermal-migraine-patch-is-now-available/): Zecuity, a skin patch containing a migraine drug sumatriptan was approved by the FDA almost two years ago, but it... - [Meditation improves quality of life in drug-resistant epilepsy, reduces seizures](https://www.nyheadache.com/blog/meditation-improves-quality-of-life-in-drug-resistant-epilepsy-reduces-seizures/): Epilepsy and migraines share many features and those with epilepsy have a higher risk of developing migraines, while those with... - [Having migraines and fibromyalgia increases the risk of suicide](https://www.nyheadache.com/blog/having-migraines-and-fibromyalgia-increases-the-risk-of-suicide/): About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a... - [Emergency room treatment of migraines](https://www.nyheadache.com/blog/emergency-room-treatment-of-migraines/): Narcotic (opioid) drugs are still widely prescribed by doctors in offices and emergency rooms. They are not only potentially addictive,... - [Can an MRI scan of the brain diagnose migraine?](https://www.nyheadache.com/blog/can-a-brain-mri-diagnose-migraine/): MRI scans of migraine sufferers are almost always normal. Occasionally we see white spots on the MRI, which can be... - [Migraine drug may be highly effective for ovarian cancer by reducing stress effects](https://www.nyheadache.com/blog/migraine-drug-may-be-highly-effective-for-ovarian-cancer-by-reducing-stress-effects/): Propranolol was first introduced as a blood pressure drug 50 years ago and about 40 years ago it was discovered... - [Headaches in pregnancy - when to worry](https://www.nyheadache.com/blog/headaches-in-pregnancy-when-to-worry/): New onset of headaches is always worrisome, but even more so in a pregnant woman. Neurologists at the Montefiore Headache... - [Smoking increases the risk of strokes in those with migraines](https://www.nyheadache.com/blog/smoking-increases-the-risk-of-strokes-in-those-with-migraines/): Migraine with aura is believed to increase the risk of strokes and possibly heart attacks, although the risk estimates vary... - [Testosterone and headaches](https://www.nyheadache.com/blog/testosterone-and-headaches/): Fluctuations in the female hormone estrogen have been proven to be involved in triggering menstrual and perimenopausal migraine headaches. Testosterone... - [The dangers of Ayurvedic medicine](https://www.nyheadache.com/blog/ayurvedic-medicines-dangers/): Ayurvedic medicine has many healthy aspects. However, a recent story on NPR described the risks involved with the traditional Ayurvedic... - [Headaches are common in Ehlers-Danlos syndrome (lax ligaments, loose joints, etc)](https://www.nyheadache.com/blog/headaches-are-common-in-ehlers-danlos-syndrome-lax-ligaments-loose-joints-etc/): Ehlers-Danlos syndrome is a group of inherited disorders that are notable for excessive joint mobility with some people also having... - [Botox works for the elderly with headaches](https://www.nyheadache.com/blog/botox-works-for-the-elderly-with-headaches/): I recently gave Botox injections to my oldest patient – an 96-year-old man who is otherwise in excellent mental and... - [Internet self-diagnosing often gives you the wrong diagnosis](https://www.nyheadache.com/blog/internet-self-diagnosing-often-gives-you-the-wrong-diagnosis/): Looking for health advice is one of the most common reason people search the web. Many websites provide health information... - [More warnings about NSAIDs (but not aspirin)](https://www.nyheadache.com/blog/more-warnings-about-nsaids-but-not-aspirin/): The Food and Drug Administration (FDA) has just released a new strengthened warning about NSAIDs. Prescription and over-the-counter NSAIDs (ibuprofen,... - [If you migraine requires injectable medicines, decline intravenous Benadryl ](https://www.nyheadache.com/blog/if-you-migraine-requires-injectable-medicines-decline-intravenous-benadryl/): Hopefully, your doctor has given you many treatment options, so that you can manage even the most severe attacks at... - [A new class of migraine drugs is on the horizon](https://www.nyheadache.com/blog/a-new-class-of-migraine-drugs-is-on-the-horizon/): For years researchers have tried to find ways to block various chemicals (neurotransmitters) released during a migraine attack, including serotonin,... - [An update on closing PFO (a heart defect) to treat migraines](https://www.nyheadache.com/blog/an-update-on-closing-pfo-a-heart-defect-to-treat-migraines/): An opening between the left and the right side of the heart, called patent foramen ovale (PFO), is found in... - [Treating concussion in children](https://www.nyheadache.com/blog/treating-concussion-in-children/): Several presentations at the annual meeting of the American Headache Society held in Washington DC last weekend discussed the treatment... - [Zomig nasal spray is also approved for adolescents](https://www.nyheadache.com/blog/zomig-nasal-spray-is-also-approved-for-adolescents/): Zolmitriptan is one of seven triptans available in the US and it comes in tablets (Zomig), orally disintegrating tablets, that... - [Another existing drug is approved for pediatric migraine](https://www.nyheadache.com/blog/another-existing-drug-is-approved-for-pediatric-migraine/): A combination pill containing 10 mg of sumatriptan with 60 mg of naproxen sodium was just approved by the FDA... - [Transcranial magnetic stimulation for migraine with medication overuse headache](https://www.nyheadache.com/blog/transcranial-magnetic-stimulation-for-migraine-with-medication-overuse-headache/): Transcranial magnetic stimulation (TMS) was approved by the FDA at the end of 2013 (see my earlier post) but it... - [Neuro-psychological effects of cluster headaches](https://www.nyheadache.com/blog/neuro-psychological-effects-of-cluster-headaches/): We are again in a cluster season. We do not see any cluster headache patients for months and then dozens... - [Anti-histamine diamine oxydase for the prevention of migraines](https://www.nyheadache.com/blog/anti-histamine-diamine-oxydase/): Another supplement to consider for the preventive treatment of migraine headaches is diamine oxidase (DAO). It is an enzyme that... - [Neck weakness and tension-type headaches](https://www.nyheadache.com/blog/neck-weakness-and-tension-type-headaches/): Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just... - [New research on how Botox relieves chronic migraines and how to predict who will respond to Botox](https://www.nyheadache.com/blog/new-research-on-how-botox-relieves-chronic-migraines-and-how-to-predict-who-will-respond-to-botox/): While Botox (OnabotulinumtoxinA) has been shown to be effective in treating chronic migraines, its exact mechanism of action is not... - [Topical cream for migraine](https://www.nyheadache.com/blog/topical-cream-for-migraine/): A topical cream seems to be effective in treating migraine headaches. Achelios Therapeutics announced results from a Phase IIa placebo-controlled... - [Video of Botox injections for chronic migraine with TMJ](https://www.nyheadache.com/blog/video-of-botox-injections-for-chronic-migraine-with-tmj/): The FDA-approved protocol for Botox injections for chronic migraines calls for 31 injections with 155 units of Botox. This is... - [Everyone should check their Vitamin D level](https://www.nyheadache.com/blog/everyone-should-check-their-vitamin-d-level/): Low vitamin D level predicts larger stroke size and poor outcome, according to a new study by University of Massachusetts... - [Yet another side effect of Topamax](https://www.nyheadache.com/blog/yet-another-side-effect-of-topamax/): Topiramate (Topamax) is a drug used for the prevention of migraine headaches (and epilepsy) in adults and last year it... - [Chronic migraine is associated with dry eyes](https://www.nyheadache.com/blog/chronic-migraine-is-associated-with-dry-eyes/): Chronic migraine sufferers appear to be more likely to have dryness of their eyes, according to a study by ophthalmologists... - [A fertility drug relieves cluster headaches](https://www.nyheadache.com/blog/a-fertility-drug-relieves-cluster-headaches/): Cluster headaches cause more severe pain than any other type of headaches. Some patients even call them suicide headaches because... - [A new name for chronic fatigue syndrome](https://www.nyheadache.com/blog/a-new-name-for-chronic-fatigue-syndrome/): Chronic fatigue syndrome sufferers have endured years of neglect and sometimes ridicule. The condition has even been called “yuppie flu”.... - [Opiates (narcotics) increase ER stay in patients with headaches](https://www.nyheadache.com/blog/opiates-narcotics-increase-hospital-stay-in-patients-with-headaches/): Narcotics are not only ineffective for the treatment of headaches, but they can also make headaches worse and transform an... - [More evidence that non-celiac gluten sensitivity is real](https://www.nyheadache.com/blog/more-evidence-that-non-celiac-gluten-sensitivity-is-real/): The existence of gluten sensitivity has been long denied by the mainstream medical establishment. A study described in a previous... - [Migraine headaches in children are poorly treated](https://www.nyheadache.com/blog/migraine-headaches-in-children-are-poorly-treated/): Doctors in St. Louis, MO examined how well headaches are treated in children. There has been little research about how... - [Effective treatment of migraine attacks prevents chronic migraines](https://www.nyheadache.com/blog/effective-treatment-of-migraine-attacks-prevents-chronic-migraines/): Several million Americans suffer from chronic migraines, headaches that occur on at least half of the days and often daily.... - [New dietary guidelines can lead to more headaches](https://www.nyheadache.com/blog/new-dietary-guidelines-can-lead-to-more-headaches/): The new dietary guidelines issued by a government advisory committee have many positive changes from the old guidelines. These include... - [Multivitamins reduce mortality in women, but only if combined with minerals.](https://www.nyheadache.com/blog/multivitamins-reduce-mortality-in-women-but-only-if-combined-with-minerals/): The Journal of Nutrition just published a study that suggests life-extending benefits of taking vitamin and mineral supplements. Multivitamin with... - [More salt leads to more headaches](https://www.nyheadache.com/blog/more-salt-leads-to-more-headaches/): Eating more salt leads to more headaches, according to a study published in BMJ Open last December. In a multicentre... - [Don't take migraine drugs Depakote and Topamax when pregnant](https://www.nyheadache.com/blog/dont-take-migraine-drugs-depakote-and-topamax-when-pregnant/): Epilepsy drugs Depakote and Topamax are two of only four drugs approved by the FDA for the prevention of episodic... - [Be careful where you buy your herbal products!](https://www.nyheadache.com/blog/be-careful-where-you-buy-your-herbal-products/): I recommend several supplements to my headache patients. However, the supplement industry is not regulated by the FDA and a... - [Magnesium and migraines.](https://www.nyheadache.com/blog/magnesium-and-migraines/): An email I just received, which is attached at the end of this post, prompted me to write again about... - [Childhood emotional abuse increases the risk of migraine.](https://www.nyheadache.com/blog/childhood-emotional-abuse-increases-the-risk-of-migraine/): Many medical and pain conditions, including migraines, are more likely to occur in people who were abused in childhood. A... - [Folic acid intake and migraines](https://www.nyheadache.com/blog/folic-acid-intake-and-migraines/): A study by Australian doctors led by Dr. Lyn Griffiths confirmed a previous observation that higher dietary intake of folic... - [Vitamin D levels in blacks and whites](https://www.nyheadache.com/blog/vitamin-d-levels-in-blacks-and-whites/): Vitamin D deficiency has received wide attention and many doctors now check for this deficiency during routine check-ups. I’ve posted... - [Bariatric surgery can improve migraines, but can also cause a new type of headaches.](https://www.nyheadache.com/blog/bariatric-surgery-can-improve-migraines-but-can-also-cause-a-new-type-of-headaches/): While being overweight doese not cause migraines, in those who do suffer with migraines there is an inverse relationship between... - [Cure yourself of vertigo](https://www.nyheadache.com/blog/cure-yourself-of-vertigo/): Vertigo and dizziness are more common in migraine sufferers than in people without migraines. A patient I am treating for... - [Bell's palsy (facial paralysis) is twice as common in migraine sufferers](https://www.nyheadache.com/blog/bells-palsy-facial-paralysis-is-twice-as-common-in-migraine-sufferers/): A report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk... - [A new study of trigeminal neuralgia ](https://www.nyheadache.com/blog/a-new-study-of-trigeminal-neuralgia/): Trigeminal neuralgia is a very painful and debilitating condition (Here is a review article I wrote for physicians). Fortunately, it... - [Treating chronic migraines with Botox is cost-effective ](https://www.nyheadache.com/blog/treating-chronic-migraines-with-botox-is-cost-effective/): Cost is the only major issue with Botox injections, which is the only FDA-approved treatment for chronic migraines and which... - [Cyclic vomiting syndrome can be a migraine variant in adults](https://www.nyheadache.com/blog/cyclic-vomiting-syndrome-can-be-a-migraine-variant-in-adults/): Cyclic vomiting syndrome (CVS) is usually seen in children. The attacks of vomiting often stop as the child gets older,... - [Migraine is not taken seriously by doctors, especially in children](https://www.nyheadache.com/blog/migraine-is-not-taken-seriously-by-doctors-especially-in-children/): Placebo effect is a well-documented phenomenon, which is particularly pronounced when treating migraine headaches. Intravenous (IV) infusion of saline water... - [Meditation relieves migraine headaches](https://www.nyheadache.com/blog/meditation-relieves-migraine-headaches/): Considering that meditation can literally change your brain, it is not at all surprising that it can also prevent migraine... - [Inpatient headache management in Germany](https://www.nyheadache.com/blog/inpatient-headache-management-in-germany/): Germany was just voted world’s favorite country, according to a report in the USA Today. It also may be the... - [More on migraine surgery](https://www.nyheadache.com/blog/more-on-migraine-surgery/): A new report by Drs. Gfrerer, Maman and their colleagues at the Massachusetts General Hospital in Boston entitled Non-Endoscopic Deactivation... - [More on benefits of fish oil](https://www.nyheadache.com/blog/more-benefits-from-fish-oil/): Fish oil, or rather omega-3 fatty acids, seem to reduce the risk of Lou Gehrig disease or ALS (amyotrophic lateral... - [Cluster headaches and solar activity?](https://www.nyheadache.com/blog/cluster-headaches-and-solar-activity/): Cluster headaches usually occur once or twice a year for a period lasting from a few weeks to a few... - [Stem cells for headaches](https://www.nyheadache.com/blog/stem-cells-for-headaches/): The first time I heard of the potential benefit of stem cells for migraine headaches was last year from one... - [Eye drops to treat an acute migraine](https://www.nyheadache.com/blog/eye-drops-to-treat-an-acute-migraine/): Beta blockers (Inderal or propranolol and similar drugs) are used for the preventive treatment of migraine headaches. Over the years,... - [Migraine raises the risk of Parkinson's ](https://www.nyheadache.com/blog/migraine-raises-the-risk-of-parkinsons/): Parkinson’s disease (PD), parkinsonian symptoms, and restless leg syndrome (RLS) are more common in people who in middle age suffered... - [Stabbing headaches as a sign of MS](https://www.nyheadache.com/blog/stabbing-headaches-as-a-sign-of-ms/): Stabbing headaches can be a sign of acute multiple sclerosis, according to a report by German doctors in the journal... - [Peripheral nerve blocks for an acute migraine](https://www.nyheadache.com/blog/peripheral-nerve-blocks-for-an-acute-migraine/): Peripheral nerve blocks can be very effective in stopping a severe migraine attack. We utilize them when a patient does... - [Antidepressants for migraines](https://www.nyheadache.com/blog/antidepressants-for-migraines/): Frequent attacks of migraine are best treated with preventive measures. Several categories of medications have been shown to be effective... - [Online cognitive-behavioral therapy](https://www.nyheadache.com/blog/online-cognitive-behavioral-therapy/): Severe persistent migraines can affect emotional, interpersonal, social, and work-related functioning. It is difficult to learn how to cope with... - [Do not throw away expired medications](https://www.nyheadache.com/blog/do-not-throw-away-expired-medications/): Expiration date on medications does not indicate that the medication is no longer effective or safe after that date. Having... - [Botox relieves new daily persistent headaches.](https://www.nyheadache.com/blog/botox-relieves-new-daily-persistent-headaches/): A report from the Cleveland Clinic and Case Western Reserve describes 22 patients with new daily persistent headaches (NDPH) who... - [A new drug combination for trigeminal neuralgia. ](https://www.nyheadache.com/blog/a-new-drug-combination-for-trigeminal-neuralgia/): A new combination of two old drugs seems to provide relief for some trigeminal neuralgia (TN) sufferers. The first line... - [Post-concussion symptoms could be due to PTSD](https://www.nyheadache.com/blog/post-concussion-symptoms-could-be-due-to-ptsd/): Post-concussion syndrome, which often includes headaches, can persist for many months especially after a minor injury (yes, mild injury is... - [Botox helps post-traumatic headaches.](https://www.nyheadache.com/blog/botox-helps-post-traumatic-headaches/): Botox is FDA-approved only for chronic migraine headaches, however, it is being used “off-label” for other types of headaches as... - [Sumatriptan appears safe in pregnancy](https://www.nyheadache.com/blog/sumatriptan-appears-safe-in-pregnancy/): Acetaminophen is what most obstetricians recommend pregnant women take for their headaches. However, it is not very effective for migraine... - [Fasting, stem cells, migraine headaches](https://www.nyheadache.com/blog/fasting-stem-cells-migraine-headaches/): Skipping meals, for some people, is a sure way to get a migraine headache. Even those who do not suffer... - [Predicting response to Botox in chronic migraine.](https://www.nyheadache.com/blog/predicting-response-to-botox-in-chronic-migraine/): Botox is a very effective treatment for chronic migraines and possibly other types of headaches and pain. However, Botox is... - [Bullying in school causes headaches.](https://www.nyheadache.com/blog/bullying-in-school-causes-headaches/): Besides many other mental and physical problems, bullying in school causes headaches. This is the conclusion of a group of... - [Another delay for a long awaited drug](https://www.nyheadache.com/blog/another-delay-for-a-long-awaited-drug/): The introduction of Levadex has been delayed again, this time for a year. It seems like deja vu all over... - [Migraine aura can start in pregnancy](https://www.nyheadache.com/blog/migraine-aura-can-start-in-pregnancy/): Migraine aura precedes the headache in about 20% of patients. The most common type of aura is visual. It consists... - ["Visual snow" and migraine](https://www.nyheadache.com/blog/visual-snow-and-migraine/): “Visual snow” is a continuous TV-static-like visual disturbance experienced by some people who suffer from migraines and by some without... - [More about white spots on brain MRIs](https://www.nyheadache.com/blog/more-about-white-spots-on-brain-mris/): The benign nature of white matter lesions (WML) on MRI scans of patients with migraine was noted in a post... - [Headaches due to increased pressure in the head ](https://www.nyheadache.com/blog/headaches-due-to-increased-pressure-in-the-head/): Idiopathic intracranial hypertension is also called pseudotumor cerebri because just like with a brain tumor, the pressure is increased inside... - [Wikipedia has wrong information](https://www.nyheadache.com/blog/wikipedia-has-wrong-information/): Don’t use Wikipedia for medical information and tell your doctor not to either. It is the most popular reference site... - [LSD, 'shrooms, psilocybin for cluster headaches](https://www.nyheadache.com/blog/lsd-shrooms-psilocybin-for-cluster-headaches/): Cluster headache patients have been coming to our office in increasing numbers in the past few weeks. We seem to... - [New migraine drugs in the pipeline](https://www.nyheadache.com/blog/new-migraine-drugs-in-the-pipeline/): Two new migraine drugs are about to be released on the market. They were mentioned in this blog in their... - [Botulinum toxin may help even the heart ](https://www.nyheadache.com/blog/botulinum-toxin-may-help-even-the-heart/): The versatility of botulinum toxin continues to amaze. The use of botulinum toxin (Botox) for the treatment of migraine headaches... - [Narcotics (opioids) are still overused in ERs for migraines](https://www.nyheadache.com/blog/narcotics-opioids-are-still-overused-in-ers-for-migraines/): Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches.... - [Antibodies bode well for migraines](https://www.nyheadache.com/blog/antibodies-bode-well-for-migraines/): Antibodies blocking a specific neurotransmitter involved in migraines appear to relieve migraine headaches. Two studies presented at the annual meeting... - [FDA warning on epidural steroid injections.](https://www.nyheadache.com/blog/fda-warning-on-epidural-steroid-injections/): Epidural steroid injections are popular for persistent neck and back pains. Patients with migraine and other headaches often have neck... - [It is not stress, but relaxation after is what triggers a migraine](https://www.nyheadache.com/blog/it-is-not-stress-but-relaxation-after-is-what-triggers-a-migraine/): Stress is considered to be one of the main migraine triggers. However, a study just published in the journal Neurology... - [Nasal sprays for migraines are underprescribed.](https://www.nyheadache.com/blog/nasal-sprays-for-migraines-are-underprescribed/): An oral tablet is the most convenient way to take medicine. However, many migraine sufferers wake up with a headache... - [Lack of sleep may not only cause headaches, but also shrink your brain.](https://www.nyheadache.com/blog/lack-of-sleep-may-not-only-cause-headaches-but-also-shrink-your-brain/): Sleep deprivation is a very common trigger of migraine and tension-type headaches. Scientists have always wondered about the purpose of... - [Vitamin D is again in the news. Enough already.](https://www.nyheadache.com/blog/vitamin-d-is-again-in-the-news-enough-already/): There is no debate about the fact that there is an epidemic of vitamin D deficiency in the United States... - [Predicting response to Botox injections](https://www.nyheadache.com/blog/predicting-response-to-botox-injections/): A good predictor of response to Botox injections in chronic migraine patients has been found by Spanish researchers. While Botox... - [Topiramate (Topamax) is approved by the FDA for adolescents.](https://www.nyheadache.com/blog/topiramate-topamax-is-approved-by-the-fda-for-adolescents/): Yesterday, the FDA approved the first preventive (prophylactic) treatment for migraines in adolescents – kids between the ages of 12... - [More evidence that Botox relieves not only migraine headaches, but also depression.](https://www.nyheadache.com/blog/more-evidence-that-botox-relieves-not-only-migraine-headaches-but-also-depression/): The beneficial effect of Botox on mood has been reported for years. I mentioned this in one of my blog... - [What to ask for if your migraine lands you in the emergency room.](https://www.nyheadache.com/blog/what-to-ask-for-if-your-migraine-lands-you-in-the-emergency-room/): A severe migraine attack can sometimes land you in an emergency room. With its bright lights, noise, and long waits,... - [Cefaly is approved by the FDA for sale in the US.](https://www.nyheadache.com/blog/cefaly-if-approved-by-the-fda-for-sale-in-the-us/): Cefaly, a TENS unit specifically developed for the treatment of migraine headaches, was cleared for sale in the US. It... - [The role of hormones in headache](https://www.nyheadache.com/blog/the-role-of-hormones-in-headache/): Imbalance of many hormones produced by our endocrine system can lead to headaches. Here is a brief summary of the... - [Invasive treatments for trigeminal neuralgia](https://www.nyheadache.com/blog/invasive-treatments-for-trigeminal-neuralgia-2/): Trigeminal neuralgia (TN) is an excruciatingly painful disorder which affects about one in a thousand people. Patients describe the pain... - [Acetaminophen (Tylenol) in pregnancy is not as safe as thought.](https://www.nyheadache.com/blog/acetaminophen-tylenol-in-pregnancy-is-not-as-safe-as-thought/): Tylenol (acetaminophen, or in Europe it is called paracetamol) is the go-to drug for pain, headaches, and fever during pregnancy.... - [Topiramate caused osteoporosis in my patient.](https://www.nyheadache.com/blog/topiramate-caused-osteoporosis-in-my-patient/): One of my patients I saw last week developed osteoporosis while taking Topamax (topiramate). Topiramate is known to cause osteoporosis... - [Vitamin D and migraine headaches.](https://www.nyheadache.com/blog/vitamin-d-and-migraine-headaches/): Vitamin D has been reported to be low in patients with migraines as well as a host of other medical... - [Beware of some generic drugs. ](https://www.nyheadache.com/blog/beware-of-some-generic-drugs/): Generic drugs provide significant savings and 80% of all prescriptions in the US are filled with generic drugs. Many doctors... - [Magnesium improves response to Tylenol and Advil in kids with migraines.](https://www.nyheadache.com/blog/magnesium-improves-response-to-tylenol-and-advil-in-kids-with-migraines/): Children with migraine headaches are usually given acetaminophen (Tylenol) or ibuprofen (Advil). A group of Italian doctors compared responses to... - [White matter lesions on MRIs of children with migraine.](https://www.nyheadache.com/blog/white-matter-lesions-on-mris-of-children-with-migraine/): White matter lesions that often seen on MRI scans of adult migraine sufferers were also found in children. A study... - [More on daily intake of triptans (sumatriptan or Imitrex and other similar drugs)](https://www.nyheadache.com/blog/more-on-daily-intake-of-triptans-sumatriptan-or-imitrex-and-other-similar-drugs/): “Daily triptan use for intractable migraine” is the title of a report by Dr. Egilius Spierings published in the latest... - [Prilosec, Nexium and other heartburn drugs cause vitamin B12 deficiency.](https://www.nyheadache.com/blog/prilosec-nexium-and-other-heartburn-drugs-cause-vitamin-b12-deficiency/): Many headache sufferers take over-the-counter medications which can cause upset stomach and heartburn due to reflux. Many will then resort... - [Placebo is underrated. ](https://www.nyheadache.com/blog/placebo-is-underrated/): Placebo effect is a curse for medical researchers. Every new treatment has to be shown to be better than placebo... - [Rest your brain after a head injury.](https://www.nyheadache.com/blog/rest-your-brain-after-a-head-injury/): Strenuous mental activity seems to delay recovery after a head injury, according to a new study published in Pediatrics .... - [What if you do have a brain aneurysm?](https://www.nyheadache.com/blog/what-if-you-do-have-a-brain-aneurysm/): Many people who experience severe headaches are often concerned about having a brain aneurysm. What prompted this post is a... - [Ordering drugs from online pharmacies.](https://www.nyheadache.com/blog/ordering-drugs-from-online-pharmacies/): Branded triptan medications are extremely expensive with one pill of Relpax or Frova costing $30 – $40. Fortunately, Imitrex, Maxalt,... - [Cognitive Behavioral Therapy Relieves Chronic Migraine in Children and Adolescents](https://www.nyheadache.com/blog/cognitive-behavioral-therapy-relieves-chronic-migraine-in-children-and-adolescents/): Another large scientific article on the benefits of cognitive behavioral therapy (CBT) was just published in the Journal of the... - [Mindfulness may reduce pain not only in adults but also in adolescents.](https://www.nyheadache.com/blog/mindfulness-may-reduce-pain-not-only-in-adults-but-also-in-adolescents/): Mindfulness appears to reduce the effect of pain on day-to-day functioning in adolescents, according to a new study published in... - [Chewing gum may cause headaches.](https://www.nyheadache.com/blog/chewing-gum-may-cause-headaches/): Research by Israeli pediatric neurologists confirms the clinical observation that chewing gum can make headaches worse. By chewing gum teenagers... - [A new device is approved to treat migraine with aura.](https://www.nyheadache.com/blog/a-new-device-is-approved-to-treat-migraine-with-aura/): Transcranial magnetic stimulation (stimulation of the brain with a magnetic field) has been researched for over 30 years. It has... - [Video of Botox injections for chronic migraine.](https://www.nyheadache.com/blog/video-of-botox-injections-for-chronic-migraine/): Botox is the most effective preventive treatment for chronic migraine headaches. It is also the only treatment approved by the... - [FDA approves lower dose Sumavel (sumatriptan) needless injection.](https://www.nyheadache.com/blog/fda-approves-lower-dose-sumavel-sumatriptan-needless-injection/): The approval of the lower dose Sumavel device is a good opportunity to again remind migraine sufferers about the benefits... - [Exercise is as good as drugs.](https://www.nyheadache.com/blog/exercise-is-as-good-as-drugs/): The risk of dying from a variety of causes can be reduced by exercise, according to a new study published... - [Cold hands and nose in migraine sufferers](https://www.nyheadache.com/blog/cold-hands-and-nose-in-migraine-sufferers/): Many migraine sufferers appear to have cold hands and nose, according to a new study by Finnish researchers described in... - [Features of 1,000 episodes of migraine aura over 18 years in one patient.](https://www.nyheadache.com/blog/features-of-1000-epidodes-of-migraine-aura-over-18-years-in-one-patient/): Dr. Andrew Charles and his associates at UCLA just published a fascinating report on migraine aura in the journal Brain.... - [Vitamin D - new benefits discovered](https://www.nyheadache.com/blog/vitamin-d-new-benefits-discovered/): Vitamin D seems to prevent relapses of multiple sclerosis, according to a large study by Dr. Ascherio and his colleagues... - [Sugary drinks not only cause headaches but can give women cancer](https://www.nyheadache.com/blog/sugary-drinks-not-only-cause-headaches-but-can-give-women-cancer/): Three out of four migraine sufferers may have reactive hypoglycemia, which may be contributing to their headaches. Reactive hypoglycemia is... - [Migraines and pain in patients with multiple sclerosis](https://www.nyheadache.com/blog/migraines-and-pain-in-patients-with-multiple-sclerosis/): Thirty-two percent of patients with multiple sclerosis experience both migraine and pain with neuropathic (related to nerve damage) characteristics, according... - [Headache experts: five things to avoid](https://www.nyheadache.com/blog/headache-experts-five-things-to-avoid/): Many medical specialty groups of doctors have been coming out with “Choosing Wisely” campaign where they recommend avoiding five things... - [Fibromyalgia may be caused by nerve damage](https://www.nyheadache.com/blog/fibromyalgia-may-be-caused-by-nerve-damage/): More patients with fibromyalgia suffer from migraine headaches than those without this fibromyalgia. Those with fibromyalgia are also more likely... - [BPA (the toxin in plastics) and migraine.](https://www.nyheadache.com/blog/bpa-the-toxin-in-plastics-and-migraine/): Migraine headaches can be triggered by exposure to a variety of chemicals, including fumes, MSG, artificial sweeteners and many other.... - [More about the white spots seen on MRI scans](https://www.nyheadache.com/blog/more-about-the-white-spots-seen-on-mri-scans/): White matter lesions (WML) are more common in people who suffer from migraine headaches with or without aura and my... - [A new way to adminster Botox for cluster and migraine headaches](https://www.nyheadache.com/blog/a-new-way-to-adminster-botox-for-cluster-and-migraine-headaches/): Botox injections are currently approved for the treatment of chronic migraines but not cluster headaches. However, my experience at the... - [Caffeine worsens headaches in adolescents.](https://www.nyheadache.com/blog/caffeine-worsens-headaches-in-adolescents/): The previous post mentioned a study confirming that caffeine makes headaches worse in adults 20 years or older. A study... - [Nutritional factors in migraine and other headaches.](https://www.nyheadache.com/blog/nutritional-factors-in-migraine-and-other-headaches/): A study of 13,573 people by a Harvard physician Catherine Beuttner examined the role of nutrition in patients with migraines... - [Chronic migraine relieved by increasing omega-3 and reducing omega-6 fatty acids](https://www.nyheadache.com/blog/chronic-migraine-relieved-by-increasing-omega-3-and-reducing-omega-6-fatty-acids/): Omega-3 and omega-6 fatty acids are needed for our body to produce pain-relieving and pain-enhancing substances. Researchers at the University... - [Migraine-related vertigo in perimenopause.](https://www.nyheadache.com/blog/migraine-related-vertigo-in-perimenopause/): Vertigo presenting during the peri-menopause can be related to migraine, according to a report by Nashville neurologists led by Dr.... - [Dihydroergotamine (DHE-45, Levadex) constricts blood vessels less than sumatriptan (Imitrex)](https://www.nyheadache.com/blog/dihydroergotamine-dhe-45-levadex-constricts-blood-vessels-less-than-sumatriptan-imitrex/): Dihydroergotamine (DHE-45) is considered to be the most effective injectable migraine drug. In addition to injections, it is been available... - [Syncope (fainting) and migraine ](https://www.nyheadache.com/blog/syncope-fainting-and-migraine/): Fainting spells (syncope) are more common in people who suffer from migraine headaches. Compared with control subjects, migraineurs have a... - [Topiramate (Topamax) may cause inability to sweat and hyperthermia](https://www.nyheadache.com/blog/topiramate-topamax-may-cause-inability-to-sweat-and-hyperthermia/): Topamax (topiramate) has been reported to cause inability to sweat which can lead to hyperthermia or overheating. At first, this... - [Cost of Botox injections for migraine headaches](https://www.nyheadache.com/blog/cost-of-botox-injections-for-migraine-headaches/): Botox injections is the only FDA-approved treatment for chronic migraine headaches. This is a very effective (works in 70% of... - [An educated consumer gets the best results.](https://www.nyheadache.com/blog/an-educated-consumer-gets-the-best-results/): Cleveland Clinic doctors established that migraine patients who are educated about sumatriptan (Imitrex) and other triptans tend to do better.... - [Income and migraines.](https://www.nyheadache.com/blog/income-and-migraines/): Migraine affects people in all socio-economic categories, however it is more likely to occur in poor, according to a report... - [MRI spots (white matter lesions) in patients with migraines.](https://www.nyheadache.com/blog/mri-spots-white-matter-lesions-in-patients-with-migraines/): Performing an MRI scan is unnecessary in the vast majority of migraine sufferers. However, many migraineurs end up having this... - [Antibiotics for back (and neck?) pain.](https://www.nyheadache.com/blog/antibiotics-for-back-and-neck-pain/): It is hard to believe the report of a group of Danish doctors who found 28 out of 61 (46%)... - [Migraine with aura increases the size of a stroke.](https://www.nyheadache.com/blog/migraine-with-aura-increases-the-size-of-a-stroke/): Migraine aura seems to indicate a different underlying brain condition than that of migraine without aura. We know that the... - [Depakote (sodium valproate) shrinks the brain in epilepsy patients.](https://www.nyheadache.com/blog/depakote-sodium-valproate-shrinks-the-brain-in-epilepsy-patients/): At the New York Headache Center we always try to avoid using medications and use alternative (i. e. non-drug) therapies... - [Alternating electric current does not help headaches.](https://www.nyheadache.com/blog/alternating-electric-current-does-not-help-headaches/): A variety of electrical devices have been tried for the treatment of headaches and have been mentioned in several of... - [Fish oil helps cope with stress, possibly headaches.](https://www.nyheadache.com/blog/fish-oil-helps-cope-with-stress-possibly-headaches/): Fish oil supplements may protect the heart in stressful situations, according to a study conducted in Michigan with 67 healthy... - [Trigeminal nerve in trigeminal neuralgia, trigeminal neuropathy and TMJ disorders.](https://www.nyheadache.com/blog/trigeminal-nerve-in-trigeminal-neuralgia-trigeminal-neuropathy-and-tmj-disorders/): Advances in MRI imaging have allowed visualizing the trigeminal nerve and a group of Australian researchers reported on their findings... - [An update on butterbur (Petadolex) - we still don't recommend it](https://www.nyheadache.com/blog/an-update-on-butterbur-petadolex-we-still-dont-recommend-it/): The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their... - [Mental illness, migraine, and doctors' attitudes.](https://www.nyheadache.com/blog/mental-illness-migraine-and-doctors-attitudes/): Bipolar disorder and other psychiatric problems are 2-3 times more common in those who suffer from migraine headaches and migraines... - [Botox relieves hemiplegic migraine.](https://www.nyheadache.com/blog/botox-relieves-hemiplegic-migraine/): Surprisingly, Botox appears to relieve hemiplegic migraines, according to a report by two neurologists from the Mayo Clinic. They describe... - [Auditory hallucinations in migraine.](https://www.nyheadache.com/blog/auditory-hallucinations-in-migraine/): Auditory hallucinations can be associated with chronic headaches, according to a report by our own Dr. Sara Crystal and three... - [Blood vessels may be responsible for migraines after all](https://www.nyheadache.com/blog/blood-vessels-may-be-responsible-for-migraines-after-all/): The vascular theory of migraine suggested that changes in the blood vessel size and blood flow were responsible for the... - [Spinal tap may detect increased pressure in the head as a cause of headaches.](https://www.nyheadache.com/blog/spinal-tap-may-detect-increased-pressure-in-the-head-as-a-cause-of-headaches/): Increased intracranial pressure is an under-diagnosed cause of difficult to treat headaches. Persistent chronic headaches that do not respond to... - [Acute care of chronic and episodic migraines is suboptimal.](https://www.nyheadache.com/blog/acute-care-of-chronic-and-episodic-migraines-is-suboptimal/): Acute treatment of episodic and chronic migraine headaches in the US leaves a lot to be desired. Results of the... - [Electrical stimulator for cluster headaches.](https://www.nyheadache.com/blog/electrical-stimulator-for-cluster-headaches/): Stimulation of the sphenopalatine ganglion seems to relieve cluster headaches according to a study by European neurologists. The study examined... - [Blood pressure drugs for the prevention of migraine.](https://www.nyheadache.com/blog/blood-pressure-drugs-for-the-prevention-of-migraine/): Candesartan (Atacand) is a relatively new blood pressure medication in the family of ACE receptor blockers (ARBs), which is also... - [In kids,cognitive therapy with medicine is better than medicine alone and is possibly better than Botox and other drugs](https://www.nyheadache.com/blog/in-kidscognitive-therapy-with-medicine-is-better-than-medicine-alone-and-is-possibly-better-than-botox-and-other-drugs/): Half of the kids seen by pediatric headache specialists suffer from chronic migraines. Dr. Hershey and his colleagues at the... - [Surprisingly, naproxen may be better than naproxen with sumatriptan](https://www.nyheadache.com/blog/surprisingly-naproxen-may-be-better-than-naproxen-with-sumatriptan/): A non-steroidal anti-inflammatory (NSAID) drug naproxen (Aleve) alone seems to be more effective than naproxen combined with sumatriptan (Treximet), according... - [Sea Bands work for nausea of migraine](https://www.nyheadache.com/blog/sea-bands-work-for-nausea-of-migraine/): Nausea of migraines responds to an acupressure device, according to two German doctors who presented their findings last week at... - [Oxygen for cluster headaches through a demand valve](https://www.nyheadache.com/blog/oxygen-for-cluster-headaches-through-a-demand-valve/): Oxygen inhalation is a proven method of treating cluster headaches. The patient usually rents a large oxygen tank and breathes... - [Infantile colic and pediatric migraine](https://www.nyheadache.com/blog/infantile-colic-and-pediatric-migraine/): Infantile colic seems to be a precursor or an early manifestation of migraine headaches in children. A new European study... - [Frequent migraines are not different from chronic migraines](https://www.nyheadache.com/blog/frequent-migraines-are-no-different-from-chronic-migraines/): Botox is approved by the FDA for the prophylactic treatment of chronic migraine headaches. Chronic migraine was arbitrarily defined by... - [Calcium promotes chronic pain](https://www.nyheadache.com/blog/calcium-promotes-chronic-pain/): Calcium inside the nerve cells (neurons) seems to be crucial in making pain chronic, according to a publication in the... - [Chronic headaches and sexual pain](https://www.nyheadache.com/blog/chronic-headaches-and-sexual-pain/): Female pelvic/genital pain is more common in women with chronic Headache, according to a study presented by Canadian neurologists. The... - [Leeches are definitely revolting, but can they help migraines?](https://www.nyheadache.com/blog/leeches-are-definitely-revolting-but-can-they-help-migraines/): Leeches are not pleasant to look at, but they have been used for medicinal purposes for hundreds of years. Growing... - [Getting medicine straight from the nose to the brain](https://www.nyheadache.com/blog/getting-medicine-straight-from-the-nose-to-the-brain/): Many migraine sufferers suffer from nausea and vomiting and cannot swallow pills or even if they can swallow them, it... - [TENS unit Cefaly is no longer available in the US](https://www.nyheadache.com/blog/tens-unit-cefaly-is-no-longer-available-in-the-us/): In my previous post I mentioned a TENS unit spcifically designed for the treatment of migraine headaches. It was available... - [Intravenous medications for trigeminal neuralgia](https://www.nyheadache.com/blog/intravenous-medications-for-trigeminal-neuralgia/): Trigeminal neuralgia is an extremely painful condition that causes electric-like pain in the face. It is often misdiagnosed as a... - [Another triptan is going generic](https://www.nyheadache.com/blog/another-triptan-is-going-generic/): Zomig (zolmitriptan) is the fourth triptan (out of seven) to become available in a generic form. This spells big relief... - [Triptans are the first line migraine drugs in pregnant women](https://www.nyheadache.com/blog/triptans-are-the-first-line-migraine-drugs-in-pregnant-women/): Pregnant women are admonished not to take any medications while pregnant. Fortunately, two out of three women stop having migraines... - [Botox helps post-traumatic headaches in soldiers](https://www.nyheadache.com/blog/botox-helps-post-traumatic-headaches-in-soldiers/): Botox appears to be effective for the treatment of chronic post-traumatic headaches in service Members with a history of mild... - [Not all narcotics are equally addictive](https://www.nyheadache.com/blog/not-all-narcotics-are-equally-addictive/): Abuse of prescription narcotic (opioid) drugs is growing at an alarming rate and they are responsible for tens of thousands... - [Fear delays recovery in whiplash injuries](https://www.nyheadache.com/blog/fear-delays-recovery-in-whiplash-injuries/): Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders, according to a new study... - [Prophylactic migraine drugs are all equally mediocre](https://www.nyheadache.com/blog/prophylactic-migraine-drugs-are-all-equally-mediocre/): Preventive drugs for migraine headaches help less than half of the patients they are given to. There is no significant... - [Anxiety and depression are associated with various pains and migraines ](https://www.nyheadache.com/blog/anxiety-and-depression-are-associated-with-various-pains-and-migraines/): It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The... - [Botox relieves myofascial (muscle) pain](https://www.nyheadache.com/blog/botox-relieves-myofascial-muscle-pain/): Botox seems to help neck and upper back muscle pains, according to a recent study by UCLA doctors. We know... - [A new procedure for pseudotumor cerebri](https://www.nyheadache.com/blog/a-new-procedure-for-pseudotumor-cerebri/): A new treatment for pseudotumour cerebri was reported by a team of interventional neuroradiologists and neurosurgeons. Pseudotumour cerebri is a... - [Levadex is delayed again](https://www.nyheadache.com/blog/levadex-is-delayed-again/): Approval of the inhaled dihydroergotamine or DHE to be sold under the name of Levadex has been delayed again by... - [Elimination diet based on antibodies in the blood helps migraines ](https://www.nyheadache.com/blog/elimination-diet-based-on-antibodies-in-the-blood-helps-migraines/): Food sensitivities have been always suspected to be a trigger for migraine headaches. A group of Turkish neurologists published a... - [Pleasant pain???](https://www.nyheadache.com/blog/pleasant-pain/): The importance of context: When relative relief renders pain pleasant, is the title of an article recently published in the... - [More about catastrophizing](https://www.nyheadache.com/blog/more-about-catastrophizing/): It is not surprising that persistent pain can cause depression, but a study just published in The Journal of Pain... - [Melatonin prevents migraine headaches](https://www.nyheadache.com/blog/melatonin-prevents-migraine-headaches/): Melatonin does seem to help prevent migraine headaches according to a new study by Brazilian researchers just presented at the... - [Vagus nerve stimulator seems to work for acute migraines](https://www.nyheadache.com/blog/vagus-nerve-stimulator-seems-to-work-for-acute-migraines/): Vagus nerve stimulation (VNS) seems to be effective for the treatment of migraine headaches. In my post over a year... - [Generic rizatriptan (Maxalt) and sumatriptan (Imitrex)](https://www.nyheadache.com/blog/generic-rizatriptan-maxalt-and-sumatriptan-imitrex/): The release of a generic substitute of the branded drug Imitrex (sumatriptan) has dramatically reduced the cost and improved the... - [Changing the meaning of pain from negative to positive reduces pain](https://www.nyheadache.com/blog/changing-the-meaning-of-pain-from-negative-to-positive-reduces-pain/): Pain is defined as a negative emotional experience that is affected by a variety of psychological factors. Some of the... - [Migraine and tension-type headache sufferers are more likely to have low back pain](https://www.nyheadache.com/blog/migraine-and-tension-type-headache-sufferers-are-more-likely-to-have-low-back-pain/): German researchers examined the possible connection between headaches and low back pain in a study published in the recent issue... - [Expect relief and you will get it](https://www.nyheadache.com/blog/expect-relief-and-you-will-get-it/): Expectation of relief can enhance pain relief, according to a new study published in The Journal of Pain by Canadian... - [Sex can relieve migraine and cluster headaches](https://www.nyheadache.com/blog/sex-can-relieve-migraine-and-cluster-headaches/): Many people report that sex relieve their migraine and tension-type headaches. We also know that sexual activity can trigger severe... - [Optimists have lower pain sensitivity](https://www.nyheadache.com/blog/optimists-have-lower-pain-sensitivity/): Optimists appear to tolerate pain better than pessimists, an old discovery that is supported by a new study published in... - [Migraine drug, Cambia (dicolfenac) can cause heart attacks](https://www.nyheadache.com/blog/migraine-drug-cambia-dicolfenac-can-cause-heart-attacks/): Cambia (diclofenac) is a prescription anti-inflammatory drug (NSAID) which is approved by the FDA for the treatment of migraine headaches.... - [Stopping high doses of triptans suddenly can cause depression](https://www.nyheadache.com/blog/stopping-high-doses-of-triptans-suddenly-can-cause-depression/): Daily and prolonged intake of high doses of triptan medications (sumatriptan, or Imitrex, rizatriptan, or Maxalt, eletriptan, or Relpax and... - [Predicting response to Botox (or rather, a similar product, Myobloc)](https://www.nyheadache.com/blog/predicting-response-to-botox-or-rather-a-similar-product-myobloc/): A recently published study by neurologists at the Military Medical Center in San Antonio led by Dr. Grogan tried to... - [Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world](https://www.nyheadache.com/blog/tension-and-migraine-headaches-are-the-2nd-and-3rd-most-common-medical-problem-in-the-world/): Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world after dental caries (cavities),... - [A potential treatment for prolonged auras](https://www.nyheadache.com/blog/a-potential-treatment-for-prolonged-auras/): A typical visual aura which precedes the headache in about 20% of migraine sufferers usually lasts 20 to 60 minutes.... - [TENS vs tDCS](https://www.nyheadache.com/blog/tens-vs-tdcs/): I failed to mention in my two previous posts that there is a difference in the type of electrical current... - [More on electrical stimulation](https://www.nyheadache.com/blog/more-on-electrical-stimulation/): An article in today’s New York Times reported on the efficacy of electrical brain stimulation for the treatment of depression.... - [Transcutaneous electrical nerve stimulation (TENS) for headaches](https://www.nyheadache.com/blog/transcutaneous-electrical-nerve-stimulation-tens-for-headaches/): Electrical stimulation of the nervous system is widely used for a variety of conditions and in a variety of ways.... - [Migraine is a risk factor for sudden hearing loss](https://www.nyheadache.com/blog/migraine-is-a-risk-factor-for-sudden-hearing-loss/): Sudden hearing loss is a rare condition, but it is more common in people who suffer from migraine headaches, according... - [Do flickering lights and exercise really trigger migraines?](https://www.nyheadache.com/blog/do-flickering-lights-and-exercise-really-trigger-migraines/): Many migraine sufferers report that flickering lights and vigorous exercise trigger their migraine attacks. Danish researchers published a study in... - [Botox converts chronic migraines into episodic in 70% of patients](https://www.nyheadache.com/blog/botox-converts-chronic-migraines-into-episodic-in-70-of-patients/): Botox (anabotulinumtoxinA) is the only treatment approved by the FDA for the treatment of chronic migraine headaches. The FDA based... - [If you had migraine surgery - what was your experience?](https://www.nyheadache.com/blog/if-you-had-migraine-surgery-what-was-your-experience/): Migraine surgery continues to be promoted by an ever increasing number of plastic surgeons. In my previous post in 2007... - [Botox relieves SUNCT - a rare headache syndrome](https://www.nyheadache.com/blog/botox-relieves-sunct-a-rare-headache-syndrome/): Botox relieved severe pain of SUNCT, a rare and very painful condition, according to a report recently published in journal... - [Zecuity - transdermal sumatriptan](https://www.nyheadache.com/blog/zecuity-transdermal-sumatriptan/): Zecuity was just approved by the FDA for the treatment of acute migraines. Zecuity is a skin patch containing sumatriptan.... - [New oral contraceptives increase the risk of strokes and other types of blood clots in patients with migrianes with aura](https://www.nyheadache.com/blog/new-oral-contraceptives-increase-the-risk-of-strokes-and-other-types-of-blood-clots-in-patients-with-migrianes-with-aura/): Newer oral contraceptives increase the risk of strokes and other types of blood clots in patients with migraines with aura,... - [Risk factors for migraine aura](https://www.nyheadache.com/blog/risk-factors-for-migraine-aura/): Some features of migraine with aura clearly set it apart from migraines without aura. Aura is present in 15% to... - [Magnetic brain stimulation may relieve migraines with aura](https://www.nyheadache.com/blog/magnetic-brain-stimulation-may-relieve-migraines-with-aura/): Transcranial magnetic stimulation (TMS) seems to be effective for the treatment of migraines with aura. “Spring TMS” device which delivers... - [Frovatriptan (Frova) helps menstrual migraines](https://www.nyheadache.com/blog/frovatriptan-frova-helps-menstrual-migraines/): Migraine headaches that occur at around the time of menstrual period tend to be more severe and more difficult to... - [Aspirin is best to prevent migraine with aura](https://www.nyheadache.com/blog/aspirin-is-best-to-prevent-migriane-with-aura/): Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from... - [ Taking medication to stop an attack prevents migraines from becoming chronic](https://www.nyheadache.com/blog/taking-medication-to-stop-an-attack-prevents-migraines-from-becoming-chronic/): The use of acute anti-migraine medications in patients with episodic migraine (migraine occurring on less than 14 days a month)... - [New treatment offers hope to sufferers with chronic cluster headaches](https://www.nyheadache.com/blog/new-treatment-offers-hope-to-sufferers-with-chronic-cluster-headaches/): A new treatment developed by Belgian neurologists was reported to help patients with chronic refractory cluster headaches. The name cluster... - [Exercise-related headaches among cyclists](https://www.nyheadache.com/blog/exercise-related-headaches-among-cyclists/): Exercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is... - [Erythromelalgia and migraine](https://www.nyheadache.com/blog/erythromelalgia-and-migraine/): Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw... - [Vaginal ring and migraines](https://www.nyheadache.com/blog/vaginal-ring-and-migraines/): Many women are denied therapy with combined (estrogen with progesterone) hormonal contraceptives because published guidelines by doctor organizations recommend against... - [More on celiac, bowels, and headaches](https://www.nyheadache.com/blog/more-on-celiac-bowels-and-headaches/): Celiac disease and gluten sensitivity is known to cause or at least increase the frequency of migraine headaches. The recently... - [ Migraine impairs school performance](https://www.nyheadache.com/blog/migraine-impairs-school-performance/): Children suffering from migraine headaches are more likely to have difficulty performing well in school, according to a new report... - [Blood pressure drugs for the prevention of migraines](https://www.nyheadache.com/blog/blood-pressure-drugs-for-the-prevention-of-migraines/): I see many patients who tell me that “I’ve tried every migraine drug” and seek me out to explore non-drug... - [Why does pituitary adenoma cause headaches?](https://www.nyheadache.com/blog/why-does-pituitary-adenoma-cause-headaches/): Pituitary adenoma is a benign tumor of an endocrine gland that is situated underneath the brain. Pituitary gland is connected... - [Occipital nerve stimulation is ineffective](https://www.nyheadache.com/blog/occipital-nerve-stimulation-is-ineffective/): Occipital nerve stimulation (ONS) has been reported to relieve refractory (difficult to treat) migraine headaches. Results of a clinical trial... - [Steroid injections and meningitis](https://www.nyheadache.com/blog/steroid-injections-and-meningitis/): Steroid injections are routinely used at our Center for the treatment of cluster headaches and occipital neuralgia. I just received... - [Long-term outcome of vestibular migraine with vertigo](https://www.nyheadache.com/blog/long-term-outcome-of-vestibular-migraine-with-vertigo/): Vertigo is a common symptom in patients suffering from migraine headaches. Vestibular migraine is a new category of migraine proposed... - [Prodrome to migraine headaches](https://www.nyheadache.com/blog/prodrome-to-migraine-headaches/): Prodrome refers to symptoms that precede an actual attack of migraine. Migraine aura also precedes an attack, but it occurs... - [When does migraine aura occur?](https://www.nyheadache.com/blog/when-does-migraine-aura-occur/): Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. The aura can... - [Infant colic and migraine](https://www.nyheadache.com/blog/infant-colic-and-migraine/): Infant colic appears to be more common in babies whose mothers suffers from migraines, according to a just published study... - [Triptans for pediatric patients](https://www.nyheadache.com/blog/triptans-for-pediatric-patients/): Rizatriptan (Maxalt) is the only migraine drug approved by the FDA for children as young as 6. Almotriptan (Axert), another... - [More about marijuana](https://www.nyheadache.com/blog/more-about-marijuana/): Marijuana seems to help some patients with migraine and cluster headaches. However a new study suggests that it has more... - [Online cognitive-behavioral therapy](https://www.nyheadache.com/blog/online-cognitive-behavioral-therapy-2/): Cognitive-behavioral therapy (CBT) has been convincingly proven to help pain and headache sufferers. Many people are very skeptical about the... - [Spinal tap (lumbar puncture) headache](https://www.nyheadache.com/blog/spinal-tap-lumbar-puncture-headache/): Spinal tap, or lumbar puncture headache occurs in one out of four people undergoing this procedure. Spinal tap is usually... - [An autoimmune reaction may cause pain](https://www.nyheadache.com/blog/autoimmune-reaction-may-cause-pain/): Autoimmune dysfunction can cause pain according to a study just published in Neurology by a group of Mayo Clinic researchers.... - [Ointments for headaches and neck pain](https://www.nyheadache.com/blog/ointments-for-headaches-and-neck-pain/): There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and... - [Children with epilepsy have more migraines](https://www.nyheadache.com/blog/children-with-epilepsy-have-more-migraines/): Children with epilepsy are more likely to suffer from migraine headaches than children without epilepsy, according to a study just... - [Omega-3 fatty acids (from fish oil) and nerve damage](https://www.nyheadache.com/blog/omega-3-fatty-acids-from-fish-oil-and-nerve-damage/): Omega-3 fatty acids (most abundantly found in fish oil) may relieve migraine headaches but only one small study found this... - [Slow breathing reduces pain](https://www.nyheadache.com/blog/slow-breathing-reduces-pain/): Slow breathing can reduce pain, according to a recently published study in The Journal of Pain. Researchers at the University... - [Meditation](https://www.nyheadache.com/blog/meditation/): Extraordinary benefits of meditation are described in the current issue of Neurology Now – The American Academy of Neurology’s Magazine... - [What type of magnesium is the best?](https://www.nyheadache.com/blog/what-type-of-magnesium-is-the-best/): Many patients ask about the best type of magnesium supplement to take for the prevention of migraines and other symptoms.... - [Boswellia - an herbal remedy for headaches](https://www.nyheadache.com/blog/boswellia-an-herbal-remedy-for-headaches/): Boswellia extract may relieve migraine, cluster and indomethacin-responsive headaches. Boswellia serrata (Indian frankincense) has been long reported to relieve migraines,... - [Butterbur - we no longer recommend it](https://www.nyheadache.com/blog/butterbur-we-no-longer-recommend-it/): We no longer recommend butterbur to our patients. We participated in a large (245 patients) placebo-controlled trial of butterbur, which... - [Migraine and restless leg syndrome](https://www.nyheadache.com/blog/migraine-and-restless-leg-syndrome/): Restless leg syndrome (RLS) is more common in women who also suffer from migraines, according to a new study published... - [Migraine and erectile dysfunction](https://www.nyheadache.com/blog/migraine-and-erectile-dysfunction/): Until now, migraine headaches have not been associated with erectile dysfunction (ED). A study by Taiwanese doctors published in journal... - [Burning mouth syndrome](https://www.nyheadache.com/blog/burning-mouth-syndrome/): Burning mouth syndrome (BMS) affects over a million Americans. It has no known cause or otherwise it would not be... - [Let-down headaches](https://www.nyheadache.com/blog/let-down-headaches/): Many migraine sufferers complain of headaches on weekends, vacations, or after a period of stress. Researchers at the Montefiore Medical... - [Underutilization of behavioral and other alternative therapies by headache specialists](https://www.nyheadache.com/blog/underutilization-of-behavioral-and-other-alternative-therapies-by-headache-specialists/): Behavioral therapies, such as biofeedback, progressive relaxation, cognitive therapy, and other alternative therapies are routinely recommended only by a quarter... - [Headaches after a head injury](https://www.nyheadache.com/blog/headaches-after-a-head-injury/): Many patients visiting the New York Headache Center with persistent post-traumatic headaches report having had a relatively mild head injury.... - [Migraine and sinus headaches](https://www.nyheadache.com/blog/migraine-and-sinus-headaches/): Sinus inflammation can seriously worsen migraine attacks according to a recent presentation by Dr. V. Martin and his colleagues made... - [Steroids for migraines](https://www.nyheadache.com/blog/steroids-for-migraines/): Steroid medications can be very effective for migraine headaches that fail to respond to other medications. Steroids, such as prednisone,... - [Injectable sumatriptan: Imitrex, Sumavel, Alsuma ](https://www.nyheadache.com/blog/injectable-sumatriptan-imitrex-sumavel-alsuma/): Injections of sumatriptan (Imitrex) are very underutilized. Many doctors fail to offer this option to their migraine and cluster headache... - [Namenda, an Alzheimer's drug for migraines](https://www.nyheadache.com/blog/namenda-an-alzheimers-drug-for-migraines/): Migraine patients can sometimes benefit from an Alzheimer’s drug, Namenda (memantine). All drugs for the preventive treatment of migraines, including... - [Indomethacin-responsive headaches](https://www.nyheadache.com/blog/indomethacin-responsive-headaches/): Chronic and episodic paroxysmal hemicrania and hemicrania continua are rare types of headaches that have one common feature – they... - [Biofeedback](https://www.nyheadache.com/blog/biofeedback/): Biofeedback is an excellent preventive headache treatment with its efficacy proven in many rigorous studies. What prompted me to write... - [Botox for trigeminal neuralgia](https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia/): Botox injections relieve pain of trigeminal neuralgia, according to a new study just published in Cephalalgia, a leading headache journal.... - [Pollution and headaches](https://www.nyheadache.com/blog/pollution-and-headaches/): Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been... - [Mal de Debarquement syndrome](https://www.nyheadache.com/blog/mal-de-debarquement-syndrome/): Mal de debarquement syndrome (MdDS) or disembarkment syndrome is a rare condition which often, but not always, occurs after getting... - [Traditional Chinese Medicine](https://www.nyheadache.com/blog/traditional-chinese-medicine/): Risks involved in using Chinese herbs are highlighted in the just released AFP report, which you can read on Yahoo... - [Health care in Holland](https://www.nyheadache.com/blog/health-care-in-holland/): We should not complain about our health care system. People in such advanced European countries as Netherlands have it much... - [Muscle relaxants for migraines](https://www.nyheadache.com/blog/muscle-relaxants-for-migraines/): Muscle relaxants can be surprisingly effective for the prophylactic treatment of migraine headaches. It is surprising because migraine is a... - [Throbbing headache starting after 60](https://www.nyheadache.com/blog/throbbing-headache-starting-after-60/): A throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a... - [Botox for chronic cluster headaches](https://www.nyheadache.com/blog/botox-for-chronic-cluster-headaches/): I just saw a man with chronic cluster headaches whom I’ve been treating for the past 5 years. He had... - [Weather and headaches](https://www.nyheadache.com/blog/weather-and-headaches/): Weather is a common trigger of migraine headaches. Review of studies linking weather to migraines suggests that there are three... - [Headaches are common in patients with HIV/AIDS](https://www.nyheadache.com/blog/headaches-are-common-in-patients-with-hivaids/): Headache is one of the most common complaints reported by patients suffering from AIDS, according to a new study by... - [Smoking during pregnancy causes headaches in offspring](https://www.nyheadache.com/blog/smoking-during-pegnancy-causes-headaches-in-offspring/): Smoking by the mother during pregnancy increases the risk that the child will suffer from headaches. Brazilian researchers published results... - [Omega-3 fatty acids (fish oil)](https://www.nyheadache.com/blog/omega-3-fatty-acids-fish-oil/): Omega-3 fatty acids, found in fish oil, have been reported to relieve migraine headaches, although the only such study was... - [Depression and migraine](https://www.nyheadache.com/blog/depression-and-migraine/): Depression is more likely to occur in people with migraines, but migraines are also more likely to develop in those... - [Another study confirming genetic link in migraine.](https://www.nyheadache.com/blog/another-study-confirming-genetic-link-in-migraine/): Genetic analysis of 594 members of 134 families by Spanish researchers confirmed the results of a previous study that discovered... - [Women with migraine are at a higher risk of widespread chronic pain](https://www.nyheadache.com/blog/women-with-migraine-are-at-a-higher-risk-of-widespread-chronic-pain-is/): Women who suffer from both episodic and chronic migraines are more likely to have widespread chronic pain, which is often... - [More serious risks of Prilosec and similar drugs](https://www.nyheadache.com/blog/more-serious-risks-of-prilosec-and-similar-drugs/): New risks of Prilosec (omeprazole), Nexium, and other similar drugs (so-called proton-pump inhibitors, or PPIs) are being highlighted by the... - [Daily use of triptans](https://www.nyheadache.com/blog/daily-use-of-triptans/): A small number of my patients take triptan medications daily. Many doctors, including neurologists and headache specialists think that taking... - [Sinus infection usually does not require antibiotics](https://www.nyheadache.com/blog/sinus-infection-usually-does-not-require-antibiotics/): Migraines are often mistaken for sinus infections, and are treated with antibiotics. The reson for this confusion is that migraines... - [A new way to stop migraines](https://www.nyheadache.com/blog/a-new-way-to-stop-migraines/): We are conducting a trial of a very novel treatment for migraine headaches. ElectroCore is a company that developed a... - [How does Botox relieves migraine headaches?](https://www.nyheadache.com/blog/how-does-botox-relieves-migraine-headaches/): Botox, or onabotulinumtoxinA was recently approved by the FDA for treatment of chronic migraine based on the results of two... - [Emergency treatment of headaches with intravenous magnesium](https://www.nyheadache.com/blog/emergency-treatment-of-headaches-with-intravenous-magnesium/): Intravenous infusion of magnesium for the treatment of an acute migraine is receiving more attention and is mentioned in the... - [Acupuncture is again shown to relieve migraine headaches](https://www.nyheadache.com/blog/acupuncture-is-again-shown-to-relieve-migraine-headaches/): Acupuncture has been widely used for the treatment of migraine headaches and it has been subjected to many clinical trials.... - [How much sumatritpan (or another triptan) is too much?](https://www.nyheadache.com/blog/how-much-sumatritpan-or-other-triptans-is-too-much/): How much sumatriptan (or another triptan) is too much is not clear. The initial FDA-approved daily dose of oral sumatriptan... - [ Swearing helps pain, to a point](https://www.nyheadache.com/blog/swearing-helps-pain-to-a-point/): Swearing is a common response to pain. A study just published in The Journal of Pain examines whether swearing can... - [Likeable patients may recieve better pain treatment](https://www.nyheadache.com/blog/likeable-patients-may-recieve-better-pain-treatment/): Likeable patients may receive better care for their pain, according to a study by Belgian researchers. The researchers asked 40... - [NSAID use increases the risk of miscarriage](https://www.nyheadache.com/blog/nsaid-use-increases-the-risk-of-miscarriage/): Pregnant women who take NSAIDs such as naproxen (Aleve), ibuprofen (Advil), diclofenac (Volaren, Cambia), celecoxib (Celebrex), and other are two... - [Botox improves quality of life](https://www.nyheadache.com/blog/botox-improves-quality-of-life/): The FDA approved Botox for the treatment of chronic migraine because of the two large double-blind and placebo controlled trials... - [High blood pressure increases the risk of trigeminal neuralgia](https://www.nyheadache.com/blog/high-blood-pressure-increases-risk-of-trigeminal-neuralgia/): Hypertension appears to increase the risk of trigeminal neuralgia, according to a new study published in Neurology by Taiwanese researchers.... - [Cyclic vomiting in children is not always migraine](https://www.nyheadache.com/blog/cyclic-vomiting-in-children-is-not-always-migraine/): Cyclic vomiting in childhood is often a precursor of migraines in adulthood. Usually a child has attacks of vomiting with... - [When is blood pressure too high?](https://www.nyheadache.com/blog/when-is-blood-pressure-too-high/): High blood pressure is not a common cause of chronic headaches. The pressure has to suddenly increase (from say 100/70... - [Cluster headaches are relieved by steroid block of the occipital nerve](https://www.nyheadache.com/blog/cluster-headaches-are-relieved-by-steroid-block-of-the-occipital-nerve/): Cluster headaches are relieved by steroid injections in the back of the head, according to a study by French doctors,... - [High cholesterol is more common in those with migraine with aura](https://www.nyheadache.com/blog/high-cholesterol-is-more-common-in-those-with-migraine-with-aura/): Having migraines with aura increases the risk of having increased total cholesterol and triglycerides. This was found to be the... - [Brain dysfunction in migraine](https://www.nyheadache.com/blog/brain-dysfunction-in-migraine/): Difficulty thinking and speaking is not unusual at the onset of a migraine attack. It is not always severe as... - [NSAIDs, but not aspirin, can cause dangerous irregular heart beat ](https://www.nyheadache.com/blog/nsaids-but-not-aspirin-can-cause-dangerous-irregular-heart-beat/): Risk of irregular heart beat, heart attacks, and death increases in people taking NSAIDs, such as ibuprofen (Advil), naproxen (Aleve),... - [Exercise is as good as drugs for migraine](https://www.nyheadache.com/blog/exercise-is-as-good-as-drugs-for-migraine/): Yet another study finds that exercise is as good for the prevention of migraines as drugs. The research report in... - [Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity](https://www.nyheadache.com/blog/aspirin-is-first-line-treatment-for-migraine-and-episodic-tension-type-headache-regardless-of-headache-intensity/): Aspirin is the first-line treatment for migraine and tension-type headaches regardless of headache intensity, according to a report published by... - [A promising new migraine drug from Merck is shelved](https://www.nyheadache.com/blog/a-promising-new-migraine-drug-from-merck-is-shelved/): Merck discontinued the development of telcagepant, a promising new drug which represents a new class of migraine drugs, so-called CGRP... - [Showing up is half the battle - predictor of improvement of headache disability ](https://www.nyheadache.com/blog/showing-up-is-half-the-battle-predictor-of-improvement-of-headache-disability/): At the NYHC, just like at all headache clinics, we see many patients with severe disability. A very interesting study... - [New drug for cluster headaches](https://www.nyheadache.com/blog/new-drug-for-cluster-headaches/): Chronic cluster sufferers may benefit from sodium oxybate (Xyrem), according to a report in the leading neurology journal,Neurology. Xyrem is... - [Botox for low spinal fluid pressure](https://www.nyheadache.com/blog/botox-for-low-spinal-fluid-pressure/): Botox has been shown to relieve headaches of low spinal fluid pressure in a case reported at the last annual... - [Abdominal migraine is underdiagnosed](https://www.nyheadache.com/blog/abdominal-migraine-is-underdiagnosed/): Abdominal migraine was the subject of a study by a group of doctors from a children’s hospital in Norfolk, VA... - [Risk of a neck artery dissection is higher in migraine sufferers](https://www.nyheadache.com/blog/risk-of-a-neck-artery-dissection-is-higher-in-migraine-sufferers/): Dissection of the cervical artery is a dangerous condition which can lead to a stroke and even death, although in... - [Invasive treatments for trigeminal neuralgia](https://www.nyheadache.com/blog/invasive-treatments-for-trigeminal-neuralgia/): Trigeminal neuralgia is an excruciatingly painful disorder which affects about one in a thousand people. Patients describe the pain of... - [Topamax recall](https://www.nyheadache.com/blog/topamax-recall/): Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This... - [Bariatric surgery relieves migraine headaches](https://www.nyheadache.com/blog/bariatric-surgery-relieves-migraine-headaches/): Obese people are more likely to suffer from more frequent and severe migraine headaches. The question that remained unanswered was... - [Migraine and chronic fatigue syndrome](https://www.nyheadache.com/blog/migraine-and-chronic-fatigue-syndrome/): Migraine headaches are very common in chronic fatigue syndrome (CFS) sufferers, according to a new study just published by researchers... - [Temporo-mandibular joint disorder and headaches](https://www.nyheadache.com/blog/temporo-mandibular-joint-disorder-and-headaches/): Temporo-mandibular joint disorders (TMD) have long been known to be associated with headaches.   A very interesting study conducted in... - [Warnings about Topamax (topiramate)](https://www.nyheadache.com/blog/warnings-about-topamax-topiramate/): Topiramate (Topamax) increases the risk of birth defects, such as cleft lip and palate, warned the Food and Drug Administration... - [Migraine prevention is most effective when drug and behavioral management are combined](https://www.nyheadache.com/blog/migraine-prevention-is-most-effective-when-drug-and-behavioral-management-are-combined/): Migraine prevention is most effective when a preventive medication and behavioral management are combined together. A study by Dr. Holroyd... - [Announcement of Body-Mind Self-Care Program](https://www.nyheadache.com/blog/announcement-of-body-mind-self-care-program/): Body–Mind, Self-Care Program: Everything you do – eat, drink, sleep, move, sit, stand, think, feel, interact – adds up to... - [Mixing triptans](https://www.nyheadache.com/blog/mixing-triptans/): Taking two different triptans (drugs such as Imitrex, or sumatriptan, Maxalt, or rizatriptan and other) within 24 hours of each... - [Botox helps headaches, makes you happier](https://www.nyheadache.com/blog/botox-helps-headaches-makes-you-happier/): Botox is now approved for chronic migraine headaches. However, it may help you feel happier not only because your headaches... - [Melatonin does not help prevent migraines](https://www.nyheadache.com/blog/melatonin-does-not-help-prevent-migraines/): Melatonin does not seem to be effective for the prevention of migraine headaches, according to a study published in Neurology.... - [How does Botox help headaches?](https://www.nyheadache.com/blog/how-does-botox-help-headaches/): Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by... - [Intranasal sumatriptan powder](https://www.nyheadache.com/blog/intranasal-sumatriptan-powder/): Intranasal sumatriptan powder seems to be a new and very promising way to deliver a migraine drug.   Sumatriptan (Imitrex)... - [Even a brief course of CBT improves TMD treatment outcomes](https://www.nyheadache.com/blog/even-a-brief-course-of-cbt-improves-tmd-treatment-outcomes/): Temporo-mandibular joint dysfunction (TMD) treated with a brief course of cognitive-behavioral therapy (CBT) in addition to standard care improves long-term... - [Botox is approved for chronic migraines ](https://www.nyheadache.com/blog/botox-is-approved-for-chronic-migraines/): Botox was just approved by the FDA for the treatment of chronic migraine headaches.   This is great news to... - [New motion sickness treatment for migraineurs](https://www.nyheadache.com/blog/new-motion-sickness-treatment-for-migraineurs/): A new treatment for motion sickness in patients with migraines was reported by a group of doctors from Pittsburgh.  ... - [Headache coach](https://www.nyheadache.com/blog/headache-coach/): Headache coach, Jan Mundo will be conducting classes at the New York Headache Center (this is a second announcement).   ... - [Aspirin is as good as sumatriptan (Imitrex) with fewer side effects](https://www.nyheadache.com/blog/aspirin-is-as-good-as-sumatriptan-imitrex-with-fewer-side-effects/): Aspirin is as effective as Imitrex (sumatriptan) in the treatment of migraine headaches with fewer side effects, according to an... - [Vertigo as a menopausal migraine](https://www.nyheadache.com/blog/vertigo-as-a-menopausal-migraine/): Vertigo and dizziness are common in migraine sufferers.   It is much less common for vertigo to be the only... - [Headache Coach, Jan Mundo](https://www.nyheadache.com/blog/headache-coach-jan-mundo/): Headache coach, Jan Mundo will be conducting classes at the New York Headache Center.    The course consists of 6... - [Medication overuse headaches](https://www.nyheadache.com/blog/medication-overuse-headaches/): Medication overuse (rebound) headache (MOH) has been the subject of many studies and reports.   Another review of this subject... - [Food allergies in migraine](https://www.nyheadache.com/blog/food-allergies-in-migraine/): Many migraine sufferers feel that food allergies cause their headaches.   There is little dispute that certain foods can trigger... - [Book on refractory migraines published.](https://www.nyheadache.com/blog/book-on-refractory-migraines-published/): There are over 4 million chronic migraine sufferers in the US.   Chronic migraine is defined as a headache with... - [Another epilepsy drug may work for headaches](https://www.nyheadache.com/blog/another-epilepsy-drug-may-work-for-headaches/): Many, but not all epilepsy drugs are also effective in preventing migraine headaches.    For example, divalproex sodium (Depakote), topiramate... - [New prescription migraine drug (actually an old, repackaged one)](https://www.nyheadache.com/blog/new-prescription-migraine-drug-actually-an-old-repackaged-one/): Aspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers.   In a recent report... - [Genetic research in medication overuse headaches](https://www.nyheadache.com/blog/genetic-research-in-medication-overuse-headaches/): Medication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin... - [Sumatriptan (Imitrex) suppositories](https://www.nyheadache.com/blog/sumatriptan-imitrex-suppositories/): Severe migraines are often accompanied by nausea and vomiting, making oral medications ineffective.   Sumatriptan (Imitrex) and Zomig (zolmitriptan) are... - [Depression and anxiety and response to sumatriptan](https://www.nyheadache.com/blog/depression-and-anxiety-and-response-to-sumatriptan/): Migraine sufferers are 2 – 3 times more likely to become depressed or anxious than those without migraines.   The... - [Occipital nerve block for an acute migraine](https://www.nyheadache.com/blog/occipital-nerve-block-for-an-acute-migraine/): Occipital nerve blocks can stop a migraine attack when other treatments fail.   This is a relatively simple procedure (although... - [Aspirin is more effective for migraine than naproxen sodium (Aleve)](https://www.nyheadache.com/blog/aspirin-is-more-effective-for-migraine-than-naproxen-sodium-aleve/): Review of 16 published scientific articles on the efficacy of naproxen sodium as a treatment of acute migraine indicates that... - [Use of tranqulizers for refractory migraine headaches](https://www.nyheadache.com/blog/use-of-tranqulizers-for-refractory-migraine-headaches/): Anxiety and depression occur in migraine patients 2 to 3 times more often than in those without headaches.   The... - [Combination therapies for difficult migraines](https://www.nyheadache.com/blog/combination-therapies-for-difficult-migraines/): We always try to use one preventive drug or Botox for the treatment of frequent or very severe migraine headaches.... - [More on migraines and vertigo](https://www.nyheadache.com/blog/more-on-migraines-and-vertigo/): Vertigo is a common complaint of migraine patients.   Ear-nose-throat specialists at the University of Pisa examined 22 patients with... - [Headaches due to fast heart rate on standing](https://www.nyheadache.com/blog/headaches-due-to-fast-heart-rate-on-standing/): Many migraine sufferers complain of dizziness, fatigue, exercise intolerance, blurred or tunnel vision, diminished concentration, tremulousness, nausea and recurrent syncope... - [Nerve stimulation for cluster headaches](https://www.nyheadache.com/blog/nerve-stimulation-for-cluster-headaches/): Occipital nerve stimulation has been under investigation for the treatment of difficult to treat migraine headaches for the past several... - [Two large studies confirm that Botox is effective for chronic migraine](https://www.nyheadache.com/blog/two-large-studies-confirm-that-botox-is-effective-for-chronic-migraine/): It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that... - [Migraine, strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol are linked](https://www.nyheadache.com/blog/migraine-strokes-heart-attacks-hypertension-poor-circulation-diabetes-and-high-cholesterol-are-linked/): A recent study by Dr. Bigal and his colleagues just published in Neurology compared more than 6,000 migraine sufferers with... - [Treatment of a very severe headache](https://www.nyheadache.com/blog/treatment-of-a-very-severe-headache/): Some headaches, usually migraines, do not respond to the usual over-the-counter and even prescription headache medications.   Once it is... - [Triptans appear to be safe in pregnancy](https://www.nyheadache.com/blog/triptans-appear-to-be-safe-in-pregnancy/): During pregnancy, two thirds of women stop having migraine headaches.   However, one third continues to have them, and sometimes... - [Preventive treatment of migraines is underutilized](https://www.nyheadache.com/blog/preventive-treatment-of-migraines-is-underutilized/): There are several effective preventive medications for migraine headaches, however they are prescribed to only a small number of people... - [Participate in clinical trials!](https://www.nyheadache.com/blog/participate-in-clinical-trials/): Large clinical trials are required to prove that a new drug or treatment is effective.   Without such proof doctors... - [Migraine and cognitive decline](https://www.nyheadache.com/blog/migraine-and-cognitive-decline/): Migraine and migraine medications do not appear to cause cognitive decline, according to a Dutch study just published in Headache.... - [Blood pressure drugs for migraine headaches](https://www.nyheadache.com/blog/blood-pressure-drugs-for-migraine-headaches/): One of the oldest preventive headache medications for migraines is propranolol (Inderal), which belongs to the family of blood pressure... - [Headaches in kids](https://www.nyheadache.com/blog/headaches-in-kids/): 74% of girls and 52% of boys have headaches at age 17, according to a Finnish study of 6,262 twins.... - [More on benefits of vitamin D](https://www.nyheadache.com/blog/more-on-benefits-of-vitamin-d/): Vitamin D deficiency is often found in patients with headaches and neuralgia, which I’ve already mentioned in previous posts.  ... - [Light and headaches](https://www.nyheadache.com/blog/light-and-headaches/): Migraines in blind people are made worse by light, according to Dr. Burstein and his associates at Harvard.   Rami... - [Headaches in pregnancy](https://www.nyheadache.com/blog/headaches-in-pregnancy/): The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study... - [Abuse and migraines](https://www.nyheadache.com/blog/abuse-and-migraines/): Childhood abuse or neglect was reported by 58% of 1,348 migraine sufferers according to a study published in the current... - [Science of acupuncture - 2](https://www.nyheadache.com/blog/science-of-acupuncture-2/): Acupuncture increases connections between different areas of the brain, according to Dhond and other Korean researchers who published their findings... - [Music and pain](https://www.nyheadache.com/blog/music-and-pain/): I’ve written in a previous post that people exposed to pleasant music feel less pain than people listening to unpleasant... - [Avoiding holiday headaches - part 2](https://www.nyheadache.com/blog/avoiding-holiday-headaches-part-2/): Alcohol can trigger a headache immediately or soon after it is consumed or the next morning.    Some people develop... - [Migralex is launched](https://www.nyheadache.com/blog/migralex-is-launched-2/): Migralex is finally available to all headache sufferers.   This is the first new brand of headache medicine in 15... - [How to avoid holiday headaches, part 1 ](https://www.nyheadache.com/blog/how-to-avoid-holiday-headaches-part-1/): Holiday headaches are quite avoidable, but to avoid them you have to have willpower.   I know myself that it... - [Botox vs Topamax](https://www.nyheadache.com/blog/botox-vs-topamax/): A blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew... - [Headache Relief iPhone app](https://www.nyheadache.com/blog/headache-relief-iphone-app/): Headache Relief is a new iPhone app which I developed to help patients better manage their headaches.   The main... - [Botox for nerve pain](https://www.nyheadache.com/blog/botox-for-nerve-pain/): Botox appears to be effective for peripheral nerve pain according to a study by French researchers.   This finding is... - [Needle-free injection of sumatriptan](https://www.nyheadache.com/blog/needle-free-injection-of-sumatriptan/): Needle-free injection of sumatriptan (Imitrex) was tested for its ease of use and for its bioequivalence in a study led... - [Dr. Oz promotes magnesium for headaches](https://www.nyheadache.com/blog/dr-oz-promotes-magnesium-for-headaches/): Dr. Oz : “Like Alexander Mauskop, I believe that magnesium can help—it relaxes arteries and muscles in the body, both... - [Botox for occipital neuralgia](https://www.nyheadache.com/blog/botox-for-occipital-neuralgia/): Botox can relieve pain of occipital neuralgia, according to a pilot study by neurologists in Ohio, published in Headache.  ... - [What to do about severe aura symptoms](https://www.nyheadache.com/blog/what-to-do-about-severe-aura-symptoms/): Some migraine patients are more disturbed and disabled by migraine aura symptoms than by the headache itself.   Some people... - [New treatment for migraines is effective in a Phase III trial](https://www.nyheadache.com/blog/new-treatment-for-migraines-is-effective-in-a-phase-iii-trial/): A new treatment for migraines is very effective and well tolerated, according to a paper published in Neurology.   Two... - [Botox is proven to help chronic migraine](https://www.nyheadache.com/blog/botox-is-proven-to-help-chronic-migraine/): Two large trials of Botox provide unequivocal proof of its efficacy in the treatment of chronic migraine headaches.   The... - [Allergy tests and migraine](https://www.nyheadache.com/blog/allergy-tests-and-migraine/): Migraine headaches are more frequent in people who suffer from allergic rhinitis and who have more than 10 positive skin... - [Facial neuralgia and vitamin B12 deficiency](https://www.nyheadache.com/blog/facial-neuralgia-and-vitamin-b12-deficiency/): Vitamin B12 (cyanocobalamine) deficiency is known to cause a wide variety of neurological symptoms.    It also seems to produce... - [Multiple sclerosis and migraines](https://www.nyheadache.com/blog/multiple-sclerosis-and-migraines/): Migraine headaches are three times more common in patients with multiple sclerosis than in people of similar age and gender... - [Severe migrainous vertigo responds to steroids](https://www.nyheadache.com/blog/severe-migrainous-vertigo-responds-to-steroids/): Migrainous vertigo seems to respond to intravenous infusion of a high dose of corticosteroids, according to a report in the... - [Another blood pressure medicine shown to prevent migraine](https://www.nyheadache.com/blog/another-blood-pressure-medicine-shown-to-prevent-migraine/): A blood pressure medication telmisartan (Micardis) was shown to be effective in the prevention of migraine headaches by a group... - [Vertigo and migraine](https://www.nyheadache.com/blog/vertigo-and-migraine-2/): Vertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology.   In this study... - [Chronic daily headaches in adolescents](https://www.nyheadache.com/blog/chronic-daily-headaches-in-adolescents/): Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to... - [Surgery for migraines - an update](https://www.nyheadache.com/blog/surgery-for-migraines-an-update/): In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is... - [Homocysteine and migraine](https://www.nyheadache.com/blog/homocysteine-and-migraine/): High homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid... - [Weight and migraine treatment](https://www.nyheadache.com/blog/weight-and-migraine-treatment/): Medications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain.  ... - [Another option for trigeminal neuralgia](https://www.nyheadache.com/blog/another-option-for-trigeminal-neuralgia/): Trigeminal neuralgia is an extremely painful condition which causes severe electric shock-like pain in one or more branches of the... - [Two other ways to administer sumatriptan](https://www.nyheadache.com/blog/two-other-ways-to-administer-sumatriptan/): In addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations.   No,... - [A new inhaled migraine drug](https://www.nyheadache.com/blog/a-new-inhaled-migraine-drug/): Trials of an inhaled version of an old migraine drug show surprisingly good results.   The drug is dihydroergotamine and... - [Facial Pain in Migraine](https://www.nyheadache.com/blog/facial-pain-in-migraine/): Lower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in... - [Generic medications](https://www.nyheadache.com/blog/generic-medications/): Imitrex and Topamax are two migraine medications that recently lost their patent protection and became available in a generic form,... - [Occipital microstimulator](https://www.nyheadache.com/blog/occipital-microstimulator/): Occipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches.   Phase II trials performed... - [Headache Diary](https://www.nyheadache.com/blog/headache-diary/): Headache diary plays an important role in the management of headache patients.   Drs. McKenzie and Cutrer from the Mayo... - [Genetic-based personalized medicine in headaches](https://www.nyheadache.com/blog/genetic-based-personalized-medicine-in-headaches/): A pharmacogenetic study by Italian researchers discovered that absence of a certain gene can predict therapeutic response in migraine patients... - [Vertigo and Migraine](https://www.nyheadache.com/blog/vertigo-and-migraine/): Vertigo is a common symptom in patients with migraine headaches.   It appears that obverse is also true – migraine... - [New forms of botulinum toxin](https://www.nyheadache.com/blog/new-forms-of-botulinum-toxin/): Botulinum toxin, which most people know as Botox is produced by a bacteria – Clostridium botulinum.   This bacteria actually... - [How to predict if Botox is going to work](https://www.nyheadache.com/blog/how-to-predict-if-botox-is-going-to-work/): Dr. Rami Burstein of Harvard University and his colleagues discovered the way to predict who is going to respond to... - [Unfair teachers cause headaches](https://www.nyheadache.com/blog/unfair-teachers-cause-headaches/): Unfair teachers can cause headaches in adolescents, according to an Italian study published in the journal Headache.   About 40%... - [Stroke and migraine in pregnancy](https://www.nyheadache.com/blog/stroke-and-migraine-in-pregnancy/): Strokes in pregnant women who suffer from migraine headaches are very rare.   This is a letter I submitted to... - [Cannabis (marijuana) for cluster headaches](https://www.nyheadache.com/blog/cannabis-marijuana-for-cluster-headaches/): Smoking marijuana and taking its legal medicinal derivative, dronabinol helped one patient with cluster headaches, according to a report from the Montefiore... - [PTSD and migraine](https://www.nyheadache.com/blog/ptsd-and-migraine/): Migraine headaches in patients with post-traumatic stress disorder tend to be more frequent and disabling, according to a study in... - [Migraines and weight](https://www.nyheadache.com/blog/migraines-and-weight/): Both overweight and underweight people are more likely to have migraine headaches, according to a recent study published in journal... - [Trigger point injections for cluster headaches?](https://www.nyheadache.com/blog/trigger-point-injections-for-cluster-headaches/): Cluster headaches, which arguably cause the worst pain of any headache, are not likely to be cured by trigger point... - [Lack of exercise contributes to headaches](https://www.nyheadache.com/blog/lack-of-exercise-contributes-to-headaches/): Physical inactivity was strongly associated with headache disorders, according to a large study by Swedish researchers published in Headache.  ... - [Red wine to treat migraines?](https://www.nyheadache.com/blog/red-wine-to-treat-migraines/): Red wine to relieve migraine?   Red wine is a well-known trigger of migraine headaches (although French tend to disagree).   A... - [Antibiotic for daily headache?](https://www.nyheadache.com/blog/antibiotic-for-daily-headache/): Doxycycline has been reported to relieve treatment-resistant new daily persistent headache in four patients.   The dose was 100 mg... - [Mindfulness meditation for chronic pain](https://www.nyheadache.com/blog/mindfulness-meditation-for-chronic-pain/): Mindfulness meditation has been shown to produce numerous benefits in older adults with chronic low back pain.   These benefits... - [New approach to difficult menstrual migraines](https://www.nyheadache.com/blog/new-approach-to-difficult-menstrual-migraines/): Treatment of menstrual migraines often is more difficult than of non-menstrual attacks.   A double-blind study by Marcelo Bigal and... - [Migraine and Omega-3 fatty acids ](https://www.nyheadache.com/blog/migraine-and-omega-3-fatty-acids/): Migraines may be helped by omega-3 fatty acids, a supplement that has gained well deserved popularity.   Several recent studies... - [Occipital nerve stimulation for migraines](https://www.nyheadache.com/blog/occipital-nerve-stimulation-for-migraines/): Refractory migraines may respond to occipital nerve stimulation, according to Dr. Joel Saper who led a multicenter trial of this... - [Breast cancer and migraines](https://www.nyheadache.com/blog/breast-cancer-and-migraines/): Patients who suffer from migraine headaches are 30% less likely to develop breast cancer.   It is well established that... - [Migraine affects 43% of women and 18% of men!](https://www.nyheadache.com/blog/migraine-affects-43-of-women-and-18-of-men/): It is well known that if you take a snapshot of the population, about 18% of women and 6% of... - [Magnesium for migraine](https://www.nyheadache.com/blog/magnesium-for-migraine/): Magnesium is effective in preventing migraine headaches according to a new study published in the last issue of journal Magnesium... - [Acupuncture for headaches](https://www.nyheadache.com/blog/acupuncture-for-headaches/): 15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by... - [Muscle relaxation for pain relief](https://www.nyheadache.com/blog/muscle-relaxation-for-pain-relief/): Progressive muscle relaxation is an integral part of biofeedback training, but can be used by itself for the treatment of... - [Botox works for chronic migraines](https://www.nyheadache.com/blog/botox-works-for-chronic-migraines/): Botox is effective for chronic migraines, according to a statement released by Allergan, maker of Botox.   The company reported... - [Zomig for cluster headaches](https://www.nyheadache.com/blog/zomig-for-cluster-headaches/): Cluster headaches cause the worst pain imaginable, leading some patients to thoughts of suicide.   They occur in about 0.... - [Thyroid dysfunction in kids with headaches](https://www.nyheadache.com/blog/thyroid-dysfinction-in-kids-with-headaches/): Children with thyroid disease are more likely to have headaches, according to a study done by Dr. David Rothner and his... - [Treating menstrual migraines with hormones](https://www.nyheadache.com/blog/treating-menstrual-migraines-with-hormones/): Women with menstrual migraines who also have chronic migraines can be successfully treated with hormonal therapy, according to a study... - [Chronic migraine is poorly treated](https://www.nyheadache.com/blog/chronic-migraine-is-poorly-treated/): Chronic migraine is very disabling and is poorly treated according to a study by Dr. Marcelo Bigal and his colleagues published... - [Migralex - first scientific presentation](https://www.nyheadache.com/blog/migralex-first-scientific-presentation/): Migralex is an over-the-counter medication for the treatment of headaches, which will become available in November of 2009.   Results... - [Vitamin D deficiency in chronic migraine](https://www.nyheadache.com/blog/vitamin-d-deficiency-in-chronic-migraine/): Vitamin D deficiency has become a very popular topic in lay and professional literature, and deservedly so.   Vitamin D... - [What makes migraines get worse?](https://www.nyheadache.com/blog/what-makes-migraines-get-worse/): A study conducted by one of the leading headache researchers, Dr. Richard Lipton looked at possible factors that worsen migraine... - [Empathy hurts!](https://www.nyheadache.com/blog/empathy-hurts/): A person  empathizing with someone in pain perceives his or her own pain as more severe and unpleasant.   Researchers... - [Delaying treatment of pain has proven negative effects](https://www.nyheadache.com/blog/delaying-treatment-of-pain-makes-it-worse/): Patients who faced delays in the treatment of their chronic pain were found to have worsening of their condition, according... - [Facial expression of pain](https://www.nyheadache.com/blog/facial-expression-of-pain/): Facial expression of pain seems to make you feel worse, according to a study published in the May issue of... - [Treating migraines in adolescents](https://www.nyheadache.com/blog/treating-migraines-in-adolescents/): Treating migraines in adolescents presents some unique challenges.   Besides difficulties, such as getting them to bed before midnight and... - [Blood pressure and headaches](https://www.nyheadache.com/blog/blood-pressure-and-headaches/): For many years headaches were thought to be triggered by elevated blood pressure.   Evidence had suggested that only very... - [A new approach to menstrual migraine](https://www.nyheadache.com/blog/a-new-approach-to-menstrual-migraine/): Menstrual migraines are at times very difficult to treat.  Triptans, such as Maxalt, Imitrex and other are usually very effective,... - [A new approach to migraine](https://www.nyheadache.com/blog/a-new-approach-to-migraine/): Scientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches.   They hypothesized that combining two... - [Doctors don't hear out migraine patients](https://www.nyheadache.com/blog/doctors-dont-hear-out-migraine-patients/): Treatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment,... - [The prognosis of migraine - will it go away?](https://www.nyheadache.com/blog/the-prognosis-of-migraine-will-it-go-away/): How long will I suffer from migraines?   Will it ever go away?   These are very common questions patients... - [Treximet - a new migraine drug](https://www.nyheadache.com/blog/treximet-a-new-migraine-drugs/): Treximet, a new migraine treatment was approved today by the FDA.   Treximet is a combination of two old drugs –... - [Migraine in left-handed](https://www.nyheadache.com/blog/migraine-in-left-handed/): For many years migraines have been thought to occur more often in left-handed people, but a new study from Germany... - [Most common time of day for migraine attack](https://www.nyheadache.com/blog/most-common-time-of-day-for-migraine-attack/): Migraine is most likely to occur at noon, according to an article just published in Headache by Norwegian researchers.  ... - [Botox helps tension headaches](https://www.nyheadache.com/blog/botox-helps-tension-headaches/): Botulinum toxin injections relieve tension headaches, according to a study just published in the European Journal of Neurology .   Most of... - [Histamine for difficult to treat migraine and cluster headaches](https://www.nyheadache.com/blog/histamine-for-difficult-to-treat-migraine-and-cluster-headaches/): Migraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine.   Dr.... - [Music relieves migraine headaches and pain](https://www.nyheadache.com/blog/music-relieves-migraine-headaches-and-pain/): Two recent studies suggest that music can relieve migraine headache in children and relieve experimentally-induced pain.   In a study... - [New drug for migraine prevention](https://www.nyheadache.com/blog/new-drug-for-migraine-prevention/): A new drug may be better for the prevention of migraines than the old ones in the same category.   A... - [Treating migraine with epilepsy drugs](https://www.nyheadache.com/blog/treating-migraine-with-epilepsy-drugs/): Anti-epilepsy drugs such as Neurontin (gabapentin), Topamax (topiramate) and Depakote (divalproex) have been proven to prevent migraine headaches.   Each... - [Memantine for migraines](https://www.nyheadache.com/blog/memantine-for-migraines/): Memantine is an old medication which has been available in Europe for over 30 years, but was only recently introduced... - [Topamax side effects](https://www.nyheadache.com/blog/topamax-side-effects/): Topamax is a popular drug for the prevention of migraine headaches.   IT works for about half of the patients... - [More on colored lenses and migraines](https://www.nyheadache.com/blog/more-on-colored-lenses-and-migraines/): Bright light can trigger migraine headaches and many migraine sufferers have increased sensitivity to light during an attack.   A... - [Preventing migraines with a stroke drug?](https://www.nyheadache.com/blog/preventing-migraines-with-a-stroke-drug/): Clopidogrel, which is also known as Plavix, is a drug used to prevent strokes and heart attacks.   It works by... - [Acupuncture for back pain](https://www.nyheadache.com/blog/acupuncture-for-back-pain/): German researchers showed that acupuncture relieves back pain significantly better than combination of medications, physical therapy and exercise.   They... - [More Botox studies](https://www.nyheadache.com/blog/more-botox-studies/): Botox has been shown to relieve migraine headaches in another two studies published in Headache.   One study compared the... - [Migraine does not cause brain damage](https://www.nyheadache.com/blog/migraine-does-not-cause-brain-damage/): Migraine does not cause cognitive impairment, according to a new Danish twin study.   This important finding reassures millions of migraine... - [Botox for arthritis?](https://www.nyheadache.com/blog/botox-for-arthritis/): Botox relieves migraine headaches and other painful conditions, such as sciatica, neuralgias and neck pain.   A recent study of... - [Migraine Brain ](https://www.nyheadache.com/blog/migraine-brain/): A recent study published in Neurology showed that migraine sufferers have thicker gray matter in the part of the brain... - [How long do you have to take medicine?](https://www.nyheadache.com/blog/how-long-do-you-have-to-take-medicine/): This is a common question people ask when we suggest that they start taking a daily preventive medication.   A... - [Vitamin D and exercise](https://www.nyheadache.com/blog/vitamin-d-and-exercise/): We always recommend exercise as one of the most effective preventive treatments for migraines and tension-type headaches.   However, it... - [Sex differences in response to opioid drugs](https://www.nyheadache.com/blog/sex-differences-in-response-to-opioid-drugs/): It appears that women respond better to morphine than men and men respond better to a different opioid (narcotic) drug,... - [Science of acupuncture ](https://www.nyheadache.com/blog/science-of-acupuncture/): A recent study by Richard Harris presented at the American Pain Society’s meeting of 18 patients with fibromyalgia showed different... - [MSG and headaches](https://www.nyheadache.com/blog/msg-and-headaches/): Many patients tell me that monosodium glutamate (MSG) gives them headaches, but we never had a scientific study to explain... - [Anne Frank's headaches](https://www.nyheadache.com/blog/anne-franks-headaches/): “Anne Frank’s headache” is the title of an article just published by RF de Almeida and PA Kowacs in the... - [Postpartum headaches](https://www.nyheadache.com/blog/postpartum-headaches/): Postpartum headaches are very common and are usually benign. A study presented at the meeting of the Society for Maternal-Fetal... - [Good news - migraine goes away!](https://www.nyheadache.com/blog/good-news-migraine-goes-away/): Migraine is known to subside in most people, often when they reach their 40s or 50s.    A recent report from... - [Promising new medicine.](https://www.nyheadache.com/blog/promising-new-medicine/): Results of a phase II study of a new headache medicine was published in journal Neurology. Merck and Co. is... - [Dental migraine ](https://www.nyheadache.com/blog/dental-migraine/): Pain of migraine can be localized to the face and around the mouth according a two recent reports. Dr. Gaul... - [New formulation of Imitrex Injection](https://www.nyheadache.com/blog/new-formulation-of-imitrex-injection/): The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient... - [How Botox relieves migraines](https://www.nyheadache.com/blog/how-botox-relieves-migraines/): It is not clear how Botox relieves migraine headaches. Oliver Dolly, an Irish researcher who devoted many years of his... - [Exercise, depression and migraines](https://www.nyheadache.com/blog/exercise-depression-and-migraines/): Depression (and anxiety) is 2-3 times more common in those suffering from migraines than in people without migraines. Depression is... - [Acupuncture for migraines ](https://www.nyheadache.com/blog/acupuncture-for-migraines/): It is no big news that acupuncture helps migraine patients. Nevertheless, it is good to see yet another study confirming... - [Botox for migraines - success predictors ](https://www.nyheadache.com/blog/botox-for-migraines-success-predictors/): A study just published by Dr. Mathew and his colleagues in the journal Headache reports that patients with chronic migraine... - [Cervical disk prolapse, headaches and Botox ](https://www.nyheadache.com/blog/cervical-disk-prolapse-headaches-and-botox-prolapse-or-herniation-of-the-upper-cervical-disc-is-known-to-cause-not-only-neck-pain-but-also-so-called-cervicogenic-headaches/): Prolapse or herniation of the upper cervical disc is known to cause not only neck pain but also so called... - [Food colorings and migraine ](https://www.nyheadache.com/blog/food-colorings-and-migraine/): A study just published in the British medical journal Lancet reports on the effect of food colorings in children. This... - [Migraine and abuse ](https://www.nyheadache.com/blog/migraine-and-abuse/): Dr. Tietjen reports in the current issue of Neurology on a survey performed at six headache clinics. A total of... - [Hemiplegic Migraine](https://www.nyheadache.com/blog/hemiplegic-migraine/): Hemiplegic migraine can be safely treated with triptans (drugs like Imitrex, Maxalt and other). This is the conclusion of a... - [MRI scan as Treatment ](https://www.nyheadache.com/blog/mri-scan-as-treatment/): Researchers at several companies are using brain images obtained by an MRI machine to train people with chronic pain how... - [Noise and Migraines ](https://www.nyheadache.com/blog/noise-and-migraines/): Noise is a well-known trigger of migraines. Recent findings by WHO researchers indicate that excessive exposure to noise causes other... - [Drug side effects ](https://www.nyheadache.com/blog/drug-side-effects/): A recent survey by Beatrice Golomb and her colleagues which was reported by Reuters Health discovered that when patients reported... - [Surgery for migraines ](https://www.nyheadache.com/blog/surgery-for-migraines/): I just received an announcement for the “2nd Annual Surgical Treatment of Migraine Headaches. ” The event is sponsored by... - [Headaches and suicide ](https://www.nyheadache.com/blog/headaches-and-suicide/): In a study presented at the recent meeting of the American Psychiatric Association Dr. Stephen Woolley found that adults suffering... - [Brain damage ](https://www.nyheadache.com/blog/brain-damage/): Brain damage from migraines? Maybe, if you are a mouse. A recent study published in the journal Nature Neuroscience discovered... - [Menstrual cluster ](https://www.nyheadache.com/blog/menstrual-cluster/): Cluster headaches are much more common in men. Cluster headaches are much more common in men. However, they do occur... - [RLS](https://www.nyheadache.com/blog/rls/): Restless leg syndrome (RLS) affects 10% of the population with 3% suffering from severe symptoms. Patients suffering from RLS complain... - [Amber contact lenses ](https://www.nyheadache.com/blog/amber-contact-lenses/): A recent small study suggests that wearing red colored contact lenses can relieve pain of a migraine attack. A recent... - [Endometriosis](https://www.nyheadache.com/blog/endometriosis/): Women with migraine have a higher chance of also having endometriosis. A study by Dr. Gretchen Tietjen and her colleagues... - [Brain lesions in migraine ](https://www.nyheadache.com/blog/brain-lesions-in-migraine/): However, presence of any brain lesion is worrisome to most patients and according to some researchers may be indicative of... - [Migraine in pregnancy and CVD ](https://www.nyheadache.com/blog/migraine-in-pregnancy-and-cvd/): Migraines at the end of pregnancy and soon after the delivery increase the risk of strokes and other vascular complications... - [Migralex](https://www.nyheadache.com/blog/migralex-migralex%e2%84%a2/): Migralex – A Breakthrough in the Treatment of Headaches. Migralex is a headache medication developed and patented by Dr. Alexander... - [Alpha lipoic acid relieves migraine headaches](https://www.nyheadache.com/blog/alpha-lipoic-acid-alpha-lipoic-acid-relieves-migraine-headaches/): According to a recent study by Magis and colleagues (Headache 2007;47:52-57) daily dose of 600 mg of alpha lipoic acid... - [Medication overuse ](https://www.nyheadache.com/blog/medication-overuse-headache-medication-overuse-headache-moh-does-not-respond-to-steroids/): Medication overuse headache (MOH) does not respond to steroids according to a new study published in the July 3 issue... - [New report on topiramate (Topamax) ](https://www.nyheadache.com/blog/new-report-on-topiramate-topamax/): Chronic migraine headaches can be helped by topiramate (Topamax) even in those patients who are having rebound headaches from daily... - [Women with migraine](https://www.nyheadache.com/blog/women-with-migraine/): Women with migraine have a higher frequency of excessive and/or prolonged menstrual bleeding and endometriosis, according to a study published... - [Another study of Botox for migraines. ](https://www.nyheadache.com/blog/another-study-of-botox-for-migraines/): Curtis Schreiber and Roger Cady reported their study at the recent annual meeting of the American Academy of Neurology. This... - [Combining drugs to treat migraine headaches](https://www.nyheadache.com/blog/combining-drugs-to-treat-migraine-headaches/): “Old Drugs In, New Ones Out”, a story in the New York Times on July 1, 2007 reports on a... - [Distress and sciatica ](https://www.nyheadache.com/blog/distress-and-sciatica/): Presence of anxiety and depression (“distress”) at the time of initial diagnosis of sciatica predict worse outcome of both surgical... - [Acupuncture treatment](https://www.nyheadache.com/blog/acupuncture-treatment/): A study just published in the journal Pain looked at the effect of patient expectations on outcome of acupuncture treatment.... - [Heart surgery to prevent migraine](https://www.nyheadache.com/blog/heart-surgery-to-prevent-migraine/): Patients who suffer from chronic migraines say they would do anything to rid themselves of the pain-but heart surgery? Click... - [Study of Occipital Nerve Stimulation ](https://www.nyheadache.com/blog/study-of-occipital-nerve-stimulation/): Medtronic Begins Study of Occipital Nerve Stimulation for Chronic, Refractory Migraine Headaches; Implanted Device Delivers Electrical Impulses to Occipital Nerves.... - [Cluster headache news ](https://www.nyheadache.com/blog/cluster-headache-news/): Intranasal use of capsaicin (on the side of the headache) has been reported to relieve cluster headaches. Capsaicin is an... --- # # Detailed Content ## Pages ## ## Posts ### Flossing teeth: a surprising link to fewer strokes and migraines - Published: 2025-04-20 - Modified: 2025-04-20 - URL: https://www.nyheadache.com/blog/flossing-teeth-a-surprising-link-to-fewer-strokes-and-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Migraine, Science of Migraine You may think of flossing as a way to keep your teeth and gums healthy, but new research shows that it may also protect your heart and brain. Recent scientific studies reveal compelling connections between gum health, stroke risk, and chronic migraines. A major study led by Dr. Souvik Sen at the University of South Carolina found that flossing at least once a week can cut your risk of ischemic stroke by 22% and cardioembolic stroke by 44%. Flossing also lowers the risk of atrial fibrillation, a heart rhythm problem that raises stroke risk. These benefits are similar to those of aspirin but without the side effects of increased bleeding and stomach ulcers. The reason may be that flossing reduces gum disease and oral inflammation, which are linked to heart and blood vessel problems. Two recent reviews have highlighted that people with gum disease (periodontitis) are more likely to suffer from migraines. One large observational study found that those with periodontitis had a 29% higher risk of migraines, and the worse the gum disease, the higher the risk. A systematic review of eight studies confirmed this link, pointing to inflammatory markers, like CGRP and PTX3, that are elevated in both conditions. Chronic inflammation from gum disease may trigger or worsen migraine attacks. Flossing is a simple, affordable way to lower your risk of stroke and potentially reduce migraine frequency. By keeping your gums healthy, you’re also helping to protect your heart and brain. Answer from Perplexity: pplx. ai/share --- ### fMRI changes in kids after a concussion; could TMS help? - Published: 2025-04-13 - Modified: 2025-04-13 - URL: https://www.nyheadache.com/blog/fmri-changes-in-kids-after-a-concussion-could-tms-help/ - Categories: Brain disorders, Chronic migraine, Head trauma, Migraine, neurostimulation, New treatments, post-traumatic headache Concussions in children are far more than just a bump on the head—they can trigger subtle yet significant changes in brain function that may linger long after the visible symptoms fade. A recent prospective, longitudinal study sheds new light on how pediatric concussion disrupts functional brain network connectivity over time. In this large-scale study, researchers tracked 385 children with concussion and 198 with mild orthopedic injuries (used as a control group) across five pediatric hospitals in Canada. Each child underwent high-resolution fMRI scans shortly after injury and again at either three or six months. The focus was on resting-state functional connectivity (FC)—how different regions of the brain communicate when the brain is not engaged in a specific task. While within-network connectivity remained largely intact, disruptions in between-network connectivity emerged over time in the concussion group. Key findings included: - Reduced connectivity between the visual and ventral attention networks across all time points after concussion. - Lower connectivity between the visual and default mode networks, specifically at six months post-injury. - Age-dependent differences in connectivity between the frontoparietal and ventral attention networks at three months: younger children showed reduced connectivity, while older children showed increased connectivity. - Sex- and symptom-related differences in attention network connectivity, with girls without persisting symptoms showing higher connectivity between dorsal and ventral attention networks than those with lingering symptoms. These findings point to long-term changes in how different brain networks interact after pediatric concussion, even after most children appear clinically recovered. It suggests that functional connectivity... --- ### Zonisamide Shows Promise as a Preventive Migraine Treatment for Kids and Teens  - Published: 2025-04-05 - Modified: 2025-04-05 - URL: https://www.nyheadache.com/blog/zonisamide-shows-promise-as-a-preventive-migraine-treatment-for-kids-and-teens/ - Categories: Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Science of Migraine A new study suggests that zonisamide (Zonegran), a medication traditionally used to treat seizures, may help reduce migraine days in children and teens. The research, led by Dr. Anisa Kelley of Northwestern University Feinberg School of Medicine, reviewed health records of 256 children and teens diagnosed with migraines who were prescribed zonisamide as a preventive treatment. Among these participants, 28% had difficult-to-treat migraines, defined as migraines that had not responded to at least two other medications. The researchers found that the median number of headache days per month dropped from 18 to six across all participants after starting zonisamide. The greatest improvement was observed in the subgroup that followed up two to six months after beginning the medication, suggesting zonisamide is most effective after at least two months of use. Zonisamide appeared to benefit both those with difficult-to-treat migraines and those without. Zonisamide shares similarities with topiramate (Topamax), the only FDA-approved preventive migraine medication for children and teens. Both drugs are anticonvulsants that can help stabilize neuronal activity linked to migraines. However, zonisamide may have an advantage: it tends to cause fewer side effects compared to topiramate. The potential side effects include cognitive issues like memory and concentration difficulties, fatigue, weight loss, and others. Dr. Kelley emphasized that while the findings are promising, the study has limitations. It did not include a control group of participants who were not taking zonisamide, and it relied on health record reviews rather than randomized clinical trials. Further research is needed to confirm these... --- ### My book, The End of Migraines: 150 Ways to Stop Your Pain, just became available as an audiobook on Amazon. - Published: 2025-03-28 - Modified: 2025-03-28 - URL: https://www.nyheadache.com/blog/my-book-the-end-of-migraines-150-ways-to-stop-your-pain-just-became-available-as-an-audiobook-on-amazon/ - Categories: Uncategorized Check it out https://a. co/d/gwB2xEw --- ### Medical Cannabis vs. Prescription Medications for Chronic Pain - Published: 2025-03-23 - Modified: 2025-03-23 - URL: https://www.nyheadache.com/blog/medical-cannabis-vs-prescription-medications-for-chronic-pain/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research In a recent study published in Pain by the University of Pittsburg researchers, the effectiveness of medical cannabis was compared with traditional prescription medications for managing chronic pain. The study involved 440 patients using medical marijuana and 8,114 patients treated with prescription medications (nonopioid or opioid) in the same healthcare system. Both groups received comprehensive pain assessments and treatment plans. Key Findings Response Rates: At three months, 38. 6% of the medical marijuana group and 34. 9% of the prescription medication group showed significant improvements in pain, function, or overall well-being. The response rate in the medical marijuana group remained stable at six months. Opioid Reduction: Among the 157 patients in the medical marijuana group who were also prescribed opioids, there was a significant reduction in opioid use, with a mean decrease of 39. 3% in morphine milligram equivalents over six months. Comparative Effectiveness: The study found that medical marijuana was more effective than prescription medications for treating chronic pain, with patients being more likely to respond positively to medical marijuana. This study suggests that medical marijuana may be at least as effective as, if not more effective than, conventional medications for chronic pain. It also highlights the potential of medical marijuana in reducing opioid use, which is a significant public health concern. I prescribe medical marijuana to our migraine patients when prescription drugs and non-drug therapies are ineffective. For many, marijuana helps relieve nausea; for some, it helps with migraine-related anxiety and insomnia; and for a smaller proportion, it... --- ### The Right Tempo in Music May Help Reduce Pain - Published: 2025-03-17 - Modified: 2025-03-17 - URL: https://www.nyheadache.com/blog/the-right-tempo-in-music-may-help-reduce-pain/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments, Pain, Pain Research, Psychology of headaches New research from McGill University published in the journal Pain suggests that the tempo—or speed—of music plays a crucial role in how well it helps reduce pain. In this study, researchers explored whether music that matches a person’s natural rhythm—called their spontaneous production rate (SPR)—could provide better pain relief. SPR is the pace at which people naturally hum or tap out a tune, almost like a personal internal metronome. Sixty participants first had their SPR measured by tapping out "Twinkle Twinkle Little Star" at a comfortable pace. Later, they were exposed to mild heat pain while listening to music specially adjusted to three tempos: their exact SPR, 15% faster, or 15% slower. A silent condition was also tested. The results? Music alone reduced pain compared to silence, confirming what many of us know instinctively—music helps us cope. But the biggest surprise was that music adjusted exactly to each person’s SPR provided the most pain relief. Faster or slower versions just weren’t as effective. Why does this happen? We think it may be because music at our natural tempo syncs better with our body’s internal rhythms, helping us relax and shift focus away from pain. What does this mean for you? The next time you’re using music to manage discomfort—whether it’s during a workout, a medical procedure, or just a headache—try finding songs that feel "just right" in speed. It might be your body’s way of telling you it’s syncing up for maximum relief. This research paves the way for more... --- ### Meeting of the Headache Cooperative of the Northeast - Published: 2025-03-09 - Modified: 2025-03-09 - URL: https://www.nyheadache.com/blog/meeting-of-the-headache-cooperative-of-the-northeast/ - Categories: Alternative Therapies, Chronic migraine, Cluster headaches, Headache medications, Migraine, neurostimulation It was an honor to participate in the 35th Annual Winter Symposium of the Headache Cooperative of the Northeast, held on March 7 and 8. Leading headache experts from across the country covered many interesting topics. I had the privilege of discussing a presentation by Dr. Chiang Chia-Chun of the Mayo Clinic on artificial intelligence in Headache Medicine. Here is my PowerPoint presentation: Artifical Intelligence discussion (1) --- ### Vitamin B12: "Normal" blood Levels are often not normal - Published: 2025-02-27 - Modified: 2025-02-27 - URL: https://www.nyheadache.com/blog/vitamin-b12-normal-blood-levels-are-often-not-normal/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, post-traumatic headache, Science of Migraine A new study published in the Annals of Neurology by researchers at UCSF challenges our current understanding of what constitutes "normal" vitamin B12 levels, particularly regarding brain health. The findings suggest that even B12 levels currently considered adequate may not be optimal for maintaining brain function, especially in older adults. Key Findings The study examined 231 healthy older adults with B12 levels that would typically be considered normal. Surprisingly, those with lower B12 levels – though still within the "normal" range – showed several concerning signs: Slower nerve conduction in visual pathways Reduced cognitive processing speed, particularly in older participants More white matter damage visible on brain MRI scans1 Why This Matters The current normal levels for vitamin B12 were determined decades ago, and it is not clear how reliable the research that led to these values was. Quest and Labcorp, two major chains of laboratories, define normal levels as 200 - 1,000 pg/ml and 232 -1,245 pg/ml, respectively. The WHO considers 480 pg/ml to be the bottom of the normal range, while it is 500 pg/ml in Japan. Some experts suggest these higher standards may contribute to lower rates of Alzheimer's and dementia in Japan. What This Means for You Your B12 levels might be worth checking if you are experiencing neurological symptoms like: Mental fogginess Memory issues Balance problems Numbness or tingling Migraine headaches, especially with visual auras Dizziness If you have this blood test done, don't accept "it's normal" from your doctor, but ask about your actual... --- ### A Breakthrough in Migraine Diagnosis - Published: 2025-02-10 - Modified: 2025-02-10 - URL: https://www.nyheadache.com/blog/a-breakthrough-in-migraine-diagnosis/ - Categories: Chronic migraine, Headaches, Migraine, Science of Migraine Recent advances in neuroimaging are bringing us closer to an objective diagnosis of migraines. Korean researchers have published groundbreaking findings showing that migraine sufferers exhibit distinctive structural and functional brain characteristics visible on MRI scans. Their report,A robust multimodal brain MRI-based diagnostic model for migraine: validation across different migraine phases and longitudinal follow-up data,was published last month in the Journal of Headache and Pain. Currently, migraine diagnosis relies on patients reporting specific symptoms. These include one-sided head pain, moderate to severe intensity, throbbing sensation, nausea, sensitivity to light and noise, and worsening pain with physical activity. A diagnosis typically requires the presence of at least three of these symptoms.  This new research confirms that migraines affect multiple brain networks rather than one area. The study identified three key markers: reduced thickness of certain parts of the brain's cortex, changes in cortical folding patterns, and abnormalities in the brain's visual, sensory-motor, and emotional processing networks. These findings represent a significant step toward more precise diagnostic tools for migraines. In the future, we may see a comprehensive diagnostic approach combining clinical symptoms, neuroimaging, and potentially other objective measures to provide more accurate diagnoses and targeted treatments. --- ### Suzetrigine: A Promising New Treatment for Pain - Published: 2025-01-30 - Modified: 2025-01-31 - URL: https://www.nyheadache.com/blog/suzetrigine-a-promising-new-treatment-for-pain/ - Categories: Brain disorders, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Pain, Pain Research FDA has approved suzetrigine (Journavx) for the treatment of moderate to severe acute pain. The drug was found to be as effective as Vicodin (hydrocodone with acetaminophen) after surgery to remove a bunion and after a "tummy tuck". Suzetrigine is a selective NaV1. 8 inhibitor, targeting a key sodium channel involved in pain signaling. The NaV1. 8 channel is crucial in transmitting nerve pain signals to the brain. However, the drug does not enter the brain and works only on the nerves outside the brain and in the body. Unlike traditional pain medications such as opioids, suzetrigine provides effective pain relief without addiction risk or severe systemic side effects. Early clinical trials suggest it may be beneficial for conditions like neuropathic pain, post-surgical pain, and chronic pain syndromes. Hopefully, it will also prove effective in the treatment of migraines and other types of headaches. In clinical trials, about 37% of patients experienced adverse events, though most were mild. These included itching, rash, constipation, and muscle spasms. As a non-opioid option, suzetrigine provides clinicians with an additional tool for acute pain management. The medication is expected to become available in the second quarter of 2025. The expected cost is about $15 a pill. --- ### Magnesium given in pregnancy reduces the risk of cerebral palsy - Published: 2025-01-19 - Modified: 2025-01-19 - URL: https://www.nyheadache.com/blog/magnesium-given-in-pregnancy-reduces-the-risk-of-cerebral-palsy/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy A new Cochrane meta-analysis has reaffirmed the significant role of magnesium sulfate in reducing the risk of cerebral palsy (CP) and death in preterm infants. This comprehensive review, which analyzed six randomized controlled trials involving nearly 6,000 pregnant participants, provides compelling evidence for the use of this inexpensive intervention in preventing lifelong disability. The review revealed that magnesium sulfate administration to pregnant women at risk of premature delivery: *Significantly reduced the risk of CP in children up to 2 years of corrected age (relative risk of 0. 71) *Decreased the combined risk of death or CP (relative risk of 0. 87) *Moderately reduced the risk of severe neonatal intraventricular (brain) hemorrhage These findings underscore the importance of magnesium sulfate as a neuroprotectant for preterm babies, a recommendation that has been supported by the World Health Organization since 2015. While not directly related to the CP study, it's worth noting that magnesium also plays a crucial role in migraine prevention and treatment. Magnesium deficiency, which is present in almost half of migraine sufferers, leads to increased migraine frequency and severity. Many neurologists recommend magnesium supplements as part of a comprehensive migraine prevention strategy. We sometimes check RBC magnesium levels (the more accurate test than serum levels) before recommending supplementation. Chelated forms of magnesium, such as magnesium glycinate, are better absorbed than magnesium oxide, which is the type most commonly sold in stores. Oral magnesium can help the majority of people who are deficient. About 10%, however, do not absorb oral magnesium.... --- ### A new device to treat chronic migraines - Published: 2025-01-14 - Modified: 2025-01-14 - URL: https://www.nyheadache.com/blog/a-new-device-to-treat-chronic-migraines/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation, New treatments The Chordate System, using a technique called Kinetic Oscillation Stimulation (K. O. S), has shown promising results in reducing monthly headache days for people with chronic migraines, according to a study just published by European neurologists in the journal Neurology. The treatment involves gentle stimulation inside the nasal cavity using a specialized catheter that delivers precise pressure and vibrations. Each session lasts 10 minutes per nostril and is administered weekly. The device works by potentially modulating the trigeminal nerve pathways involved in migraine attacks. Study design: The study was randomized, double-blind, and sham-controlled. Participants: Patients with chronic migraine (defined as headaches occurring on 15 or more days per month, with at least 8 of those being migraine days). The active treatment was given to 67 patients and the sham to 65. Treatment: Weekly K. O. S sessions for six weeks. Primary Endpoint: Change in monthly headache days with moderate to severe intensity (MHDs) from baseline to the performance assessment period (days 14–42). Secondary Endpoints: These included changes in monthly migraine days (MMDs), reductions in headache severity, use of abortive medications, and improvements in quality of life. Key Findings The results demonstrated that K. O. S provided significant benefits for patients with chronic migraine: Reduction in Monthly Headache Days (MHDs): Active treatment resulted in a reduction of 3. 5 MHDs during the assessment period, compared to a 1. 2-day reduction with sham treatment. This improvement persisted into the follow-up period, with a 2. 7-day reduction in MHDs compared to sham. Reduction... --- ### Why I Take These Supplements - A Doctor's Personal Perspective - Published: 2024-12-16 - Modified: 2024-12-16 - URL: https://www.nyheadache.com/blog/the-supplements-i-take/ - Categories: Alternative Therapies, Brain disorders, Migraine As a 68-year-old physician, I'm often asked about my own supplement regimen. Here is my approach to supplementation. The uncomfortable truth about our modern diet is that even those of us eating "healthy" may not be getting adequate nutrition. Our food supply, while abundant, often lacks the nutrient density of previous generations. Even fresh vegetables and fruits grown in depleted soils may not provide the nutrition we expect. Having practiced medicine for decades, I've observed this reality in countless blood tests and patient outcomes. My own blood tests have revealed borderline-low levels of vitamins D, B12, and magnesium - technically "normal" but at the bottom of the range. Scientific studies have shown that laboratory "normal" ranges are often too wide. When you're at the bottom of that range, you're likely functioning sub-optimally. With few exceptions, herbal supplements are rarely subjected to large, controlled clinical trials. A rigorous study of turmeric showed that it improves memory. Astragalus has been subjected to many small clinical and preclinical studies that point to many possible benefits. Other herbal supplements I take have various degrees of evidence for their efficacy and safety. You can see all the supplements I take in the photo below. You can also see the brands of these products. To select the best brands, I usually consult Consumerlab. com. This independent testing organization is funded by membership fees and does not accept advertising or payments from manufacturers. They provide an extensive description of clinical trials and potential side effects and rank... --- ### Can Magnetic Brain Stimulation (rTMS) Prevent Pain? - Published: 2024-12-02 - Modified: 2024-12-02 - URL: https://www.nyheadache.com/blog/can-magnetic-brain-stimulation-rtms-prevent-pain/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine, TMJ Modern technology may help manage or even prevent pain before it becomes chronic. A recent study exploring the effects of repetitive transcranial magnetic stimulation (rTMS) on pain sensitivity offers some intriguing insights. What is rTMS? rTMS is a non-invasive method of brain stimulation. It involves sending magnetic pulses to specific areas of the brain through a coil placed on the scalp. This technique has been used to treat conditions like depression and chronic pain, but researchers are now looking at its potential to prevent pain. We used rTMS at the New York Headache Center to treat chronic migraine, other pain and neurological conditions that do not respond to usual treatment. In a controlled experiment, researchers led by Nahian Chowdhury examined the role of rTMS in reducing future pain in healthy volunteers. The results were published in the latest issue of Pain, a journal of the International Association for the Study of Pain. The subjects were divided into two groups: Active rTMS Group: Received high-frequency rTMS to the area of the brain responsible for hand movements. Sham rTMS Group: Received a fake treatment for comparison. Both groups were then given an injection of nerve growth factor (NGF) into their jaw muscles, which causes prolonged pain similar to temporomandibular disorders (TMD), a condition causing jaw pain and dysfunction. Results: Pain Reduction: Participants who received active rTMS reported significantly less pain when chewing or yawning than the sham group. This effect was more pronounced in the early stages after the injection but persisted... --- ### A new textbook on headaches and facial pain. - Published: 2024-11-21 - Modified: 2024-11-21 - URL: https://www.nyheadache.com/blog/a-new-textbook-on-headaches-and-facial-pain/ - Categories: Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Trigeminal and other neuralgias It’s an honor to have contributed, alongside Andrew Blumenfeld and Sait Ashina, a chapter on Botox injections to the upcoming textbook Headache and Facial Pain Medicine. Edited by Sait Ashina of Harvard Medical School and published by McGraw Hill, the book is set for release in 2025 but is already available on Amazon. The book includes chapters on Primary Headaches, Secondary Headaches, Facial Pain and Cranial Neuralgias, Special Treatments and Procedures, Special Populations, and Special Topics. It is an excellent textbook for health care providers. --- ### It's good to see the lasting impact of our research - Published: 2024-11-16 - Modified: 2024-11-16 - URL: https://www.nyheadache.com/blog/its-good-to-see-the-lasting-impact-of-our-research/ - Categories: Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine "Dr. Mauskop,Congratulations on hitting a new milestone - over 3800 citations of your articles! This places you in the top 5% for citations within the Doximity community. "Some of the most cited articles:- Intravenous Magnesium Sulphate Relieves Migraine Attacks in Patients with Low Serum Ionized Magnesium Levels: A Pilot Study- Botulinum toxin type A for the prophylaxis of chronic daily headache: Subgroup analysis of patients not receiving other prophylactic medications: A randomized double-blind, placebo-controlled study- Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain- Effect of noninvasive vagus nerve stimulation on acute migraine: an open-label pilot study- Foods and supplements in the management of migraine headaches. --- ### Hemicrania continua is a very disabling headache and it is often misdiagnosed - Published: 2024-11-08 - Modified: 2024-11-08 - URL: https://www.nyheadache.com/blog/hemicrania-continua-is-a-very-disabling-headache-and-it-is-often-misdiagnosed/ - Categories: Botox, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, Trigeminal and other neuralgias Hemicrania continua, a rare but severe headache condition, literally means "continuous one-sided headache" in Latin. This chronic condition manifests as an intense, unrelenting pain concentrated on one side of the head, typically around the eye area. It is more common in women. The condition often presents with distinctive features beyond the constant one-sided pain. Patients frequently experience: Redness and tearing of the affected eye Nasal congestion and runny nose Forehead and facial sweating Eyelid swelling Pupil size changes Restlessness or agitation The diagnosis of hemicrania continua can be particularly challenging, especially when the only symptom is a one-sided headache. Doctors often misdiagnose it as migraine or tension headache because of its rarity and overlap with other headache types. What makes hemicrania continua unique is its remarkable response to indomethacin, a powerful non-steroidal anti-inflammatory drug (NSAID). The response to this medication is so dramatic that hemicrania continua is one of two headache types that are called indomethacin-sensitive headaches. While indomethacin is highly effective, some patients may experience stomach-related side effects. For those who cannot tolerate indomethacin, several alternatives exist: Other NSAIDs (though generally less effective) Boswellia, an herbal supplement with anti-inflammatory properties Botox injections Chronic paroxysmal hemicrania shares features with hemicrania continua but differs in its pattern. It causes more intense pain attacks lasting minutes but occurring many times throughout the day. Like hemicrania continua, it also responds extremely well to indomethacin. --- ### Having migraines does not lead to brain damage with age - Published: 2024-10-17 - Modified: 2024-10-17 - URL: https://www.nyheadache.com/blog/having-migraines-does-not-lead-to-brain-damage-with-age/ - Categories: Brain disorders, Chronic migraine, Headaches, Migraine, Science of Migraine If you're one of the millions of people who suffer from migraines, you might be worried about the long-term effects on your brain. Recent studies have suggested that people with migraines might be at higher risk for structural brain changes, such as damage to small vessels in the brain and shrinkage of the brain or brain atrophy. A recent study published in Cephalalgia by Dutch researchers examined the connection between migraines and brain health in over 4,900 middle-aged and elderly people. The researchers used magnetic resonance imaging (MRI) to study the brains of the participants and assess any structural changes. The study found that people with migraines were not any more likely to have structural brain changes than those without migraines. There were no significant differences between the two groups in terms of: Total brain volume Grey matter volume White matter volume White matter hyperintensity volume (a marker for small vessel disease) Presence of lacunes (tiny holes in the brain) Presence of cerebral microbleeds (small bleeds in the brain) This study suggests that having migraines may not increase your risk of developing structural brain changes as you age. This is reassuring news for people who suffer from migraines and are concerned about the long-term effects on their brain health.   --- ### Severe vitamin B12 deficiency can occur with normal blood levels of B12 - Published: 2024-10-15 - Modified: 2024-10-15 - URL: https://www.nyheadache.com/blog/severe-vitamin-b12-deficiency-with-a-normal-blood-level-of-b12/ - Categories: Alternative Therapies, Brain disorders, Migraine, Pain Research, Science of Migraine Vitamin B12 deficiency is common in the elderly, vegetarians, people with diabetes, and other chronic conditions. This deficiency can cause neurological, psychiatric, hematological, and other symptoms. It can be a contributing factor to migraines, especially in people who experience visual auras. If not treated, vitamin B12 deficiency can cause dementia, spinal cord damage, loss of vision, and permanent nerve damage. I check vitamin B12 levels in all of my patients. The blood test, however, is not always reliable. There are reports of severe deficiency with perfectly normal levels. This is why when a deficiency is suspected, additional tests are needed. These are homocysteine and methylmalonic acid levels. These tests can disclose the presence of a deficiency when vitamin B12 level is in the normal range. To further complicate matters, a report by neurologists at UCSF described a patient with normal blood tests who nevertheless had a severe vitamin B12 deficiency in the brain. They discovered that this patient had antibodies to a receptor (CD320) that is necessary for the uptake of vitamin B12 from the blood into the brain across the blood-brain barrier. The spinal fluid of this patient completely lacked vitamin B12. Her presenting symptoms were difficulty speaking, unsteadiness, and tremor. She had no peripheral manifestations of vitamin B12 deficiency, only those related to the brain. She recovered with high doses of vitamin B12 supplementation and immunosuppressive therapy to reduce the amount of antibodies against the CD320 receptor. The authors screened a few hundred patients with lupus, multiple sclerosis,... --- ### New Daily Persistent Headache may respond to TMS - Published: 2024-10-06 - Modified: 2024-10-06 - URL: https://www.nyheadache.com/blog/new-daily-persistent-headache-may-respond-to-tms/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain Researchers at a hospital in Northern India reported good results in treating New Daily Persistent Headache (NDPH) with repetitive transcranial magnetic stimulation (rTMS). NDPH is a type of headache that begins suddenly and persists daily without specific features, distinct MRI presentation, or blood test abnormalities. It can present similarly to chronic migraines or chronic tension-type headaches. While published reports suggest NDPH is difficult to treat, this is often not the case. However, patients who do not respond to initial standard treatments may become discouraged. The Indian researchers conducted a pilot study with 50 NDPH patients who received 10 Hz rTMS sessions on the left prefrontal cortex of the brain for three consecutive days. They found that after 4 weeks: 70% of patients had at least a 50% reduction in headache severity Patients gained an average of 11 headache-free days per month 76% had significant improvements in headache-related disability Depression and anxiety scores also improved significantly The treatment was well-tolerated, with only minor side effects in a few patients. The benefits seemed especially pronounced in patients who had NDPH that resembled chronic migraine. I never give the diagnosis of NDPH, but diagnose it as a condition it most resembles and treat the person with a wide variety of available options. Many respond. For those who do not, we offer rTMS, a procedure that uses magnetic fields to stimulate nerve cells in the brain. An electromagnetic coil device is placed against the scalp near the forehead. The coil painlessly delivers a magnetic... --- ### The best drug to treat an acute migraine is eletriptan - Published: 2024-09-22 - Modified: 2024-09-22 - URL: https://www.nyheadache.com/blog/the-best-drug-to-treat-an-acute-migraine-is-eletriptan/ - Categories: Chronic migraine, Headache medications, Migraine, Migraine in pregnancy Dr. Messoud Ashina of the Danish Headache Center led a group of European researchers in analyzing the efficacy of migraine medications for treating acute migraine attacks. Their paper published in the British Medical Journal, “Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis”, looked at 137 randomised controlled trials comprising 89,445 participants allocated to one of 17 active interventions or placebo. They concluded that “Overall, eletriptan, rizatriptan, sumatriptan, and zolmitriptan had the best profiles, and they were more efficacious than the recently marketed drugs lasmiditan, rimegepant, and ubrogepant. ” When I decided to specialize in treating headaches in 1987, the options for the treatment of acute migraine attacks were very limited. We had NSAIDs, like aspirin and ibuprofen, opioids (narcotics), and ergotamines. Now, we have a cornucopia of options – seven triptans (the first in this group, sumatriptan, was introduced in 1992), three gepants, and one ditan. Triptans work on serotonin receptors, gepants affect CGRP, and ditan, lasmiditan (Reyvow) works on a different serotonin receptor than triptans. Over more than 30 years, triptans have proven to be exceptionally safe and effective. In many countries, they are sold without a prescription. Since patents for these drugs have mostly expired, they have become inexpensive. Gepants were introduced almost five years ago. Ubrogepant(Ubrelvy) and rimegepant (Nurtec) came out first, and more recently, a nasal spray of zavegepant (Zavzpret) was added to this group. They also appear effective and safe, although they have not... --- ### A novel migraine drug shows promise - Published: 2024-09-08 - Modified: 2024-09-08 - URL: https://www.nyheadache.com/blog/a-novel-migraine-drug-shows-promise/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments Two sets of "designer drugs" have been developed based on our understanding of the neurobiology of migraines. The first, sumatriptan (Imitrex), introduced in 1992, was the pioneer in a class of seven triptan drugs, all targeting serotonin mechanisms. Erenumab (Aimovig), which targets the CGRP (calcitonin gene-related peptide) mechanism, was approved by the FDA in 2018. This class now includes four injectable, three oral, and one nasal drug. Additionally, many older drugs, although not specifically developed for migraine treatment, have proven effective for some patients. Despite these numerous options, a significant minority of patients do not respond to any of these treatments. This is why the development of drugs targeting different parts of the migraine cascade is so promising. Danish neurologists, led by Dr. Mesoud Ashina, have published results from a phase 2 double-blind study of a new drug that blocks PACAP (pituitary adenylate cyclase-activating peptide). In this study, patients were divided into two groups, receiving an infusion of a placebo or two different doses of the active drug, currently known as Lu AG09222, developed by the Danish company Lundbeck. In the final analysis, the reduction in migraine days was compared between 94 patients who received a placebo and 97 patients who received the higher dose of the active drug. The higher dose significantly reduced the number of migraine days in the month following the infusion (6. 2 vs. 4. 2 days reduction). The side effects reported were mild and infrequent. Phase 2 studies are relatively small and short in duration.... --- ### What can you do about long COVID - Published: 2024-08-26 - Modified: 2024-08-26 - URL: https://www.nyheadache.com/blog/what-can-you-do-about-long-covid/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments Long COVID, also known as post-COVID conditions, can present with a wide range of symptoms that persist for weeks or months after the initial COVID-19 infection. The most common symptoms of long COVID include: Neurological Symptoms Headaches Difficulty thinking or concentrating, often referred to as "brain fog" Memory problems Changes in smell or taste Psychological Symptoms Depression or anxiety Mood changes Other Symptoms Fatigue or tiredness that interferes with daily life Shortness of breath or difficulty breathing Cough Chest pain or heart palpitations Sleep problems Dizziness when standing up (orthostatic hypotension) Joint or muscle pain Fever Stomach pain or other gastrointestinal issues Changes in menstrual cycles There is evidence of persistent inflammation in people with long COVID. This inflammation of blood vessels, brain tissues, and other organs is likely the cause of all of the above symptoms. Receiving a COVID vaccination may prolong the symptoms of long-term COVID-19 in people who have already contracted COVID and now suffer from long COVID. However, vaccines seem to reduce the risk of severe COVID and long COVID. Unfortunately, we do not have any proven therapies for long COVID. However, it is very important to make sure that nutritional deficiencies do not contribute to long COVID symptoms. I often find a deficiency of vitamin B12 and other B vitamins, vitamin D, magnesium, CoQ10, omega-3 fatty acids, zinc, and others. I recommend looking at your test results yourself since doctors may glance at the report and tell you everything is fine if nothing is flagged.... --- ### Disruption of brain networks by chronic pain can be prevented. - Published: 2024-08-18 - Modified: 2024-08-18 - URL: https://www.nyheadache.com/blog/disruption-of-brain-networks-by-chronic-pain-can-be-prevented/ - Categories: Alternative Therapies, Brain disorders, Pain, Pain Research, Psychology of headaches Chronic pain is known to alter the brain's default mode network (DMN). The DMN is a group of interconnected brain regions activated when a person is not focused on the external world. Key DMN functions include mind wandering (daydreaming, thinking about the past or future, imagining scenarios), self-reflection (considering thoughts, feelings, and experiences), theory of mind (understanding others' thoughts and intentions), and memory (retrieval and processing). A recent study published in the journal Pain by German researchers investigated the relationship between chronic back pain and DMN alterations. The study, titled "Beyond the chronic pain stage: default mode network perturbation depends on years lived with back pain," examined patients with chronic back pain (CBP), subacute back pain (SBP), and healthy controls using fMRI. Results showed that the DMN is significantly altered in CBP patients compared to healthy individuals. Importantly, the degree of DMN disruption increased with the duration of pain, suggesting that the brain adapts to persistent pain over time. This adaptation is influenced by cognitive coping strategies or how individuals mentally manage their pain. The study found that coping attitudes mediate the link between DMN changes and pain duration. This implies that how people think about and handle pain impacts their brain's adaptation to it. Effective pain coping strategies could potentially lessen the negative effects of chronic pain on the brain, emphasizing the importance of psychological interventions like meditation, cognitive behavioral therapy (CBT), and acceptance-commitment therapy (ACT). These findings also provide a scientific basis for treatments like transcranial magnetic stimulation... --- ### If two antidepressants fail, TMS may offer relief. - Published: 2024-08-11 - Modified: 2024-08-11 - URL: https://www.nyheadache.com/blog/if-two-antidepressants-fail-tms-may-offer-relief/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headache medications, neurostimulation, Psychology of headaches The FDA approved transcranial magnetic stimulation (TMS) to treat anxiety, depression, and OCD about 15 years ago. Most insurers cover this treatment. However, it remains highly underutilized. A study just published by Dutch researchers in Psychiatry Online compared TMS with a third antidepressant in people who did not respond well to two different antidepressants. Both treatments were combined with psychotherapy. 89 people with depression who hadn't improved with at least two previous treatments took part. They were randomly assigned to either TMS or a new antidepressant. The treatment lasted eight weeks. TMS involved 25 sessions of magnetic stimulation. The medication group switched to a new antidepressant following standard guidelines. The primary outcome measure was the degree of improvement in depression symptoms. TMS was more effective than switching medications. More people responded well to MS (38% vs 15%) and more people's depression went into remission with TMS (27% vs 5%). TMS was better at improving symptoms of anxiety and lack of enjoyment (anhedonia) Both treatments were equally effective for improving sleep, overthinking, and negative thought patterns. People's expectations about their treatment were linked to how much their depression improved. In conclusion, for people with depression that hasn't responded well to a couple of medication attempts, TMS might be a more effective option than trying another antidepressant. The study also suggests that the choice between TMS and medication might depend on which specific symptoms a person struggles with most. We started using TMS for people with migraine headaches if they do not... --- ### Focused ultrasound to specific brain regions relieves pain - Published: 2024-08-04 - Modified: 2024-08-04 - URL: https://www.nyheadache.com/blog/focused-ultrasound-to-specific-brain-regions-relieves-pain/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, neurostimulation, New treatments, Pain The use of focused ultrasound to treat brain disorders was one of the topics discussed at the 2024 NYC Neuromodulation Conference in NYC. Coincidentally, a study on this topic was published last month by Jan Kubanek and his colleagues in Pain, the journal of the International Association for the Study of Pain: “Noninvasive targeted modulation of pain circuits with focused ultrasonic waves”. Researchers developed a technique that targets the anterior cingulate cortex, a deep brain region involved in processing pain. By using focused ultrasound, this region can be modulated without surgery. This breakthrough has the potential to revolutionize pain management. Twenty patients with chronic pain participated in a randomized crossover trial. They received two 40-minute sessions of either active or sham stimulation and were monitored for one week. The results were remarkable: 60% of patients experienced a significant reduction in pain on day 1 and day 7 after active stimulation. Sham stimulation only benefited 15% and 20% of patients, respectively. Active stimulation reduced pain by 60. 0% immediately after the intervention and by 43. 0% and 33. 0% on days 1 and 7. Sham stimulation only reduced pain by 14. 4%, 12. 3%, and 6. 6% on the same days. The stimulation was well tolerated and the side effects were mild and resolved within 24 hours. Since we have been using transcranial magnetic stimulation (TMS) to treat refractory migraines and other neurological conditions, it was good to read this part of the authors’ conclusion: “The ultrasonic intervention is conceptually related... --- ### Another MRI study attempts to diagnose migraine - Published: 2024-07-22 - Modified: 2024-07-22 - URL: https://www.nyheadache.com/blog/another-mri-study-attempts-to-diagnose-migraine/ - Categories: Brain disorders, Chronic migraine, Headaches, Migraine, neurostimulation, Science of Migraine The diagnosis of migraine still relies on the patient's description of symptoms. We do not have an objective test to confirm the diagnosis. Several studies using functional MRI (fMRI) attempted to identify people with migraines. A new study published by Korean doctors in The Journal of Headache and Pain used a different imaging technique to achieve this goal. The researchers used diffusion MRI, a technique that focuses on the movement of water molecules within the brain's tissues (fMRI measures blood flow to different areas of the brain). It is particularly useful for mapping the brain's white matter tracts, which are the pathways that connect different brain regions. 47 patients with migraine were compared to 41 healthy controls Significant differences were found in brain regions such as the orbitofrontal cortex, temporal pole, and sensory/motor areas. Changes in connections between deeper brain structures (like the amygdala, accumbens, and caudate nuclei) were also noted. Using machine learning, the researchers could distinguish between migraine patients and healthy individuals based on these brain connectivity features. Hopefully, larger studies and easier access to advanced imaging techniques may eventually lead to an objective test of migraines. More importantly, identifying specific connectivity patterns may lead to more individualized treatments. These could be treatments with pharmaceuticals or neurostimulation techniques such as transcranial magnetic stimulation (TMS), which we use in our clinic. --- ### Some people's genes prevent them from having migraines - Published: 2024-07-09 - Modified: 2024-07-09 - URL: https://www.nyheadache.com/blog/some-peoples-gene-prevent-them-from-having-migraines/ - Categories: Brain disorders, Headaches, Migraine, Science of Migraine Given enough triggers, almost anyone can develop a migraine. There is a very good chance that even someone who has never had a migraine to become sleep-deprived, dehydrated, drunk, and stressed will develop a migraine headache. However, I have encountered people who told me that they have never had a headache and cannot even imagine what a headache would feel like. Scientists have discovered why some people never get headaches.  Researchers studied the DNA of nearly 64,000 people in Denmark, including about 3,000 who reported never having had a headache. The researchers found a specific area in a gene called ADARB2 that seems to protect against headaches. People with a certain variation in this gene were 20% more likely to be completely headache-free. ADARB2 is mostly active in the brain, particularly nerve cells that reduce brain activity. However, scientists don’t fully understand how this gene works yet. While this discovery is exciting, more research is needed to confirm how ADARB2 helps prevent headaches. This study is the first to examine the genetics of being headache-free rather than focusing on what causes headaches. It opens up a new approach to understanding and potentially treating headache disorders. --- ### Creatine is good for your brain, not just muscles - Published: 2024-06-23 - Modified: 2024-06-23 - URL: https://www.nyheadache.com/blog/creatine-is-good-for-your-brain-not-just-muscles/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine Athletes have been using creatine supplementation for over 30 years. It seems to improve the energy supply to muscle tissues and increase fat-free mass. Creatine also supplies energy to nerve cells in the brain. Taking a creatine supplement increases the levels of creatine in muscles and the brain. A review of six studies suggested that creatine improves short-term memory, intelligence, and reasoning. Creatine did not improve any cognitive abilities in young people. Vegetarians benefited more than non-vegetarians in memory tasks. A study by Taiwanese researchers published in Cephalalgia showed reduced creatine levels in the thalamus (the pain-processing area in the brain) in patients with medication-overuse headaches. Greek doctors published a report, Prevention of traumatic headache, dizziness and fatigue with creatine administration. A pilot study. They studied 39 patients who sustained a severe traumatic brain injury. There were 19 patients in the control group and 20 in the active group. The active group was given 0. 4 g/kg of creatine. Treatment was administered within 4 hours of injury and was continued for 6 months. This treatment improved the duration of post-traumatic loss of memory, the duration of being on a respirator, and the duration of stay in an intensive care unit. They also showed improvement in headaches, dizziness, and fatigue. No side effects were reported. Some studies suggest that creatine can improve bone health. Here is what WebMD says about creatine: "While most people get low amounts of creatine by eating seafood and red meat, larger amounts are found in synthetic creatine... --- ### Another study confirms that candesartan relieves migraines - Published: 2024-06-12 - Modified: 2024-06-12 - URL: https://www.nyheadache.com/blog/another-study-confirms-that-candesartan-relieves-migraines/ - Categories: Chronic migraine, Headache medications, Migraine, Science of Migraine Candesartan ((Atacand) is a blood pressure medication in the class of angiotensin receptor blockers (ARBs). A recently published study involving 86 patients confirmed that candesartan can improve migraines. This was not a double-blind but rather an observational study, meaning that the results were not as reliable. However, the study is worth publicizing since candesartan is often overlooked as an effective migraine drug. Here is more about candesartan from my previous post: Candesartan was first shown to work for the prevention of migraine headaches in a 60-patient Norwegian trial published in JAMA in 2003.  This was a double-blind crossover trial, which means that half of the patients were first placed on a placebo and then switched to candesartan and the second group started on candesartan and then were switched to placebo. This trial showed that when compared to placebo, 16 mg of candesartan resulted in a very significant reduction in mean number of days with headache, hours with headache, days with migraine, hours with migraine, headache severity index, level of disability, and days of sick leave. Candesartan was very well tolerated – there was no difference in side effects in patients taking the drug and those taking the placebo. In another trial, the researchers compared candesartan to placebo as well as to propranolol, which is an FDA-approved blood pressure drug for the prevention of migraines. This trial in 72 migraine sufferers compared 16 mg of candesartan with placebo and 160 mg of propranolol. Candesartan and propranolol were equally effective in reducing migraine... --- ### Abnormal functional connectivity in patients with post-traumatic headaches - Published: 2024-06-03 - Modified: 2024-06-03 - URL: https://www.nyheadache.com/blog/abnormal-functional-connectivity-in-patients-with-post-traumatic-headaches/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation A new study from Mayo Clinic researchers, published in The Journal of Headache and Pain, has examined the brain changes associated with acute post-traumatic headaches (PTH). These headaches can occur after a head injury or trauma and can be debilitating. The study involved 60 participants with acute PTH and 60 age-matched healthy controls. Using functional MRI (fMRI), the researchers found two key differences in the brains of PTH patients compared to healthy individuals. Increased Iron Accumulation in Specific Brain Regions First, the PTH patients showed higher levels of iron deposition in two brain areas: the left posterior cingulate and the bilateral cuneus regions. These areas are involved in various functions, including pain processing, attention, and visual processing. The accumulation of iron in these regions may disrupt normal brain function and contribute to the development and persistence of post-traumatic headaches. Abnormal Functional Connectivity Patterns Secondly, the researchers observed stronger functional connectivity between the bilateral cuneus (the visual processing area) and the right cerebellum (a region involved in motor control and coordination, and other functions) in PTH patients compared to healthy controls. Functional connectivity refers to the communication and synchronization between different brain regions. The abnormal connectivity patterns seen in PTH patients suggest disruptions in the brain networks responsible for processing sensory information, including pain signals. Implications for Targeted Therapy While these findings may have lacked utility in the past, they now have important implications for the treatment of post-traumatic headaches. We have been treating patients with repetitive transcranial magnetic stimulation (rTMS),... --- ### Abnormal functional connectivity in brains of patients with vestibular migraine - Published: 2024-05-27 - Modified: 2024-05-27 - URL: https://www.nyheadache.com/blog/abnormal-functional-connectivity-in-brains-of-patients-with-vestibular-migraine/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, post-traumatic headache, Science of Migraine Functional MRI (fMRI) studies have shown that people with migraines have altered functional connectivity and activation patterns in pain-processing brain regions like the insula, thalamus, somatosensory cortex, as well as visual cortex. Some patients also have changes in the default mode and salience networks involved in attention and stimulus processing. A study published this month by Chinese researchers in the Journal of Headache and Pain reports on connectivity changes in people with vestibular migraines. They found abnormal resting-state functional connectivity in brain regions involved in multi-sensory and autonomic processing as well as impaired ocular motor control, pain modulation, and emotional regulation. Until now, there has been little practical application for fMRI findings. However, with the help of Omniscient Neurotechnology, we have just started using fMRI data to better target our treatment with transcranial magnetic stimulation (TMS). TMS applied to motor and visual cortices has been reported to help relieve migraine headaches. We have also found it effective in a significant proportion of patients who did not respond to various other treatments. We have not yet accumulated enough data to determine if fMRI-guided TMS treatment is superior to TMS administered over a predetermined set of targets. The main obstacle to wider use of TMS in clinical practice is the cost. TMS is approved by the FDA and is covered by insurance for the treatment of anxiety and depression, but not migraines or pain. fMRI is an expensive research tool and is also not covered by insurance. Hopefully, the NIH and other... --- ### Our brains are getting bigger, and hopefully, we are getting smarter. - Published: 2024-05-13 - Modified: 2024-05-13 - URL: https://www.nyheadache.com/blog/our-brains-are-getting-bigger-and-hopefully-we-are-getting-smarter/ - Categories: Brain disorders The famous Framingham Heart Study, spanning over 80 years from 1902 to 1985, looked at brain volumes across multiple generations of participants. The study analyzed MRI brain scans from 3,226 participants aged 45-74, born between the 1930s and 1970s. It found significant trends of larger brain volumes in several regions for individuals born in more recent decades:- Intracranial volume, which represents the total brain size, was 6. 6% greater in those born in the 1970s compared to the 1930s. - Cerebral white matter volume, representing connections between brain cells, was 7. 7% greater in the 1970s vs. 1930s cohort. - Hippocampal volume, the area responsible for memory and other functions, was 5. 7% larger in the 1970s compared to the 1930s. - Cortical surface area, which correlates with the number of brain cells, was 14. 9% greater in those born in the 1970s vs. 1930s. The authors suggest these findings likely reflect improvements in early life factors over time, such as better nutrition, education, healthcare, and management of cardiovascular risk factors. While the increase in brain size for any one individual is small, across entire populations, it can have a meaningful impact. Larger brain volumes are associated with higher cognitive abilities and resilience against degenerative neurological diseases like stroke, Parkinson's, and Alzheimer's. So, the gradual increase in brain size over generations, even if subtle, may be contributing to higher average intelligence levels and lower rates of dementia in the population. --- ### EPA in fish oil prevents migraines - Published: 2024-05-05 - Modified: 2024-05-05 - URL: https://www.nyheadache.com/blog/epa-in-fish-oil-prevents-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Science of Migraine Several studies have suggested that fish oil helps prevent migraine headaches. A new clinical trial by Taiwanese doctors provides the strongest evidence for this effect to date. The paper, "A 12-week randomized double-blind clinical trial of eicosapentaenoic acid intervention in episodic migraine" was published this month in the journal Brain, Behavior, and Immunity. Unlike previous studies, this one used a high dose of one of the two omega-3 fatty acids found in fish oil, eicosapentaenoic acid, or EPA. 70 people with episodic migraine participated in a 12-week trial. One group of 35 people took 2 grams of fish oil daily, which contained 1. 8 grams of EPA. The other group of 35 people took a placebo of 2 grams of soybean oil daily. The researchers tracked several measures related to migraine frequency, severity, disability, anxiety/depression, quality of life, and sleep quality before and after the 12 weeks. The results showed that the EPA group did significantly better than the placebo group on multiple measures: - They had 4. 4 fewer monthly migraine days on average compared to 0. 6 fewer days in the placebo group. - They used acute migraine medication 1. 3 fewer days compared to 0. 1 more days in the placebo group. - Their headache severity scores improved more than the placebo group. - Their disability scores related to migraine improved more. - Their anxiety and depression scores improved more. - Their migraine-specific quality of life scores improved more. Notably, women seemed to particularly benefit from taking the... --- ### PPIs are the worst, but all heartburn drugs increase the risk of severe headaches - Published: 2024-04-28 - Modified: 2024-04-28 - URL: https://www.nyheadache.com/blog/ppis-are-the-worst-but-all-heartburn-drugs-increase-the-risk-of-severe-headaches/ - Categories: Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine A new study just published in Neurology showed that people taking proton pump inhibitors (PPIs) such as omeprazole (Prilosec) and esomeprazole (Nexium) have a 70% higher risk of having migraines or severe headaches. The risk was 40% higher with the use of H2 blockers such as famotidine (Pepcid) and 30% higher in those taking generic antacids. The study analyzed data from 11,818 participants out of 31,127 in the National Health and Nutrition Examination Survey who were taking acid-suppressing drugs. Interestingly, those on H2 blockers had a higher migraine risk if they also had a higher intake of magnesium, though this finding was based on only 75 H2 blocker users, making it potentially unreliable. The likely cause of the association between acid-suppressing drugs and headaches is the previously documented decrease in absorption of magnesium, vitamin B12, and other nutrients. PPIs have been also found to increase the risk of dementia. These acid-suppressing drugs are available without a prescription and people assume that they are safe. They are indeed safe when used for short periods of time. Once a person starts taking PPIs, they are very difficult to stop because stopping them often leads to a rebound of acid production. This sometimes makes heartburn worse than before a PPI was started. One way to try to stop them is to switch to an H2 blocker and then, to an antacid such as Gaviscon or Rolaids. For those who require long-term PPI use, supplementing with magnesium, sublingual vitamin B12, and a multivitamin may... --- ### Visit with the Nolan Williams' TMS team at Stanford - Published: 2024-04-24 - Modified: 2024-04-24 - URL: https://www.nyheadache.com/blog/visit-with-the-nolan-williams-tms-team-at-stanford/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache Nolan Williams has been at the forefront of developing breakthrough TMS protocols for the treatment of depression and other psychiatric indications. It was very stimulating and informative to discuss techniques, protocols, indications, and research into TMS for various neurological and psychiatric indications with the members of Nolan Williams' lab Greg Sahlem and Ika Kaloiani. Thank you for sharing your knowledge. --- ### I am honored to speak at the 2024 China Headache Conference - Published: 2024-04-14 - Modified: 2024-04-14 - URL: https://www.nyheadache.com/blog/i-am-honored-to-speak-at-the-2024-china-headache-conference/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine I will be speaking on nutritional supplements for migraines and an update on triptans on April 20, 2024. --- ### Pain relief from transcranial magnetic stimulation is possibly opioid-mediated - Published: 2024-04-07 - Modified: 2024-04-07 - URL: https://www.nyheadache.com/blog/pain-relief-from-transcranial-magnetic-stimulation-is-possibly-opioid-mediated/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Headaches, Headaches in children, Migraine, neurostimulation, New treatments, Pain, Pain Research, Science of Migraine Repetitive transcranial magnetic stimulation (rTMS) is approved by the FDA for the treatment of depression and anxiety. We have been using it to treat migraine headaches and other neurological conditions that are not responsive to standard therapies. Improvement in headaches and pain may be at least in part due to improvement in depression. However, additional mechanisms play a role since we see patients who are not depressed but whose pain improves with rTMS. A new study by Chinese and Australian researchers published in Pain suggests that opioid mechanisms (endorphins, encephalin, and other peptides) may underlie the mechanism of pain relief produced by rTMS. This was a double-blind, placebo-controlled study. 45 healthy participants were randomized into 3 groups: one receiving rTMS over the primary motor cortex (M), dorsolateral prefrontal cortex (DLPFC), or sham stimulation. Experimental pain was induced by applying capsaicin (hot pepper extract) over the skin of the right hand followed by application of heat. Participants received intravenous naloxone (an opioid receptor antagonist) or saline before the first rTMS session to block or allow opioid effects, respectively.  After 90 minutes to allow naloxone metabolism, participants received a second rTMS session. For the M1 group, naloxone abolished the analgesic effects of the first rTMS session compared to saline. Pain relief returned in the second session after naloxone was washed out of the body.  For the DLPFC group, only the second prolonged rTMS session induced significant analgesia in the saline condition compared to naloxone.  rTMS over M1 selectively increased plasma ? -endorphin... --- ### New Survey Sheds Light on High Migraine Burden and the Unhelpful Label of “Acute Medication Overuse” - Published: 2024-03-25 - Modified: 2024-03-25 - URL: https://www.nyheadache.com/blog/new-survey-sheds-light-on-high-migraine-burden-and-the-unhelpful-label-of-acute-medication-overuse/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine A recent national survey called the "Harris Poll Migraine Report Card" provides insight into the profound impact migraine has on people's lives, especially those dealing with frequent attacks and high acute medication use. The survey compared those currently experiencing high-frequency migraine (8 or more attack days per month) and using acute medication on 10 or more days per month, to those who previously had this pattern but now have reduced attack frequency and medication use. Most respondents were first diagnosed with migraine or headache disorders in their mid-20s. However, despite meeting criteria for migraine, one-third did not self-identify as having migraine disease. This underscores how migraine is still underrecognized and misdiagnosed, with people often being mislabeled with terms like "stress headache. " Regardless of diagnosis, the burden was clear - over 50% reported a negative impact on their overall quality of life. What's more, at least half had experienced anxiety or depression, with almost half to over half saying migraine negatively affected their mental/emotional health. These findings align with prior research showing a significant burden can start at just 4 monthly migraine days. In an attempt to improve their condition, most made lifestyle changes like stress management, limiting caffeine and improving diet. However, their treatment choices differed - those with more frequent migraine were more likely to use newer acute treatments like gepants, diclofenac and dihydroergotamine compared to the other group using more NSAIDs, triptans and ergotamines. The high-frequency group was also more inclined to try non-pharmacological options like supplements,... --- ### Another study on triptan safety - Published: 2024-03-14 - Modified: 2024-03-14 - URL: https://www.nyheadache.com/blog/another-study-on-triptan-safety/ - Categories: Brain disorders, Headache medications, Migraine A study published in the current issue of JAMA Neurology examined the risk of stroke and myocardial infarction (heart attack) after starting a triptan. Triptans have been in use for over 30 years and include drugs such as sumatriptan (Imitrex), rizatriptan (Maxalt), and five others. In many countries, they are sold without a prescription. Danish researchers identified 429,612 individuals who redeemed their first prescription for a triptan. Unlike all previous studies, they found a slight increase in the risk of stroke or heart attack. Surprisingly, in the abstract of this report, the authors present higher unadjusted numbers than in the discussion section. Of those 429,612 patients, 13 had a heart attack or a stroke within a week or two after they filled the prescription. This means that the risk is 1 in 30,000. Notably, patients who suffered from a stroke or heart attack were older than 60 and had risk factors for cardiovascular disease, such as hypertension, diabetes or previous heart attacks and strokes. The authors concluded that their study supports the current US FDA recommendation that triptans should not be prescribed to patients with a history of coronary artery disease, transient ischemic attacks, or stroke. They also stated that their "findings do not raise concern" about triptan use in patients with low cardiovascular risk. In a previous post, I mentioned a report that found NSAIDs such as ibuprofen, and naproxen to be more likely to cause major cardiovascular events than triptans in a ratio of 3. 8 to 1.... --- ### CGRP drugs in pregnancy - Published: 2024-03-02 - Modified: 2024-03-02 - URL: https://www.nyheadache.com/blog/cgrp-drugs-in-pregnancy/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine, New treatments A new report suggests that CGRP-blocking drugs (CGRP-A) are safe in pregnancy. In the latest study, Swiss doctors examined the World Health Organization's pharmacovigilance database and looked at reporting differences between CGRP drugs and triptans. Triptans (drugs like sumatriptan or Imitrex and six others) were introduced over 30 years ago.   We know frompregnancy registries, retrospective, and prospective observationalstudiesthat triptans are safe in pregnancy. The WHO database had 467 safety reports of exposure to CGRP-A in pregnancy. Of these, 386 were reports of exposure to CGRP monoclonal antibodies (mAbs), 76 to gepants, and 5 to both. The authors found "... no signals of increased reporting with CGRP-A compared to triptans in relation to pregnancy". CGRP drugs represent a major breakthrough in treating migraine headaches. A large proportion of migraine sufferers are women of childbearing age. We always have to consider the effect of a drug on the developing fetus. Erenumab (Aimovig), the first drug in this category was introduced almost six years ago. This is a relatively short period to assess the safety of a drug in pregnant women and the current report is not a definitive proof of safety. There might be a difference in safety between oral CGRP antagonists (gepants), which are small molecules and injectable mAbs, which are large molecules. Gepants have the advantage of being completely washed out of the body within a few days of stopping them.   Monoclonal antibodies are injected every one or three months and can take a few months to completely leave the... --- ### Caffeine and headaches - Published: 2024-02-26 - Modified: 2024-02-26 - URL: https://www.nyheadache.com/blog/caffeine-and-headaches/ - Categories: Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine A new study by Harvard researchers suggests that there is no connection between caffeine consumption and migraine headaches. I am not convinced. This study was small and had only 12 out of 97 participants consume 3-4 cups a day, while 65 consumed 1-2 cups and 20 consumed no caffeine. Statistics based on such small numbers are unreliable. Most headache sufferers who drink large amounts of caffeine develop a caffeine-withdrawal headache when they don't get their usual dose of caffeine on time.   My most dramatic case was that of a man who drank about 10 cups of coffee a day. He also set an alarm for 3 AM to have a cup of coffee. If he skipped that 3 AM cup, he would wake up with a debilitating migraine. A double-blind caffeine withdrawal study published in the New England Journal of Medicine. It showed that 52% of people consuming an average of 2. 5 cups of coffee developed a moderate or severe headache when caffeine was stopped. Caffeine can play positive role in the treatment of migraine and tension-type headaches. It is considered to be an adjuvant analgesic and is included in over-the-counter and prescription drugs along with pain medications. It enhances pain relief produced by acetaminophen, aspirin, and other pain drugs. The problem arises from excessive intake of caffeine. Two cups of coffee at breakfast, a cup of caffeinated soda at lunch, and a couple of Excedrin do not appear excessive until you consider the total amount of caffeine... --- ### Monitoring your blood sugar levels - Published: 2024-02-19 - Modified: 2024-02-19 - URL: https://www.nyheadache.com/blog/monitoring-your-blood-sugar-levels/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Headaches in children, Migraine, Science of Migraine Because of my research and publications on magnesium, I was contacted by Nutrisense. This company helps people without diabetes improve their diet and "metabolic health". They are interested in educating people about the role of magnesium, a very underappreciated mineral. The company offered me a free 2-week trial of their continuous glucose monitor (CGM). I have a healthy diet and normal weight so I was not sure that I could get any useful information. But I thought that some of my patients could benefit and wanted to see what they would experience. CGM did provide some interesting observations. After exercise, I gulped down 12 oz of unsweetened coconut water. My glucose went up to 150, the upper limit of what is considered normal. I ate a golden delicious apple for a snack one afternoon. Healthy, isn't it? My glucose level shot up to 165. The next day, I went to a birthday party for a 3-year-old and ate two slices of pizza, without toppings. The glucose level went up to 164. Another night, I had some sushi. The level was 169 (sushi rice is always cooked with sugar). Then, after dinner out with my family, we decided to have ice cream. I had two scoops with the good excuse of wanting to see how high my glucose would go. Surprisingly, it went up only to 151. It is well known that eating protein and fat first will slow down the absorption of carbohydrates. This is why an apple, eaten between... --- ### If you are healthcare provider, attend the annual meeting of the Headache Cooperative of the Northeast - Published: 2024-02-10 - Modified: 2024-02-10 - URL: https://www.nyheadache.com/blog/if-you-are-healthcare-provider-attend-the-annual-meeting-of-the-headache-cooperative-of-the-northeast/ - Categories: Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Head trauma, Headache medications, Headaches, injections, Migraine, neurostimulation, Psychology of headaches I am once again honored to participate in the annual meeting of the Headache Cooperative of the Northeast to be held March 7-9 at the Stamford Marriott Hotel and Spa in Stamford, CT. You will get a chance to learn about the latest scientific breakthroughs from Rami Burstein, president of the International Headache Society. You will also hear from other prominent figures in the field, renowned for their pioneering work and extensive contributions over several decades - Drs. Steven Baskin, Elizabeth Loder, Thomas Ward, Morris Levin, Richard Lipton, Steven Silberstein, Allan Purdy, Alan Rapaport, Paul Rizzoli, Sait Ashina, and others. --- ### More on TMS - Published: 2024-02-08 - Modified: 2024-02-08 - URL: https://www.nyheadache.com/blog/more-on-tms/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headaches, Headaches in children, Migraine, neurostimulation, New treatments, Pain, post-traumatic headache, Trigeminal and other neuralgias We use a neuronavigation system from Soterix (on the left) for precise targeting of transcranial magnetic stimulation (TMS). And we use the most advanced TMS machine from MagVenture (on the right) to treat chronic pain, migraines, fibromyalgia, and other neurological conditions. --- ### TMS for medication overuse (rebound) headaches - Published: 2024-01-28 - Modified: 2024-01-28 - URL: https://www.nyheadache.com/blog/tms-for-medication-overuse-rebound-headaches/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache Medication overuse or rebound headaches can occur as the result of excessive intake of caffeine, opioid analgesics, and short-acting barbiturate drug, butalbital (contained in Fioricet, Esgic and similar drugs). These three substances not only worsen migraine headaches, they are also addictive.   Two of my patients with medication overuse headaches were able to stop the offending drugs with the help of repetitive transcranial magnetic stimulation (rTMS). One patient, a 51-year-old man, had his migraines under control with Botox and infusions of eptinezumab (Vyepti) until he sustained a head injury with a skull fracture. His migraines worsened and he became disabled. A variety of therapies failed to reduce his pain. His pain was partially relieved by 60 mg of oxycodone a day, although he still was unable to work. After six weekly sessions of rTMS he was able to start reducing his oxycodone intake and after eight, he completely stopped it. He was able to return to work with the help of injections of fremanezumab (Ajovy). Another patient, a 50-year-old woman, had been taking butalbital with caffeine and acetaminophen (Fioricet) for 20 years. The number of pills increased over time and for the previous several years, she had been taking 10 to 12 tablets every day. She was also receiving Botox injections, infusions of eptinezumab, and taking rizatriptan (Maxalt), 10 mg three times a day as well as 60 mg of nortriptyline, 12 mg of tizanidine nightly and atogepant, 60 mg. She had tried a wide variety of other treatments but... --- ### We now offer transcranial magnetic stimulation (TMS) for migraines and other neurological conditions - Published: 2024-01-20 - Modified: 2024-01-20 - URL: https://www.nyheadache.com/blog/we-now-offer-transcranial-magnetic-stimulation-tms-for-migraines-and-other-neurological-conditions/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, Headaches in children, Migraine, Migraine in pregnancy, neurostimulation, New treatments, Pain, Pain Research, post-traumatic headache Neurologists frequently find themselves managing patients resistant to standard treatments due to limited proven therapies for many neurological conditions. Some patients cannot tolerate or have contraindications to medications, particularly for such common disabling conditions like migraine and chronic pain.  One promising treatment is transcranial magnetic stimulation (TMS). It is a proven procedure for anxiety, depression, obsessive-compulsive disorder (OCD), smoking cessation, and acute migraines. TMS utilizes magnetic fields to stimulate nerve cells in the brain that are underactive or reduce the excitability of overactive cells. TMS can change the flow of information between different parts of the brain in various neurological conditions. Published reports show the potential benefit of TMS in fibromyalgia, neuropathic pain, cluster headaches, facial pain, trigeminal and other neuralgias, back pain, insomnia, memory disorders, tinnitus, post-concussion syndrome, post-traumatic stress disorder (PTSD), restless leg syndrome, and long COVID. The evidence for the efficacy of TMS for these neurological disorders, however, is still limited. Single-pulse TMS is approved by the FDA for the acute treatment of migraines with aura. The patient uses a portable device during the aura phase to self-administer a single pulse of TMS to the back of the head. This can abort the attack. Repetitive TMS (rTMS) has been studied for the prevention of migraines and other types of pain. It appears effective, but compared to depression trials, migraine studies were relatively small and the FDA has not cleared rTMS for the treatment of migraines. This means that insurance companies are not likely to pay for this... --- ### More on the dangers of PPIs such as Prilosec, Nexium, Dexilant, et al. - Published: 2024-01-14 - Modified: 2024-01-14 - URL: https://www.nyheadache.com/blog/more-on-the-dangers-of-ppis-such-as-prilosec-nexium-dexilant-et-al/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine Proton Pump Inhibitors (PPIs) are a class of medications commonly used to treat conditions such as acid reflux, ulcers, and heartburn. They include omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), Dexlansoprazole (Dexilant), and pantoprazole (Protonix). Several of these are available without a prescription. While PPIs are generally considered safe and effective, several studies have suggested a potential association between PPI use and several medical and neurological problems. These include osteoporosis, kidney problems, impaired hearing, vision, memory, and an increased risk of conditions such as migraines, dementia, peripheral neuropathies, and seizures. The evidence is circumstantial and not definitive. However, considering the large number of studies and a large number of conditions, PPIs are probably not safe for long-term use. In the case of migraines, one study found that past and current use of PPI increased the odds of migraine by 2. 56-fold and 4. 66-fold, respectively. The exact reason for this link is still a mystery, but researchers are exploring several possibilities: Nutrient deficiencies: PPIs can interfere with the absorption of important nutrients like vitamin B12, other B vitamins, and magnesium, which can contribute to headaches. Gut microbiome changes: PPIs can alter the gut microbiome, which may indirectly impact brain function and migraine susceptibility. Inflammation: Some studies suggest PPIs might trigger low-grade inflammation, a potential factor in migraine development. This post was prompted by a recent study showing an association between PPI intake and the risk of dementia. Those who used PPIs for a cumulative four and a half years or longer had a 33%... --- ### Attend the Diamond Research & Educational Foundation's course - Published: 2024-01-06 - Modified: 2024-01-06 - URL: https://www.nyheadache.com/blog/attend-the-diamond-research-educational-foundations-course/ - Categories: Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Cluster headaches, Head trauma, Headache medications, Headaches, Headaches in children, injections, Migraine, Migraine in pregnancy, New treatments, Science of Migraine 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.     --- ### Have your homocysteine level checked - Published: 2024-01-01 - Modified: 2024-01-01 - URL: https://www.nyheadache.com/blog/have-your-homocysteine-level-checked/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Migraine, Science of Migraine 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. Highhomocysteinelevels are associated with an increased risk of cardiovascular disease, cancer, and migraine with aura. High homocysteine levels may also mean you have avitamin 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 includecholestyramine, 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. A recent large study of the role of pollution in the development of dementia revealed that pollution increases this risk only in those with high homocysteine levels. The good... --- ### Why sleep regularity is important - Published: 2023-12-25 - Modified: 2023-12-25 - URL: https://www.nyheadache.com/blog/why-sleep-regularity-is-important/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Science of Migraine Lack 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... --- ### More on combination supplements - Published: 2023-12-21 - Modified: 2023-12-21 - URL: https://www.nyheadache.com/blog/more-on-combination-supplements/ - Categories: Alternative Therapies, Chronic migraine, Headaches in children, Migraine My recent blog post on supplement combinations mentioned one that contains magnesium, riboflavin, and feverfew. I did not mention its name to avoid the appearance of a conflict of interest. I am a paid consultant to the manufacturer. However, many readers of this blog want to know the name of this mystery product. It is called MigreLief. Akeso, the manufacturer, also makes several related products. One is MigreLief NOW, which contains magnesium, feverfew, ginger, and boswellia. Both ginger and boswellia have proven anti-inflammatory properties. Another product is a daily MigreLief supplement for children. It also contains magnesium, riboflavin and feverfew but at a lower dose and in smaller caplets. --- ### Migraine and thyroid disease - Published: 2023-12-11 - Modified: 2023-12-11 - URL: https://www.nyheadache.com/blog/migraine-and-thyroid-disease/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Science of Migraine The thyroid function test is in the initial battery of blood tests we order on all our headache patients (along with RBC magnesium, vitamins D, B12, folate, and others). Having either an overactive or underactive thyroid is known to worsen migraine headaches. A new study published by Indian researchers confirmed that treating an underactive thyroid improves headaches. The researchers studied 87 headache patients with a mild decrease in thyroid function. Half of them were prescribed thyroid medicine and the other half received a placebo. Correcting thyroid deficiency improved headache frequency, severity, and disability (MIDAS score) at three months of follow-up in the treatment group compared to the placebo group. The conclusion was that it is logical to check thyroid function status in patients presenting with migraine headaches. Thyroid function can sometimes decline precipitously and cause worsening of headaches without any other symptoms. This can happen after delivering a baby and the cause is often misinterpreted. Lack of sleep, stress, hormonal changes (female hormones, not thyroid hormone), occlusion of veins inside the head, and even stroke are suspected.   All those conditions can cause headaches after the delivery. But we should not forget to check the thyroid. --- ### fMRI scan can establish the diagnosis of migraine - Published: 2023-12-02 - Modified: 2023-12-02 - URL: https://www.nyheadache.com/blog/fmri-scan-can-establish-the-diagnosis-of-migraine/ - Categories: Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Science of Migraine 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... --- ### Meditation can be harmful - Published: 2023-11-26 - Modified: 2023-11-26 - URL: https://www.nyheadache.com/blog/meditation-can-be-harmful/ - Categories: Alternative Therapies, Chronic migraine, Migraine, Psychology of headaches I tell most of my patients that after physical exercise, meditation is the second-best preventive treatment for migraine headaches. It turns out that meditation is not an unalloyed good. In a recent podcast, Tim Ferris interviews a psychologist, Dr. Willoughby Britton whose research is devoted to the negative effects of meditation. Tim Ferris describes his experience of going on a week-long silent meditation retreat, while also fasting and taking psychedelic mushrooms. It is not too surprising that Tim Ferris ended up needing professional help. However, even meditation alone, if taken to an extreme can cause psychological problems. In California, the joke is that meditation is a competitive sport. Dr. Britton and her colleagues identified a staggering 59 different symptoms that can be triggered by meditation. Cheetah House, an organization led by Dr. Britton, is dedicated to assisting individuals who have experienced negative effects from meditation. According to one study, the most common adverse effects are anxiety, traumatic re-experiencing, and heightened emotional sensitivity. Those with a history of adverse childhood experiences are at a higher risk. But surprisingly, even individuals with adverse effects reported being glad they had meditated. Dr. Britton suggests that meditating for less than 30 minutes is not likely to result in negative effects. I have been meditating for years, and it was only when I extended my meditation time to 45 minutes about a year ago that my migraines completely stopped. Fortunately, I have not encountered any side effects. --- ### Combining supplements - Published: 2023-11-20 - Modified: 2023-11-20 - URL: https://www.nyheadache.com/blog/combining-supplements/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine Every patient visiting our clinic undergoes a routine blood test, which includes an assessment for magnesium and vitamin deficiencies. We know that close to 50% of patients with migraines are deficient in magnesium and many are deficient in riboflavin and other nutrients. In addition to vitamins and magnesium, we often recommend herbal supplements. One of the herbal remedies that has been used for centuries, is feverfew. It is helpful not only for migraines but also for fever, arthritis, and other conditions. Often referred to as "medieval aspirin". Most importantly, it has proven to be safe, that is if it is manufactured by a reputable company or you grow your own. Many patients find it daunting to have to take multiple tablets every day. There are several products on the market that combine various supplements in one tablet. One such supplement that has been on the market the longest, includes magnesium, riboflavin (vitamin B2), and feverfew. I've helped develop and promote this combination, so I may be biased. However, it has high-quality ingredients and the same experienced and knowledgeable team that developed it still stands behind it. Some products also include CoQ10. One-third of migraine sufferers are deficient in this supplement. Because CoQ10 is relatively expensive, many combination products contain insufficient amounts of it. I usually check CoQ10 levels in the blood and if a patient is deficient, I recommend that she takes it separately, 200-300 mg a day. An important consideration is that you may have a vitamin or RBC... --- ### Shingles vaccine for the prevention of cluster headaches - Published: 2023-11-12 - Modified: 2023-11-12 - URL: https://www.nyheadache.com/blog/shingles-vaccine-for-the-prevention-of-cluster-headaches/ - Categories: Alternative Therapies, Cluster headaches, Headache medications, Headaches, New treatments Cluster headaches arguably cause the worst imaginable pain, hence the moniker, suicide headaches.   Fortunately, there are many treatments for this condition, including two FDA-approved drugs. One is sumatriptan injections taken as needed to stop an attack. The other is a preventive monthly injection of galcanezumab (Emgality). We also use Botox injections, oxygen and a variety of medications. Nevertheless, some people do not respond to these treatments. A report by Japanese neurologists from Tokyo suggests a new treatment. One theory of the origin of cluster headaches is the reactivation of the varicella-zoster virus that causes chickenpox and shingles. The study included over 160 patients with episodic cluster headaches who received a shingles vaccine. The response to the vaccine was measured by the amount of antibodies in the blood. Those patients who had more antibodies had a longer delay to the next cluster episode than those with low antibody counts. They also found that those who had a COVID infection and received multiple COVID vaccines, tended to do worse. It is premature to recommend shingles vaccine to patients with cluster headaches unless they are over 50, the age when everyone is advised to get it. --- ### More research on vitamin D and migraine - Published: 2023-11-06 - Modified: 2023-11-06 - URL: https://www.nyheadache.com/blog/more-research-on-vitamin-d-and-migraine/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine, New treatments There is growing evidence that vitamin D is important in the development and treatment of migraines. In the past 15 years, I have written a dozen posts on the role of vitamin D in migraines. At the last meeting of the International Headache Society, Maria Papasavva and her Greek colleagues presented a study entitled, Genetic variability in vitamin D receptor and migraine susceptibility: a case-control study. Their study aimed to investigate an association of three genetic variants of vitamin D receptor with the susceptibility to develop migraine. DNA sample was collected and extracted from 191 patients diagnosed with migraine and 265 headache-free subjects. According to their statistical analysis, a significant association between migraine susceptibility and abnormal variants of vitamin D receptors was found.   They also showed a significant association of two variants with migraine without aura. Their conclusion was that there is a clear association between migraine susceptibility and two vitamin D receptor variants. This further supports the role of vitamin D and its receptor in migraine. Vitamin D is important not only for migraines but also for your immune system. Vitamin D deficiency increases the risk of COVID and other viral infections. Lower levels of vitamin D are associated with a higher risk of attacks of multiple sclerosis even if the level is still within normal range. There are many other reasons to maintain your blood vitamin D level at least in the middle of the normal range. The normal range is 30 to 100, so keep it... --- ### A double-blind study of cannabis for the acute treatment of migraine - Published: 2023-10-30 - Modified: 2023-10-30 - URL: https://www.nyheadache.com/blog/a-double-blind-study-of-cannabis-for-the-acute-treatment-of-migraine/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, New treatments Since the legalization of medical marijuana in New York in 2014, I have prescribed it to several hundred patients. My experience suggests that approximately one-third of my patients benefit from its use and continue to rely on it for their medical needs. Some have reported relief from symptoms such as nausea and anxiety, often associated with migraines, while others find it highly effective in aiding sleep. Additionally, there are patients who have reported significant pain relief. It is possible that the relatively low response rate I see in my patients is due to the fact that I reserve medical marijuana for those patients who do not respond to multiple drugs. At the recent meeting of the International Headache Society, Dr. Nathaniel Schuster and his colleagues presented a study titled "Vaporized cannabis versus placebo for the acute treatment of migraine: a randomized, double-blind, placebo-controlled, crossover trial. " This study aimed to investigate the potential of medical marijuana in alleviating pain and associated migraine symptoms. In this study, participants were instructed to treat moderate-to-severe migraine attacks within four hours of onset using vaporized cannabis flower. They were asked to treat up to four separate migraine attacks, using vaporized cannabis with different compositions: 1) THC-dominant (6% THC), 2) CBD-dominant (11% CBD), 3) THC/CBD mix (6% THC/11% CBD), and 4) placebo cannabis, with the order randomized and double-blinded. Out of the 92 participants enrolled, 71 treated at least one migraine attack. Two hours after vaporization, the THC/CBD mix outperformed the placebo in achieving pain... --- ### Another report on triptan safety - Published: 2023-10-22 - Modified: 2023-10-22 - URL: https://www.nyheadache.com/blog/another-report-on-triptan-safety/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine A presentation by Jing Jie Yu, Joshua E. Levine, and others from U. of Florida at the last meeting of the International Headache Society described their analysis of the potential risks of triptans. Triptans are drugs that were first approved in 1992 and include sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert),  and frovatriptan (Frova). Because triptans have the potential to constrict blood vessels they are contraindicated in patients who have coronary artery disease (CAD) or cerebrovascular disease (CVD). The study was entitled, Association between Triptan Use and Cardiovascular Disease and All-Cause Mortality among Patients with Migraine: A Systematic Review and Meta-analysis This meta-analysis of several studies showed that triptan use was not associated with increased risk of stroke, TIA, or all-cause death risk but with a decreased CAD risk in migraine patients. A report presented in 2022 showed not only that triptans are safe in people without CVD, but are relatively safe even in those who have CVD. The risk of major adverse cardiovascular events with triptans was 1% while with NSAIDs, such as ibuprofen and naproxen, it was 3. 8%.   --- ### Magnificent Magnesium and Movement Disorders - Published: 2023-10-15 - Modified: 2023-10-15 - URL: https://www.nyheadache.com/blog/magnificent-magnesium-and-movement-disorders/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine Magnificent Magnesium is the title of a book my colleague and friend, cardiologist Dr. Dennis Goodman wrote about this underappreciated mineral. Magnesium produces magical results, albeit only in those who are deficient.   And millions of Americans are deficient. Our research has shown that close to half of migraine sufferers are. Magnesium saves lives in cardiac care units by reducing the risk of arrhythmias. It is given intravenously for acute asthma attacks and treats eclampsia and pre-eclampsia in pregnancy. The list goes on. A report by Canadian neurologists just published in a leading neurology journal, Neurology, describes magnesium’s role in the treatment of movement disorders. Sixty patients with low magnesium levels who had a movement disorder were identified in medical journals. Movement disorders observed were postural tremor (14 patients), resting tremor (5), intention tremor (6), ataxia involving the trunk (29) or limbs (15) and dysarthria (13), athetosis (5), myoclonus (4), and chorea (1). Some patients also had downbeat nystagmus, tetany (muscle cramping), drowsiness, vertigo, and proximal muscle weakness. The most common culprit in these patients was a class of drugs called proton pump inhibitors (PPIs). These are drugs like omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and dexlansoprazole (Dexilant). They are known to interfere with the absorption of not only magnesium but also other vitamins. Long-term users of these drugs are at a higher risk of dementia, most likely because they prevent absorption of vitamin B12.   I try to get all of my patients off PPIs. This is not easy... --- ### New Daily Persistent Headache is very treatable - Published: 2023-10-09 - Modified: 2023-10-09 - URL: https://www.nyheadache.com/blog/new-daily-persistent-headache-is-very-treatable/ - Categories: Alternative Therapies, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments, Psychology of headaches, Science of Migraine 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... --- ### Gut bacteria and migraine - Published: 2023-09-18 - Modified: 2023-09-18 - URL: https://www.nyheadache.com/blog/gut-bacteria-and-migraine/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, New treatments, Science of Migraine Most 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... --- ### Anxiety may facilitate transformation of pain from acute to chronic - Published: 2023-09-07 - Modified: 2023-09-07 - URL: https://www.nyheadache.com/blog/anxiety-may-facilitate-transformation-of-pain-from-acute-to-chronic/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Psychology of headaches, Science of Migraine Our 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... --- ### A better fix for Benign Paroxysmal Positional Vertigo - Published: 2023-08-21 - Modified: 2023-08-21 - URL: https://www.nyheadache.com/blog/a-better-fix-for-benign-paroxysmal-positional-vertigo/ - Categories: Brain disorders, Chronic migraine, Migraine, New treatments, Science of Migraine People 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. --- ### The role of a physical therapist in treating migraines - Published: 2023-08-14 - Modified: 2023-08-14 - URL: https://www.nyheadache.com/blog/the-role-of-a-physical-therapist-in-treating-migraines/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, Migraine in pregnancy Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their contribution can be profoundly impactful, provided they have a keen interest in the nuances of migraine care. One such physical therapist to whom I refer patients, Pete Schultz, just co-wrote an article, A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist’s Perspective. This article shows how experienced physical therapists approach migraine patients. They usually perform a very thorough examination and they can sometimes detect a serious problem that was missed by a physician. The physical therapist often discovers general weakness, muscle tension, poor posture, diminished endurance, neck pain, teeth clenching, visual symptoms, dizziness, poor balance and coordination and high stress levels. The interventions may include exercise directed at strengthening neck and upper back muscles, manual therapy, general conditioning exercise, biofeedback and mindfulness techniques, and vestibular therapy. There is a wealth of data on the therapeutic effect of exercise in migraine patients. Interestingly, weight training seems to be more effective in the prevention of migraines than aerobic exercise. Vestibular symptoms, such as dizziness and unsteadiness, are very common and are highly responsive to vestibular therapy. Biofeedback is typically done by mental health professionals, but also by physical therapists. Over 100 clinical trials have been performed utilizing biofeedback in the treatment of headaches. The consensus is that this is a very effective technique. An additional benefit that physical therapists can provide is what psychologist call a shift in locus of control,... --- ### Depakote, oral and infusion, for migraines in children - Published: 2023-08-10 - Modified: 2023-08-14 - URL: https://www.nyheadache.com/blog/depakote-oral-and-infusion-for-migraines-in-children/ - Categories: Chronic migraine, Headache medications, Headaches in children, Migraine, Migraine in pregnancy A recently published study suggests that valproic acid (Depakene) given intravenously in an emergency room can relieve migraine headaches in children. The researchers also showed that giving these children an oral version of this drug, divalproex sodium (Depakote), does not reduce the frequency of future migraine attacks.   Divalproex sodium was first approved by the FDA in 1983 for the treatment of epilepsy. Subsequently, it was also approved for the treatment of mania and for the prevention of migraine headaches. Notably, the FDA-approved label does not place any age limit on the use of this drug. It took years to discover all the risks associated with this medication. In rare instances, the drug may lead to liver failure and severe pancreatitis, both of which can be fatal. Moreover, divalproex sodium can result in significant congenital malformations, as well as diminished IQ scores and neurodevelopmental disorders when the fetus is exposed to the drug in utero. It is strictly contraindicated in pregnant women. Women of childbearing age must use effective contraception. Divalproex can also cause many other less dangerous but unpleasant side effects. With all this in mind, why would anyone want to take this drug? It is certainly not on the list of my top 20 or 30 drugs for the prevention of migraines. I do, however, have several patients whose migraines did not respond to many drugs but are significantly improved with divalproex sodium. Such patients must have proper monitoring with regular blood tests. We do occasionally give intravenous... --- ### Botox in pregnancy - Published: 2023-07-24 - Modified: 2023-07-24 - URL: https://www.nyheadache.com/blog/botox-in-pregnancy/ - Categories: Alternative Therapies, Botox, Chronic migraine, Headaches, Migraine, Migraine in pregnancy Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant women receiving Botox for various medical and cosmetic reasons, and no evidence suggests that the fetus gets harmed during this treatment. The botulinum toxin molecule is too large to cross the placenta and enter the circulation of the fetus, which further supports its safety during pregnancy. An analysis of pregnancy outcomes after onabotulinumtoxinA exposure over a 29-year period was conducted to gain more insights into the safety of the treatment during pregnancy. The researchers examined data from the Allergan Global Safety Database from 1990 to 2018, focusing on pregnant women or those who became pregnant within three months of receiving onabotulinumtoxinA treatment. They analyzed the outcomes of these pregnancies to estimate the prevalence of birth defects in live births. Out of 913 pregnancies, the study considered 397 with known outcomes. The majority of the mothers were 35 years or older, and most of the onabotulinumtoxinA exposures occurred before conception or during the first trimester of pregnancy. Among the 197 fetuses from 195 pregnancies, there were 152 live births and 45 fetal losses (including spontaneous and elective abortions). Four of the 152 live births had abnormal outcomes, with one major birth defect, two minor fetal defects, and one birth complication. The overall prevalence of fetal defects in live births was 2. 6%, with a prevalence of 0. 7% for major defects, similar to the rates seen in the general population. Among... --- ### Controlled trial of meditation for migraines - Published: 2023-07-17 - Modified: 2023-07-17 - URL: https://www.nyheadache.com/blog/controlled-trial-of-meditation-for-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Psychology of headaches Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to 45 minutes. I have found that sumatriptan has always been very effective and migraines have never disrupted my daily life, even when I experienced prolonged periods of daily headaches. Because of meditation I hardly ever need to take sumatriptan. My personal experience and that of many of my patients align with the viewpoint of a small group of headache specialists who believe that triptans do not cause medication overuse headaches. Mindfulness has been gaining a lot of attention as a potential way to manage migraines, but there haven't been many scientific studies to support this. A group of Italian researchers investigated whether a specific mindfulness-based treatment, consisting of six sessions of mindfulness practice and daily self-practice, would be effective when added to the usual treatment for patients with chronic migraine and medication overuse headaches. They conducted a study with 177 patients. Half of the participants received the usual treatment alone, which included withdrawing from overused medications, education on proper medication use and lifestyle, and tailored prevention. The other half received the usual treatment plus the mindfulness-based intervention. They looked at various factors to assess the effectiveness of the mindfulness-based treatment, including headache frequency, medication intake, quality of life, disability, depression and anxiety, sensitivity to touch, awareness of inner states, work-related difficulties, and disease-related costs. After analyzing the data, they found that the patients who received the mindfulness-based treatment in addition... --- ### Zavegepant, a new abortive migraine drug, is now available - Published: 2023-07-05 - Modified: 2023-07-05 - URL: https://www.nyheadache.com/blog/zavegepant-a-new-abortive-migraine-drug-is-now-available/ - Categories: Chronic migraine, Cluster headaches, Headache medications, New treatments Zavegepant (Zavzpret), the first CGRP nasal spray for the treatment of acute migraine attacks, was approved by the FDA in March and is now readily available in all US pharmacies. . Zavegepant belongs to the family of CGRP antagonists, which work by blocking excessive amounts of the neurotransmitter CGRP. Elevated levels of CGRP are known to contribute to the development of migraines. By inhibiting its action, zavegepant can effectively stop an ongoing migraine attack. While there are already two oral CGRP medications for the acute treatment of migraines (Nurtec and Ubrelvy), zavegepant is the first nasal spray option. Nasal sprays offer several advantages, including faster onset of action compared to tablets and the ability to bypass the stomach. These benefits are particularly valuable for individuals experiencing migraines accompanied by nausea and vomiting. Clinical studies have demonstrated that zavegepant is superior to placebo in promptly eliminating all pain and the most bothersome symptom within two hours of administration. The most commonly reported bothersome symptoms associated with migraines are nausea, sensitivity to light (photophobia), and sensitivity to noise (phonophobia). Side effects of zavegepant were generally mild and infrequent. Participants in clinical trials noted an unpleasant taste in 18% of cases, compared to 4% in the placebo group. Additional side effects included nausea (4% vs. 1%), nasal discomfort (3% vs. 1%), and vomiting (2% vs. 1%). Taste-related issues have been observed with other nasal sprays used for migraines, particularly among patients who experience nausea. However, this can be easily addressed by sucking on... --- ### Effects of observational learning on placebo responses, or why sham remedies seem to work so well - Published: 2023-06-19 - Modified: 2023-06-19 - URL: https://www.nyheadache.com/blog/effects-of-observational-learning-on-placebo-responses-or-why-sham-remedies-seem-to-work-so-well/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Pain, Pain Research, Psychology of headaches Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied customers. Recent research suggests that these individuals might genuinely benefit from hearing others express positive experiences. A study published in the journal Pain, titled "Learning pain from others: a systematic review and meta-analysis of studies on placebo hypoalgesia and nocebo hyperalgesia induced by observational learning" explores the impact of observational learning on placebo and nocebo responses. Placebo hypoalgesia refers to when a fake treatment (placebo) reduces pain, while nocebo hyperalgesia is when the placebo actually increases pain. Learning processes, such as classical conditioning and operant conditioning, have been shown to play a role in these effects. Verbal suggestions and observational learning from others also influence placebo and nocebo responses. However, the magnitude of these effects can vary depending on the specific learning process used. This meta-analysis of 17 studies showed that observational learning can effectively modulate pain and pain expectancies. However, the magnitude of these effects varies across studies. Observing a model in person resulted in larger effects compared to observing a videotaped model. The analysis also suggested that placebo effects can be induced through observational learning, but nocebo effects were not consistently observed. Empathy, specifically the empathic concern component, was found to be associated with the magnitude of observational learning effects. The article concludes that observational learning can indeed influence pain experience and pain expectancies. Further studies possibly could lead to methods to enhance the treatment effects of proven... --- ### PTSD biomarkers - Published: 2023-06-12 - Modified: 2023-06-12 - URL: https://www.nyheadache.com/blog/ptsd-biomarkers/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, post-traumatic headache, Psychology of headaches Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder (PTSD). These biomarkers could lead to more accurate methods of screening for PTSD, allowing for early intervention and prevention strategies. Additionally, they could help monitor treatment progress, identify different subtypes of PTSD, and enhance our understanding of the underlying mechanisms of the disorder. The study was conducted by the PTSD Systems Biology Consortium, initiated by the Department of Defense, and involved approximately 45 researchers. The team analyzed blood samples from 1,000 active-duty Army personnel from the Fort Campbell Cohort (FCC), who were assessed before and after deployment to Afghanistan in 2014. The researchers focused on four biomarkers: glycolytic ratio, arginine, serotonin, and glutamate. They categorized the participants into four groups based on their PTSD symptoms, resilience levels, and clinical assessments. The findings revealed that individuals with PTSD or subthreshold PTSD had higher glycolytic ratios and lower arginine levels compared to those with high resilience. Additionally, participants with PTSD exhibited lower serotonin and higher glutamate levels. These associations were independent of factors such as age, gender, body mass index, smoking, and caffeine consumption. The study results require further validation. The researchers also aim to determine the optimal time to screen soldiers for PTSD, considering the psychological challenges that arise around 2 to 3 months post-deployment. Moreover, they recognize the need for gender-specific biomarkers to improve the clinical assessment of female soldiers, given the increasing number of women serving in combat roles.... --- ### Weather and headaches – AI confirms the connection - Published: 2023-06-05 - Modified: 2023-06-05 - URL: https://www.nyheadache.com/blog/weather-and-headaches-ai-confirms-the-connection/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Science of Migraine The 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.... --- ### Structural brain connectivity predicts pain - Published: 2023-05-29 - Modified: 2023-05-29 - URL: https://www.nyheadache.com/blog/structural-brain-connectivity-predicts-pain/ - Categories: Head trauma, Headaches, Migraine, Pain, Pain Research, post-traumatic headache In a recent post, I mentioned a study in which researchers using functional MRI (fMRI) were able to link functional connectivity within the default mode network (DMN) and between DMN and executive control network (ECN) with the degree of disability in migraine patients. In a new study published in the journal Pain, researchers examined the brains of patients with mild traumatic brain injury (mTBI) using fMRI imaging to understand the brain networks associated with early acute pain following a motor vehicle collision. Here are some key findings: The properties of the brain's white matter explained a significant portion of the variation in pain experienced after mTBI. This suggests that certain brain features make patients more likely to report higher levels of pain after the injury. These white matter connections are associated with physiological and psychological characteristics related to pain sensitivity. The interactions between these connections and parameters of sensory testing and pain sensitivity can explain about one-third of the variability in pain. The connectivity patterns in the brain's white matter do not change over time, as observed up to a year after the injury. The same connectivity measures collected shortly after the injury and at six months post-injury can predict the level of pain reported by patients at the six-month mark. The study further indicates that the strength of white matter connections in the sensorimotor, thalamic-cortical, and default-mode networks is associated with pain severity. These findings highlight the involvement of these brain networks in pain perception and suggest that connections... --- ### Migraine, strokes, and oral contraceptives - Published: 2023-05-22 - Modified: 2023-05-22 - URL: https://www.nyheadache.com/blog/migraine-strokes-and-oral-contraceptives/ - Categories: Brain disorders, Headaches, Migraine, Migraine in pregnancy Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for individuals with migraines. The results of their study were recently published in the journal of the American Headache Society, Headache. The overall stroke risk among OCP users in this study was low. Out of the 203,853 women aged 18-55 who used OCPs, 127 were confirmed to have had a stroke. The case group had a higher proportion of individuals diagnosed with migraines (34/127, 26. 8%) compared to a control group of 635 women (109/635, 17. 2%; p = 0. 011). The risk of stroke was higher among those using OCPs with 30 mcg or more of estrogen compared to those using OCPs with less than 30 mcg. Having a personal history of migraines increased the likelihood of stroke compared to those without migraines. There was no significant increase in stroke risk among those with migraine with aura, but migraine without aura did increase the risk. Interestingly, previous studies have suggested the opposite—that migraine with aura carries a higher stroke risk compared to migraine without aura. The researchers speculate that this discrepancy could be because patients with migraine with aura are rarely prescribed OCPs, and the number of such patients in this study was small. Traditionally, young and healthy women diagnosed with migraine with aura have been advised against using estrogen contraceptives due to concerns about increased stroke risk compared to those without aura. However, the risk of unintended pregnancies should... --- ### Avoid screen time after a concussion - Published: 2023-05-15 - Modified: 2023-05-15 - URL: https://www.nyheadache.com/blog/avoid-screen-time-after-a-concussion/ - Categories: Brain disorders, Head trauma, Headaches, Headaches in children, Migraine A new study published in JAMA Pediatrics found that engaging in screen time within the first 48 hours after concussion may prolong recovery time. The study was conducted by researchers at UCSF. They looked at data from 125 patients aged 12 to 25 who had recently been diagnosed with a concussion. The participants were divided into two groups: one group was allowed to use screens, and the other group was asked to abstain from screen time. The study found that the group permitted to use screens had a significantly longer median recovery time of 8. 0 days compared to 3. 5 days in the group that abstained from screens. Additionally, individuals who used screens reported experiencing more symptoms such as headaches, dizziness, and fatigue. The screen time permitted group reported a median screen time of 630 minutes during the intervention period, while the screen time abstinent group reported 130 minutes. The study's authors concluded that avoiding screen time in the first 48 hours after concussion may help to shorten the duration of symptoms. However, this was a relatively small study and more research is needed to confirm these findings. In a recent post, I mentioned a large Canadian study that showed that early return to school after a concussion was associated with better outcomes. These two reports are not contradictory. Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations. Prolonged periods of complete physical and... --- ### Magnesium makes your brain bigger, according to a 6,000 person study. - Published: 2023-05-08 - Modified: 2023-05-08 - URL: https://www.nyheadache.com/blog/magnesium-makes-your-brain-bigger-according-to-a-6000-person-study/ - Categories: Alternative Therapies, Brain disorders, Migraine, New treatments Our research at the New York Headache Center and that of many of our colleagues, as well as the clinical experience of doctors and thousands of patients, have proven the role of magnesium in treating migraine headaches. I've written many blog posts on the role of magnesium in a wide variety of other medical conditions. A new report in the European Journal of Nutrition suggests that dietary intake of magnesium is related to the size of the brain. This study looked at how the amount of magnesium in people's diets is related to the size of their brains and the presence of white matter lesions (which are abnormalities in the brain seen on the MRI scan) as they get older. The researchers used data from 6,000 middle-aged to older adults in the UK. They measured magnesium intake through a questionnaire and used statistical models to analyze the data. The results showed that people who had higher magnesium intake generally had larger brain volumes, including the gray matter and specific areas called the left and right hippocampus. When they looked at different patterns of magnesium intake over time, they found three groups: one with high magnesium intake that decreased over time, one with low magnesium intake that increased, and one with stable and normal magnesium intake. In women, those in the high-decreasing group had larger brain volumes compared to the normal-stable group. On the other hand, women in the low-increasing group had smaller brain volumes and more white matter lesions. The... --- ### Antidepressant use during pregnancy - Published: 2023-04-30 - Modified: 2023-04-30 - URL: https://www.nyheadache.com/blog/antidepressant-use-during-pregnancy/ - Categories: Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication. Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine. Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent's mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children. The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies. The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders. However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify... --- ### How to reduce pain recollection - Published: 2023-04-24 - Modified: 2023-04-24 - URL: https://www.nyheadache.com/blog/how-to-reduce-pain-recollection/ - Categories: Brain disorders, Headaches, Migraine, Pain, Pain Research, Psychology of headaches A recent study published in the journal Pain showed that adding a non-painful stimulus at the end of a Pap smear can reduce pain recollection. The study, titled "Adding a Nonpainful End to Reduce Pain Recollection of Pap Smear Screening: A Randomized Controlled Trial," was conducted by Taiwanese researchers and involved 266 women. The study involved an intervention group that received a modified Pap test, where the operator kept the speculum still in the vagina for an additional 15 seconds after rotating it back, instead of immediately removing it. Participants in the modified Pap test group were unaware of this additional step, as they were behind a privacy curtain. The outcomes of the study included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects, the modified Pap group experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale and on a 0 to 10 visual analog scale. Subgroup analyses showed that these results were not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Additionally, the modified Pap test attenuated 1-year recalled pain on both pain scales and increased the 1-year willingness grade to receive further Pap tests. This technique could potentially be applied to many other painful procedures, including Botox injections, blood draws, vaccine injections, dental procedures, and more. --- ### Using AI to predict who will respond to placebo - Published: 2023-04-16 - Modified: 2023-04-16 - URL: https://www.nyheadache.com/blog/using-ai-to-predict-who-will-respond-to-placebo/ - Categories: Headache medications, Headaches, Pain, Pain Research, Psychology of headaches Placebo response is a bane of clinical trials but it can be very helpful in practice. A team of American and Canadian researchers used AI to help identify predictors of the placebo response. The results were recently published in Pain, under the title, Predicting placebo analgesia in patients with chronic pain using natural languageprocessing: a preliminary validation study. Since they used AI for their study, I thought it would be fitting to use ChatGPT to edit their abstract for the lay public. Patients with chronic pain often experience significant pain relief from placebos (inert pills), and this effect can last for days or even weeks. However, it's still unclear whether we can reliably predict who will respond to placebo and how to do so. Previous research has shown that people who respond well to placebos tend to talk about their pain and their life in a certain way. In this study, the researchers looked at whether these language patterns can predict who will respond to a placebo before they even receive the treatment, and whether we can distinguish between people who will respond to a placebo versus a real drug. To do this, they analyzed language patterns from patients with chronic back pain who received a placebo in one study and used this information to build a language model that could predict who would respond to a placebo in a separate study. They found that this language model was able to predict, before treatment, which patients would respond well to a placebo in the second study.... --- ### Functional brain networks in migraine and meditation - Published: 2023-04-09 - Modified: 2023-04-09 - URL: https://www.nyheadache.com/blog/functional-brain-networks-in-migraine-and-meditation/ - Categories: Uncategorized 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. --- ### How long to rest after a concussion - Published: 2023-04-03 - Modified: 2023-04-03 - URL: https://www.nyheadache.com/blog/how-long-to-rest-after-a-concussion/ - Categories: Botox, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate for this approach, several studies have suggested that an early return to activity after a concussion may lead to better outcomes. Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations. The latest pediatric study was done in Canada. It examined data for 1630 children aged 5 to 18 with a mean age of 12 and of whom 38% were girls. The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory. Missing fewer than 3 days after concussion was defined as an early return to school. An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group. Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental, as it can be challenging for many people to remain inactive for such an extended period. This approach, which involves refraining from activities such as reading, writing, screen time, and exercise, can lead to depression, increased anxiety, and may even delay recovery. After a brief period of rest lasting 24 to 48 hours, I typically recommend a gradual return to full activities. The key is to monitor for any exacerbation of post-concussion symptoms such... --- ### The top 10 non-drug therapies for migraines - Published: 2023-03-27 - Modified: 2023-03-27 - URL: https://www.nyheadache.com/blog/the-top-10-non-drug-therapies-for-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, neurostimulation, Psychology of headaches Most people are right in not wanting to take medications. They can have serious or just very bothersome side effects, they help only some people and can be expensive. Fortunately, there are many ways to control migraines without drugs. Here are the top 10 non-drug therapies for migraine headaches among several dozen described in my book, The End of Migraines: 150 Ways to Stop Your Pain. Non-drug therapies Aerobic exercise Meditation Magnesium CoQ10 Cognitive-behavioral therapy Acupuncture Nerivio Cefaly Riboflavin Boswellia --- ### The Top 10 Prophylactic Treatments for Migraines - Published: 2023-03-20 - Modified: 2023-03-20 - URL: https://www.nyheadache.com/blog/the-top-10-prophylactic-treatments-for-migraines/ - Categories: Botox, Chronic migraine, Headache medications, Migraine In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book, The End of Migraines: 150 Ways to Stop Your Pain. Here is a list of the top 10 preventive drug therapies for migraines. In the next post, I will list the top 10 non-drug therapies. The order of choices can vary depending on co-morbidities, potential side effects, cost, and other factors. For example, patients with coexistent anxiety and/or depression would have duloxetine and nortriptyline move higher on this list. Patients with rapid heartbeat, anxiety, or PTSD could start with nebivolol. Those with high blood pressure, could start with candesartan or nebivolol, and so on. OnabotulinumtoxinA (Botox) Atogepant (Qulipta) Rimegepant (Nurtec) Galcanezumab (Emgality) Nebivolol (Bystolic) Propranolol (Inderal) Candesartan (Atacand) Duloxetine (Cymbalta) Nortriptyline (Pamelor) Fremanezumab (Ajovy) --- ### Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases - Published: 2023-03-14 - Modified: 2023-03-14 - URL: https://www.nyheadache.com/blog/thank-you-for-making-the-end-of-migraines-1-bestseller-in-nervous-system-diseases/ - Categories: Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Psychology of headaches, Science of Migraine --- ### A new migraine drug and my top 10 acute treatments for migraines - Published: 2023-03-13 - Modified: 2023-03-13 - URL: https://www.nyheadache.com/blog/a-new-migraine-drug-and-my-top-10-acute-treatments-for-migraines/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the family of gepants. These drugs abort migraine attacks by blocking the CGRP receptor. CGRP (calcitonin gene-related peptide) is released during a migraine attack. Blocking this molecule or the receptor it attaches to relieves migraines in about 50% of people. There are four CGRP monoclonal antibodies, or mAbs, that are injected once every one or three months to prevent migraine attacks. Gepants are taken by mouth. Two of them - ubrogepant (Ubrelvy) and rimegepant (Nurtec) - are approved for the acute treatment of migraine attacks. Rimegepant, along with atogepant (Qulipta), is also approved for the prevention of migraines. Nasal sprays to treat migraines have the advantage of faster onset of action. They are particularly useful for people who have nausea or vomiting and have difficulty absorbing or holding down oral medications. Other migraine drugs in a nasal spray include sumatriptan, zolmitriptan, dihydroergotamine, and ketorolac. For patients for whom these older drugs are ineffective, cause side effects, or are contraindicated, zavegepant could be a very good option. If there are no contraindications for the use of a triptan (e. g. heart or other vascular diseases), I would use sumatriptan first because of the cost. It is also likely that insurance companies will require that the patient fails sumatriptan before they agree to pay for a new and more expensive drug. This is what they usually require before paying for oral gepants. Here... --- ### Attend the Migraine World Summit! - Published: 2023-03-09 - Modified: 2023-03-09 - URL: https://www.nyheadache.com/blog/attend-the-migraine-world-summit/ - Categories: Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine I am honored to speak at this year's Migraine World Summit on Sunday, March 12. My topic is Safety Update: DHE, Triptans, Magnesium, Butterbur, and more. The Migraine World Summit gives you a chance to improve your understanding of migraine headaches. 2023 dates: March 8-16. Register for free access at MigraineWorldSummit. com   Call: 8885256449,   Email: info@migraineworldsummit. com   Facebook: www. facebook. com/MigraineWorldSummit/    Instagram: @migrainesummit   --- ### Predicting response to migraine treatment - Published: 2023-03-05 - Modified: 2023-03-05 - URL: https://www.nyheadache.com/blog/predicting-response-to-migraine-treatment/ - Categories: Chronic migraine, Headache medications, injections, Migraine Updated on 3/5/23 Even the best migraine medications work for only about half of the people who try them. In the next decade or so, advances in pharmacogenomics, neuroscience, and artificial intelligence will allow us to predict who is going to respond to which drug. This will eliminate the trial-and-error approach we have to use now. German researchers led by Dr. Uwe Reuter just published a study that attempts to predict who is going to respond to injections of CGRP monoclonal antibodies (mAbs) that are used for the prevention of migraines. These drugs include erenumab (Aimovig), galcanezumab (Emgality), and fremanezumab (Ajovy). The fourth drug in this family that is given intravenously, eptinezumab (Vyepti) was not available in Germany at the time of the study. They compared super-responders (patients with 75% or greater reduction of monthly headache days) with non-responders (patients with 25% or lower reduction of monthly headache days after trying all three mAbs). Of 260 patients with chronic and episodic migraine they evaluated, 11% were super-responders, and 10% were non-responders. Non-responders were more likely to have chronic migraines. Super-responders were significantly more likely to report good improvement of their acute migraine headache with a triptan. Non-responders were more likely to have depression and overuse acute medications. It was interesting that only 10% of patients were non-responders. The authors explained this by the fact that they had to fail all three mAbs to be considered non-responders. An earlier German study showed that one-third of patients who did not respond to... --- ### An instructive case of dramatic relief of migraines - Published: 2023-02-26 - Modified: 2023-02-26 - URL: https://www.nyheadache.com/blog/an-instructive-case-of-dramatic-relief-of-migraines/ - Categories: Chronic migraine, Headache medications, Migraine, Science of Migraine 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... --- ### More on exercise - timing matters - Published: 2023-02-20 - Modified: 2023-02-20 - URL: https://www.nyheadache.com/blog/more-on-exercise-timing-matters/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine In a recent blog post, I wrote about the benefit of different types of exercises for the relief of migraines and other types of headaches. It mentioned that strength training may be more beneficial than aerobic (cardio) exercise. A study just published in Nature Communications suggests that the time of day when you exercise also matters. Not specifically for headaches but for "all-cause and cardiovascular disease mortality". This was a very rigorous study of 92,139 UK participants over an average of 7 years of follow-up which added up to 638,825 person-years. The timing of exercise was recorded by an activity tracker (accelerometer). Moderate-to-vigorous intensity physical activity at any time of day was associated with lower risks for all-cause, cardiovascular disease, and cancer mortality. However, the morning group (5:00 - 11:00), midday-afternoon (11:00 - 17:00), and mixed timing groups, but not the evening group (17:00-24:00), had lower risks of all-cause and cardiovascular disease mortality. This study suggests that exercising before 5 PM has more health benefits than exercising after 5. It is likely that this may also apply to the relief of migraines and other headaches. --- ### More on Zinc - could help migraines - Published: 2023-02-16 - Modified: 2023-02-16 - URL: https://www.nyheadache.com/blog/more-on-zinc-could-help-migraines/ - Categories: Alternative Therapies, Botox, Brain disorders, Headache medications, Headaches, Migraine In a post last August, I mentioned that zinc could possibly extend the duration of the effect of Botox. A new report by Chinese neurologists in Headache describes their findings of an inverse association between dietary zinc intake and the occurrence of migraine in American adults. The researchers used the data from a five-year study conducted by the CDC to assess the health and nutritional status of Americans. Data were collected using a computer-assisted dietary interview system which proved to be very reliable. Over 11,000 adults were included in the analysis of zinc intake. These subjects were divided into quintiles, according to their zinc intake. The data were adjusted for various confounding factors. These included age, sex, race, ethnicity, smoking status, body mass index, and others. People in the lowest quintile were at least 30% more likely to suffer from migraine compared to people in the other four quintiles. Associaion does not mean causation and this study does not prove that taking zinc will prevents migraines. However, a few small studies did show the benefit of taking a zinc supplement in migraine patients. Checking your blood for zinc levels before taking a supplement would be ideal. However, there is very little downside to taking 10-25 mg of zinc daily even if you don't know your zinc level. Zinc is very important for the normal functioning of the immune system, it possibly prevents macular degeneration, and has many other benefits.   Taking too much zinc can cause serious side effects. The... --- ### GABA supplement for anxiety and insomnia - Published: 2023-02-05 - Modified: 2023-02-05 - URL: https://www.nyheadache.com/blog/gaba-supplement-for-anxiety-and-insomnia/ - Categories: Alternative Therapies, Headache medications, Pain, Science of Migraine GABA, or gamma-aminobutyric acid, is a popular supplement for the relief of anxiety and insomnia. Until recently, I was not recommending it to my patients. There are no scientific studies showing that it works. So why did I start recommending it? A report by a single patient, or as we say in scientific literature, an N of 1. This 65-year-old woman had been suffering from anxiety from a young age. When her summer camp friends would write down everyone's most common sayings, hers was, "I am so nervous". This sense of anxiety persisted throughout her life. She is a successful career woman with a loving family. After a death in her family, she started seeing a psychologist who suggested taking GABA for insomnia. Within days, she was overcome by a sense of calmness she never experienced in her life. It's been several months now and she remains calmer than ever before. Certainly, this could be a placebo effect. In addition to the lack of controlled clinical trials, it is not even clear if GABA gets into the brain by crossing the so-called blood-brain barrier (BBB). It is possible, however, that it does not have to cross BBB. There is evidence that GABA may work through the enteric nervous system (ENS) - nerve endings lining the intestines. Both GABA and its receptors are widely distributed in the gut. Certain probiotics such as Lactobacillus and Bifidobacterium were found to increase GABA concentrations in the ENS. Probiotics have been shown to improve mood.... --- ### The review of my book, "The End of Migraines: 150 Ways to Stop Your Pain" by Lisa Robin Benson - Published: 2023-01-31 - Modified: 2023-01-31 - URL: https://www.nyheadache.com/blog/the-review-of-my-book-the-end-of-migraines-150-ways-to-stop-your-pain-by-lisa-robin-benson/ - Categories: Alternative Therapies, Headache medications, Migraine, Migraine in pregnancy, New treatments, Science of Migraine Thank you, Lisa Robin Benson for a kind review of my book. This is a video review on the Migraine. com website. Many of my colleagues have written very positively about my book. It is even more gratyfing to hear that patients and patient advocates also find it useful. --- ### If you can't fall asleep, try this! - Published: 2023-01-25 - Modified: 2023-01-25 - URL: https://www.nyheadache.com/blog/if-you-cant-fall-asleep-try-this/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine, Psychology of headaches Insomnia is a very common problem. Sleep aids, over-the-counter and prescription have been proven to be harmful if taken long-term. They even raise the risk of Alzheimer's. A small dose of melatonin (300 mcg, or 0. 3 mg) can help better than the usual 3 mg dose sold in most stores. You can also try valerian root and definitely adhere to sleep hygiene. This includes no reading or watching TV in bed, no screens for at least an hour before bedtime, no eating or exercising within two hours of going to bed, and sleeping in a cold room (65 to 68 degrees). Going to bed at the same time also helps. If you still can't fall asleep, try visualization. Actually, you don't just use your visual memory but engage all the senses. This post was prompted by a WSJ article on this topic, A Happy Memory Can Help You Fall Asleep, if You Know How to Use It. I usually imagine myself on a beach in a hammock under a tree, feeling a warm breeze on my body, seeing a beautiful view of the beach and the ocean, smelling fragrant flowers, and hearing the sound of waves lapping at the shore. Once you find your happy place and can vividly recreate it, always use the same setting without variation. This way you will fall asleep within minutes.   --- ### I am speaking on refractory migraines at the Winter HCNE Headache Symposium - Published: 2023-01-24 - Modified: 2023-01-24 - URL: https://www.nyheadache.com/blog/i-am-speaking-on-refractory-migraines-at-the-winter-hcne-headache-symposium/ - Categories: Chronic migraine Another excellent educational course for healthcare professionals will be held on March 10th and 11th in Greenwich, CT. The Headache Cooperative of New England has held these symposia for over 20 years.   The topic of my presentation is The approach to the Refractory Headache Patient. In addition to the East Coast headache specialists, several notable headache experts from the West Coast will be presenting as well - Dr. Morris Levine, the director of the UCSF headache center and Dr. Robert Cowan of Stanford. --- ### Dr. Lisa Gfrerer to speak on migraine surgery at the NY Headache Club meeting on January 25 - Published: 2023-01-21 - Modified: 2023-01-21 - URL: https://www.nyheadache.com/blog/dr-lisa-gfrerer-to-speak-on-migraine-surgery-at-the-ny-headache-club-meeting-on-january-25/ - Categories: Alternative Therapies, Blocks, Chronic migraine, Headaches, Migraine Migraine surgery is controversial. I would not consider it until most of the less invasive options have been tried. In my latest book, I give migraine surgery a score of 3, on a 1 to 10 scale. This rating may not be fair because clinical trials suggest that it can be very effective for some patients. So, when is a referral to a surgeon warranted? Dr. Lisa Gfrerer is highly qualified to address this topic. She will speak on January 25th at a dinner of the NY Headache Club, an informal gathering of headache specialists who practice in the greater NYC area. If you are a headache specialist and would like to attend, send me a message. The meeting is not open to the lay public. Here is Dr. LisaGfrerer's short bio. Dr. Gfrereris an Assistant Professor in Plastic and Reconstructive Surgery at Weill Cornell Medicine (WCM). She received her MD degree at the Medical School of Vienna prior to completing a PhD in Genetics at the Harvard Stem Cell Institute. She graduated from the Harvard Integrated Plastic Surgery Residency Program and completed the Advanced Peripheral Nerve and Microsurgery at the  Massachusetts General Hospital (MGH). Clinically, her focus is peripheral nerve surgery including headache surgery, treatment of nerve pain and compression, breast reinnervation, as well as advanced nerve reconstruction for restoration of motor and sensory function after an iatrogenic and accidental injury. She has built a multi-institutional and multidisciplinary research program for headache surgery, breast/chest reinnervation, as well as functional... --- ### Multivitamins proven to improve brain health! - Published: 2023-01-15 - Modified: 2023-01-15 - URL: https://www.nyheadache.com/blog/multivitamins-proven-to-improve-brain-health/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine Daily multivitamin use was compared to cocoa extract in more than 2,200 people over 65. After three years, taking a cocoa extract had no benefit while taking a multivitamin led to a significantly slower age-related cognitive decline. This included measures of global cognition, memory, and executive function. Many physicians discourage their patients from taking a multivitamin. They should stop. There is little downside to taking a multivitamin. It is very inexpensive and safe. Many people also feel that if they eat a well-balanced healthy diet they should not need to take vitamins. Unfortunately, that is not the case. Even foods that are considered healthy are often processed, stored for a long time, or grown in depleted soil. Another problem is that as we age our body loses its ability to absorb vitamins and minerals (as well as protein, which is a different topic). Taking a multivitamin should be a standard recommendation for those over 65. Many younger individuals need supplements as well. Ironically, a healthy diet (especially vegan or vegetarian) is often deficient in vitamin B12. Many young people whom I see for migraine headaches are deficient in vitamin D and magnesium. The role of vitamin D is also often underappreciated by primary care doctors. Multiple studies have shown that your vitamin D level should be not only within the normal range but in the upper half of the normal range for your brain to function normally. Most people who died of COVID had low vitamin D levels. And I've... --- ### Attend an excellent headache course for health care providers in San Diego - Published: 2023-01-11 - Modified: 2023-01-11 - URL: https://www.nyheadache.com/blog/attend-an-excellent-headache-course-for-health-care-providers-in-san-diego/ - Categories: Alternative Therapies, Botox, Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine, New treatments, Psychology of headaches, Science of Migraine Opportunities & Challenges in the Management of Headache is one of the two annual courses organized by the Diamond Headache Clinic Research & Educational Foundation. This year, it will be held in San Diego from February 16th through February 19th. The other annual event, Headache Update 2023 will be held in Orlando, Fl from July 13th through July 16th. Both courses have been always well attended and have been receiving very high marks from the attendees. It's been my privilege to participate in these annual courses over the past 25 years. This year I will be speaking on February 17th on Nutritional Approaches and Alternative Therapies in Migraine. --- ### Botox for trigeminal neuralgia due to multiple sclerosis - Published: 2023-01-07 - Modified: 2023-01-07 - URL: https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia-due-to-multiple-sclerosis/ - Categories: Botox, Brain disorders, Pain, Trigeminal and other neuralgias Botox has been shown to relieve the pain of trigeminal neuralgia (TN). TN is an excruciatingly painful and debilitating condition. The most common cause of TN is compression of the trigeminal nerve by a blood vessel. This tends to occur in older people in whom blood vessels may harden with age. The definitive treatment of TN is surgical decompression of the trigeminal nerve. This is done by opening the skull and placing a Teflon patch between the nerve and the blood vessel. Several medications and invasive procedures directed at the peripheral nerve have been also proven effective. They are usually tried before surgery because of the risk of complications from surgery. Besides the elderly, younger people with multiple sclerosis (MS) are also predisposed to developing TN. The mechanism is somewhat different. There is less or no compression of the nerve but rather there is damage to myelin, a sheath that covers the nerve inside the brainstem. Myelin prevents cross-talk between nerve fibers, which is the cause of the pain. According to a report by Turkish neurologists that was recently published in Headache, Botox can relieve the pain of TN in MS patients as well. They compared the response to Botox in 22 patients with primary TN and 31 with MS-related TN. Ten patients of 22 in the first group and 16 out of 31 in the second group improved with Botox. Patients who had interventional treatments in the past did not respond as well. Those who had mild continuous pain... --- ### Go ahead, have a drink. Science proves that it won't give you a migraine. - Published: 2022-12-18 - Modified: 2022-12-18 - URL: https://www.nyheadache.com/blog/go-ahead-have-a-drink-science-proves-that-it-wont-give-you-a-migraine/ - Categories: Alternative Therapies, Migraine, Science of Migraine Holidays are again upon us. There are many reasons why people experience more migraines this time of year. Family drama, all the delicious unhealthy food, and alcohol. A report just published in the journal Headache brings some good news. Scientists proved that alcohol does not trigger migraines. The researchers evaluated the digital diaries of 493 migraine sufferers who reported drinking alcohol. They used sophisticated statistical analysis including standard deviations, Bayesian statistics, Markov Chain Monte Carlo simulations, and the like, to show that there was no correlation between drinking alcohol and developing a migraine the next day. If you still insist that alcohol gives you migraines, to paraphrase Groucho Marx, who are you going to believe, the scientists or your own lying eyes? Another amusing paper comparing red wine with vodka as a trigger of migraines was published years ago by British researchers in The Lancet  Migraine patients who believed that red wine but not vodka triggered their attacks were challenged either with red wine or vodka. It was a blinded study - patients were not told what they were drinking. Vodka was diluted to equivalent alcohol content, and both were "consumed cold out of dark bottles to disguise colour and flavour". And indeed, only wine triggered a migraine attack. A group of French doctors responded to this study in a letter to the editor. They stated that the only thing this study proved was that the Brits can't tell wine from vodka. --- ### Strength training vs aerobic exercise for migraine - Published: 2022-12-05 - Modified: 2022-12-05 - URL: https://www.nyheadache.com/blog/strength-training-vs-aerobic-exercise-for-migraine/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine Multiple posts on this blog have described clinical trials that prove the benefit of exercise for the prevention of migraine headaches. In a recent paper published in The Journal of Headache and Pain Stanford researchers compared the efficacy of aerobic and strength training exercises. They conducted a meta-analysis of 21 clinical trials that involved a total of 1,195 migraine patients. Simplifying the statistics, compared to no exercise, strength training was 3. 55 times more effective, high-intensity aerobic exercise was 3. 13 times more effective, and moderate-intensity aerobic exercise was 2. 18 times more effective. For general health and for the prevention of migraines, 2-3 weekly sessions of strength training and 2-3 sessions of aerobic exercise would be an ideal regimen. As I mentioned in a recent post, an additional benefit of exercise is a larger brain volume. The only other intervention that has been shown to expand the brain and prevent its shrinkage with age is meditation. Exercise and meditation are the first two recommendations on my list of top 10 treatments described in my latest book, The End of Migraines: 150 Ways to Stop Your Pain. --- ### Cognitive impairment due to migraine - Published: 2022-11-25 - Modified: 2022-11-25 - URL: https://www.nyheadache.com/blog/cognitive-impairment-due-to-migraine/ - Categories: Brain disorders, Chronic migraine, Headaches, Migraine According to a new report by Spanish researchers published in The Journal of Headaches and Pain, effective preventive treatment of migraines can improve cognitive impairment in patients with frequent attacks. Patients with migraines often complain that their memory is not as good as it used to be, that they have difficulty concentrating, or can't think clearly. There are many possible causes of such symptoms. Stress is probably the most common reason people have trouble with memory and concentration. There is just too much on their mind. Certain drugs, most notably topiramate (Topamax), can cause pronounced cognitive impairment.   Nutritional deficiencies, particularly of vitamin B12 and other B vitamins, magnesium and vitamin D can cause brain fog and other cognitive problems. Alzheimer's disease, which is what people fear most, thankfully is rare at the age when most people suffer from migraines. I also see patients who do not have any of the above reasons. There are several possible explanations for why migraines alone can cause cognitive problems. We know that if a patient has only a few attacks a month, the brain remains hyperexcitable even between attacks. Some patients have a prodrome - one or two days of brain dysfunction prior to an attack. Others have post-drome - a feeling of exhaustion as if being hungover for a day or two after the attack. There is also a likely contributing effect of anticipatory anxiety - living in fear of the next attack. Christina Gonzalez-Mingot and her colleagues in Lleida, Spain, compared... --- ### Thiamine (vitamin B1) may be more effective for migraines than riboflavin (vitamin B2) - Published: 2022-11-20 - Modified: 2022-11-20 - URL: https://www.nyheadache.com/blog/thiamine-vitamin-b1-may-be-more-effective-for-migraines-than-riboflavin-vitamin-b2/ - Categories: Alternative Therapies, Headache medications, Migraine, Science of Migraine Riboflavin (vitamin B2) has been a popular supplement for the prevention of migraine headaches. The evidence for its efficacy is limited. Only one small double-blind, placebo-controlled trial showed that a very high dose of riboflavin (400 mg daily) is better than a placebo. The study included only 55 patients, which makes the results not very reliable. Besides, the difference between the riboflavin and the placebo groups appeared only in the third month. There was no difference during the first two months. This study was published over 20 years ago and my clinical impression over this long period of time has been fairly negative. A study just published in the journal Headache examined dietary intake of riboflavin and thiamine (vitamin B1) and correlated it with the occurrence of migraines or severe headaches. The researchers used the data from 13,439 adult participants in the National Health and Nutrition Examination Survey conducted between 1999 and 2004 in the United States. They found that people with a high intake of thiamine were significantly less likely to suffer from severe headaches or migraines. This was more pronounced in women. They found no such association for riboflavin. Supplements with the most evidence in treating migraines are magnesium and CoQ10. I recommend riboflavin, folate (vitamin B9) and vitamin B12, to patients with an elevated homocysteine level. Excessive amounts of this amino acid are damaging to blood vessels and may be responsible for the increased risk of strokes in patients who have migraine with aura. It is worth... --- ### Microdosing for chronic pain - Published: 2022-11-14 - Modified: 2022-11-14 - URL: https://www.nyheadache.com/blog/microdosing-for-chronic-pain/ - Categories: Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Pain, Pain Research Psychedelics are being actively studied for depression and post-traumatic stress disorder (PTSD). These trials usually involve hallucinogenic doses. Microdosing psychedelic substances such as psilocybin, lysergic acid diethylamide (LSD), and methylenedioxymethamphetamine (MDMA) has become a popular treatment for depression. Microdosing means that the amount of a psychedelic is too low to cause hallucinations or other overt sensory experiences. There is an accumulation of evidence that psychedelics can provide pain relief.  A case series just published in the journal Pain describes three patients with chronic pain who obtained significant relief from microdosing psilocybin-containing mushrooms. The first patient was a 37-year-old man with severe pain due to traumatic quadriplegia. He had almost complete relief of pain and was able to stop taking tramadol, an opioid analgesic, diazepam (Valium), and marijuana. The relief was ongoing for six months when he was last seen by the doctors. The second patient was a 69-year-old woman with complex regional pain syndrome (also known as reflex sympathetic dystrophy) secondary to left leg trauma. She had tried nerve blocks, other invasive procedures, stem cell injections, acupuncture, opioid analgesics, and many other medications, all with no relief. At the time of the published report, microdosing was providing continued significant relief for over a year. The third patient was a 40-year-old woman with pain in her leg due to degenerative disk disease in her spine. Her pain did not improve with epidural injections, back surgery, muscle relaxants, opioid drugs, and physical therapy. Psychedelic mushrooms had a profound effect on her pain.... --- ### Acupuncture relieves chronic tension-type headaches - Published: 2022-11-07 - Modified: 2022-11-07 - URL: https://www.nyheadache.com/blog/acupuncture-relieves-chronic-tension-type-headaches/ - Categories: Alternative Therapies, Headaches A recent study by Chinese researchers showed that acupuncture is an effective treatment for tension-type headaches. The results were published in a leading neurology journal, Neurology. Being published in such a journal suggests that the study was scientifically rigorous and the results are likely to be reliable. The study included 218 patients with half receiving true acupuncture and the other half, sham acupuncture. In the first group, after inserting each needle, the acupuncturist induced a specific deqi sensation. Patients describe it as a sensation of fullness, aching, or tingling. You can experience this sensation without needles - try squeezing hard the thick muscle between your thumb and the index finger. Needling or pressing on this acupuncture spot can provide relief of a headache and facial pain. The second, control group, had needles inserted without any further manipulation. The main outcome measure in this trial was the number of patients who achieved at least a 50% reduction in the number of monthly headache days. In the true acupuncture group, 68% achieved this result compared to 48% in the control group. The difference was statistically highly significant. These results are not surprising. Hundreds of clinical trials (admittedly, of varying quality) have shown that acupuncture can relieve migraine headaches and other painful conditions. I am a licensed acupuncturist but use this treatment very infrequently. It is time-consuming (it should be done at least once a week) and expensive, especially if done by an MD (it is not covered by most insurance plans). For... --- ### The 6th Annual International Headache Symposium in Israel - Published: 2022-10-29 - Modified: 2022-10-29 - URL: https://www.nyheadache.com/blog/the-6th-annual-international-headache-symposium-in-israel-2/ - Categories: Alternative Therapies, Botox, Chronic migraine, Headache medications, Migraine, New treatments, Science of Migraine It was an honor to speak in Israel at the 6th Annual International Headache Symposium along with past presidents of the International Headache Society, Drs. Messoud Ashina and Alan Rapaport, the current IHS president, Cristina Tassorelli, the president-elect, Dr. Rami Burstein, and other leading headache experts. The symposium was organized by the President of the Israeli Headache Association, Dr. Oved Daniel, and by Dr. Arieh Kuritzky.   --- ### The 2nd edition of The End of Migraines, 150 Ways to Stop Your Pain was just published - Published: 2022-10-15 - Modified: 2022-10-15 - URL: https://www.nyheadache.com/blog/the-2nd-edition-of-the-end-of-migraines-150-ways-to-stop-your-pain-was-just-published/ - Categories: Uncategorized 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. --- ### How to treat nummular headache - Published: 2022-10-05 - Modified: 2022-10-05 - URL: https://www.nyheadache.com/blog/how-to-treat-nummular-headache/ - Categories: Alternative Therapies, Botox, Headaches Nummular (coin-shaped) headache is an uncommon condition.   It is defined as intermittent or continuous pain in a small circumscribed area of the scalp with the following four characteristics: sharply-contoured, fixed in size and shape, round or elliptical and 1-6 cm in diameter. The pain is usually mild or moderate in intensity, but some patients have severe pain. These headaches often occur in patients who also have migraines. Nummular headaches often respond to ibuprofen, naproxen, and other NSAIDs. Botox injections are also very effective. They provide relief for 3 months, obviating the need for daily medications which are more likely to cause side effects. A very small amount of Botox is needed to treat nummular headaches, so the cost is much lower than when treating migraine headaches. A case report just published in the journal Headache describes a patient who suffered from migraines and nummular headaches. His nummular headaches did not respond to medications and Botox injections but he had complete elimination of his nummular headaches along with improvement of his migraines after he received an injection of galcanezumab (Emgality). Galcanezumab and other CGRP monoclonal antibodies have been also reported to help trigeminal neuralgia as has rimegepant (Nurtec ODT), an oral CGRP receptor blocker. It is possible that nummular headache is the result of damage or irritation of a small terminal branch of a nerve. This is suggested by the fact that the pain is invariably superficial. And we know that CGRP is involved in pain messaging along the nerves. So... --- ### Exercise prevents not only migraines but also shrinkage of the brain - Published: 2022-09-26 - Modified: 2022-09-26 - URL: https://www.nyheadache.com/blog/exercise-prevents-not-only-migraines-but-also-shrinkage-of-the-brain/ - Categories: Alternative Therapies, Brain disorders, Headaches, Migraine, Science of Migraine Regular exercise has been proven to prevent migraine headaches in many studies. A Swedish study of 91 patients established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate, however, caused significant side effects.  Another study by the same group of researchers of 46,648 people found a strong inverse correlation between physical activity and the frequency of headaches. A report by German researchers in the September 13 issue of the journal Neurology provides strong evidence that physical activity leads to larger brain volumes. This was a rigorous study that included 2,550 participants. The physical activity was measured using an accelerometer, a device similar to a fitness tracker. The authors discovered that "Physical activity dose and intensity were independently associated with larger brain volumes, gray matter density, and cortical thickness of several brain regions. " The most notable change occurred in people who went from a sedentary lifestyle to a modest amount of low-intensity exercise when compared with those who already engaged in at least moderate amounts of physical activity. And this trend continued - very high frequency and intensity of training did not offer any additional benefits. Two other reports of various benefits of exercise were published this month. One was a study published in JAMA Neurology. This study also used accelerometers to count the steps made by 78,430 people. The researchers found that a higher number of steps prevented the development of dementia. The optimal dose was... --- ### Daxxify, a new Botox competitor - Published: 2022-09-08 - Modified: 2022-09-08 - URL: https://www.nyheadache.com/blog/doxxify-a-new-botox-competitor/ - Categories: Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain No, Daxxify is not really a competitor in the treatment of chronic migraines or any other medical condition. Daxxify, a new botulinum toxin, was just approved by the FDA only for cosmetic use. Daxxify does stand out from five other botulinum toxin brands in that its effect lasts longer. The other toxins are Xeomin, Dysport, Jeuveau, and Myobloc. Myobloc is approved only for medical conditions, Jeuveau only for cosmetics, and Xeomin and Dysport are approved for both cosmetics and a few medical conditions. Initially, Botox was approved by the FDA in 1989 to treat eye problems. Since then, it has been approved for many medical and cosmetic indications, including chronic migraine. None of the other toxins are approved for such a wide range of indications. It remains by far the most widely used type of botulinum toxin with tens of millions of people treated for medical and cosmetic reasons. Yes, having a longer-acting botulinum toxin is an advantage. You will need to have less frequent treatments. However, if you have any side effects, they will also take longer to go away. We are talking mostly about cosmetic side effects, such as droopy eyelids. When treating headaches, with proper technique, side effects are uncommon. These may include weakness of the neck muscles or, if treating TMJ syndrome, difficulty chewing. Since Botox is approved by the FDA for chronic migraines, Botox is the drug insurance companies cover. Allergan (a division of Abbvie), the manufacturer of Botox, has many more years left on... --- ### Post-COVID headaches - Published: 2022-08-19 - Modified: 2022-08-19 - URL: https://www.nyheadache.com/blog/post-covid-headaches/ - Categories: Brain disorders, Chronic migraine, Headaches Headache is a common symptom of any infectious illness, including COVID. A group of Spanish researchers analyzed six published studies of headaches in adult Spanish COVID patients. According to their review, headache is an early symptom of COVID. It typically lasts two weeks. Patients in these studies were followed for up to a year. One out of five patients had developed a headache that persisted for at least a year. Women and older patients were more likely to be affected. This persistent headache most often resembled chronic migraine. The pain was throbbing with associated sensitivity to light and noise, and worsening with physical activity.   The authors did not observe a difference between patients with and without prior history of headache. Patients with more intense headaches were more likely to develop a chronic headaches. The published studies reviewed by the authors did not address the treatment of headaches. Considering that the persistent headaches resembled migraines, we tend to treat them as we do chronic migraines. This means the use of antidepressants, epilepsy drugs, blood pressure medications, Botox, triptans, and CGRP drugs (both oral and injectable). It is likely that with early and aggressive treatment, many patients would not have headaches persist for such a long time. Doctors in Europe are less likely to prescribe medications and use Botox in headache patients than we are in the US. COVID vaccination also carries a risk of developing persistent headaches. As mentioned in a previous post, people who received Pfizer or Oxford-AstraZeneca vaccine... --- ### If the effect of Botox does not last 3 months, taking a zinc supplement might help. - Published: 2022-08-08 - Modified: 2022-08-08 - URL: https://www.nyheadache.com/blog/if-the-effect-of-botox-does-not-last-3-months-taking-a-zinc-supplement-might-help/ - Categories: Alternative Therapies, Botox, Headaches, Migraine Dr. Brian Loftus, a Texas neurologist, alerted me to the possibility that the shortening of the effect of Botox can be reversed by taking a zinc supplement. Dr. Loftus shared an unpublished report by Houston physicians who showed that zinc supplementation can extend the effect of Botox. There is a good theoretical reason to suggest that for Botox to work, you need to have sufficient amounts of zinc. You can read about this connection in a review article by one of the leading movement disorders specialist, Dr. Mark Hallet.   He concludes that "Toxins are zinc dependent proteases, and supplemental zinc may produce a greater effect. " It is very likely that taking zinc will benefit mostly people who are deficient. I just saw a patient in whom Botox provides relief for only 2 months and whose blood test showed a low zinc level. I suggested that he takes 50 mg of zinc every day. Zinc is necessary for the activity of over 100 different enzymes that are involved in vital chemical processes of the body. Zinc is involved in the immune system, growth of cells, building proteins, and many other functions. We might consider adding zinc to the usual battery of tests done on the first visit to our clinic. These include RBC magnesium, vitamins B12 and D, and routine blood tests. --- ### Migraine patients stick with Botox longer than with injections of CGRP mAbs - Published: 2022-07-30 - Modified: 2022-07-30 - URL: https://www.nyheadache.com/blog/migraine-patients-stick-with-botox-longer-than-with-injections-of-cgrp-mabs/ - Categories: Botox, Headache medications, injections, Migraine Patients with chronic migraine who were started on Botox were significantly more likely to continue to be treated with Botox after one year than patients who were started on a CGRP monoclonal antibody (mAb). mAbs are given monthly by injection. This category includes erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality). The results of this large retrospective study that included 1,974 patients were presented at the last meeting of the American Headache Society held in June of this year. The lead authors were Dr. Todd Schwedt of the Mayo Clinic and Dr. Andrew Blumenfeld. The study was sponsored by the manufacturer of Botox which makes it inherently biased. However, the difference between the two groups was striking. Of patients who were started on Botox, 66% continued the treatment at the end of the year. Less than a third of patients who were started on a mAb were still getting it at the end of the year. The researchers looked at differences in outcomes in patients enrolled before and during COVID. The results were similar before and during the pandemic. This is surprising because, during the pandemic, many patients were reluctant to come to the office for Botox injections. Many preferred to self-inject mAbs at home. Despite this obstacle, Botox patients were twice as likely to continue treatment at the end of the year. Besides efficacy, the major reason I recommend Botox ahead of mAbs and other drugs is its proven long-term safety. Botox was first approved by the FDA in 1989.... --- ### Rimegepant for trigeminal neuralgia: a case report - Published: 2022-07-18 - Modified: 2022-07-18 - URL: https://www.nyheadache.com/blog/rimegepant-for-trigeminal-neuralgia-a-case-report/ - Categories: Brain disorders, New treatments, Pain, Trigeminal and other neuralgias A case report presented at the annual meeting of the American Headache Society described a patient with trigeminal neuralgia (TN) whose pain responded well to rimegepant (Nurtec). Rimegepant is a drug approved for the acute and preventive treatment of migraines. This patient did not obtain relief from surgery and several medications. He was taking 300 mg of oxcarbazepine, buprenorphine (narcotic) patch, and up to 120 mg of oxycodone with partial relief. Within 12 hours of starting rimegepant he was pain-free. In the six months of taking rimegepant he experienced very infrequent and mild pain. There have been several reports indicating that injections of CGRP monoclonal antibodies such as erenumab can relieve the pain of TN. So it is not surprising that an oral CGRP drug helped this patient. I've treated several TN patients with CGRP antibodies. One such patient has been receiving injections of galacanezumab for over 3 years. He requires injections of 240 mg every 3 weeks and also has to take daily medications. This combination has allowed him to be fully functional and to keep his job. I may now try him on an oral CGRP drug. In addition to rimegepant, there are two other oral CGRP drugs - ubrogepant (Ubrelvy) and atogepant (Qulipta). They are very similar but many patients have a clear preference for one over the others. It may be worth trying them all if the first drug is not fully effective. A major obstacle to using these medications "off label" for TN is their... --- ### Magnesium and migraines - an interview with Dr. Amelia Scott Barrett - Published: 2022-07-11 - Modified: 2022-07-11 - URL: https://www.nyheadache.com/blog/magnesium-and-migraines-an-interview-with-dr-amelia-scott-barrett/ - Categories: Alternative Therapies, Chronic migraine, Migraine, Science of Migraine Last week I spoke to Dr. Amelia Scott Barrett, a neurologist and headache specialist based in Denver. She shares my interest in combining medications with various non-drug therapies. In our first conversation, we discussed the role of magnesium in treating migraines. --- ### The 6th Annual International Headache Symposium in Israel - Published: 2022-07-06 - Modified: 2022-07-06 - URL: https://www.nyheadache.com/blog/the-6th-annual-international-headache-symposium-in-israel/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, Science of Migraine The 6th Annual International Headache Symposium in Israel will be held at Daniel Hotel, Herzliya (8 miles from Tel Aviv), on October 27, 2022. THe symposium is organized by the President of the Israeli Headache Association, Dr. Oved Daniel and by Dr. Arieh Kuritzky. I am honored to have been invited to speak alongside the President of the International Headache Society Dr. Messoud Ashina, Dr. Rami Burstein of the Harvard Medical School, and other leading headache experts. The topic of my presentation will be "What to do when nothing works". Other topics to be discussed include, Molecular signaling pathway in migraine: update, (Messoud Ashina), Connecting the line between dizziness, occipital headache, muscle tenderness and the cerebellum (Sait Ashina), Open-label studies: do they have any value? (Cristina Tassorelli), and others. You can see the full program and registration information on this website. --- ### Intravenous magnesium prevents migraines in children - Published: 2022-06-27 - Modified: 2022-06-27 - URL: https://www.nyheadache.com/blog/intravenous-magnesium-prevents-migraines-in-children/ - Categories: Alternative Therapies, Headaches in children, Migraine Regular intravenous infusions of magnesium prevented migraines in five children, according to a report presented at the annual meeting of the American Headache Society by A. J. Freed and S. Sahai-Srivastava. The children were between the ages of 11 and 16. Four of them had the diagnosis of chronic migraines and one, episodic. Two of them continued to have daily headaches but they were mild with the infusions. The other three also had a significant drop in the number of headache days. Over the past 30 years, we've given monthly infusions to thousands of patients, including children as young as 6. Genetic factors play a role in some patients with magnesium deficiency. We've had three generations of a family coming for monthly infusions. Besides genetics, other reasons for magnesium deficiency include stress, alcohol, gastrointestinal disorders, poor diet, and others. About half of migraine sufferers are deficient. They are likely to respond to oral magnesium supplementation. Many, however, do not absorb magnesium taken by mouth. If we know that a patient is deficient because they have other symptoms of magnesium deficiency (cold extremities, muscle cramping, PMS, palpitations, brain fog, and others) or because their blood level (RBC magnesium) is low or is at the bottom of the normal range, we give magnesium intravenously. If you cannot find a doctor who gives infusions of magnesium, you may want to search for an infusion center or an urgent care facility that would do it. In many large cities, magnesium and vitamin infusions are... --- ### Acute migraine therapy in pregnancy - triptan is the safest choice. - Published: 2022-06-20 - Modified: 2022-06-20 - URL: https://www.nyheadache.com/blog/acute-migraine-therapy-in-pregnancy-triptan-is-the-safest-choice/ - Categories: Chronic migraine, Headache medications, Migraine, Migraine in pregnancy Two out of three women stop having migraines during pregnancy, especially in the second and third trimester. The difficult question is how to treat migraines in the first trimester and in women whose migraines do not improve or get worse in pregnancy. Acetaminophen (Tylenol, paracetamol) is considered safe in pregnancy and that is what many women take for migraines and other pains. Unfortunately, acetaminophen is usually ineffective for severe migraines. It is also not as safe as many physicians and the general public thinks. Several studies indicate that acetaminophen increases the risk of attention-deficit hyperactivity disorder (ADHD) and with heavy use, possibly even autism spectrum disorder. Some obstetricians strongly advise against taking any migraine medications. However, the stress of an acute migraine attack with severe pain, vomiting, and dehydration is likely to have a deleterious effect on the fetus. A Danish study of 22,841 pregnancies among women with migraine showed that untreated migraine leads to an increased risk of low birth weight, preterm birth, and cesarean delivery. A report just published in the journal of the American Medical Association (JAMA) examined "Association of Maternal Use of Triptans During Pregnancy With Risk of Attention-Deficit/Hyperactivity Disorder in Offspring". The study used the data from the Norwegian Mother, Father and Child Cohort Study, linked to the Medical Birth Registry of Norway, the Norwegian Patient Registry, and the Norwegian Prescription Database using the mother’s personal identification number. The conclusion of this large and rigorous study was: "This cohort study found no association between prenatal... --- ### Cove presents its data on the efficacy of telemedicine in treating migraines - Published: 2022-06-11 - Modified: 2022-06-11 - URL: https://www.nyheadache.com/blog/cove-presents-its-data-on-the-efficacy-of-telemedicine-in-treating-migraines/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine With tens of millions of Americans suffering from migraines, access to care is a major problem. Cove, a telemedicine startup, offers a practical and affordable solution. They deliver evidence-based therapies to patients in need. To prove that their approach works, Cove collects and analyzes vast amounts of data. The study I just presented at the annual scientific meeting of the American Headache Society shows that with Cove underserved minorities obtain excellent outcomes that are equal to those of whites. Disclosure: I am a paid consultant to Cove. --- ### Triptans are safe even in those with cardiovascular conditions - a new report - Published: 2022-06-10 - Modified: 2022-06-10 - URL: https://www.nyheadache.com/blog/triptans-are-safe-even-in-those-with-cardiovascular-conditions-a-new-report/ - Categories: Chronic migraine, Headache medications, Migraine A paper presented at the annual meeting of the American Headache Society that is taking place this weekend examined the risk of major adverse cardiovascular events (MACE) in patients with preexisting cardiovascular (CV) conditions. The researchers compared the risk of triptans with that of opioid/barbiturate drugs (drugs like codeine, Vicodin, Percocet, Fioricet) and non-steroidal anti-inflammatory drugs (NSAIDs). They used Mass General Brigham Research Patient Data Registry database to identify 12,121 prescriptions. Of these, 33% were for triptans, 50% for opioid/barbiturate drugs, and 17% for NSAIDs. MACE occurred in 1% of those taking triptans, 4. 5% taking opioid/barbiturate drugs, and 3. 8% taking NSAIDs. This goes against the established dogma of avoiding triptans in patients with CV problems. Instead, doctors are advised to offer opioid/barbiturate drugs or NSAIDs. Unfortunately, according to the FDA-approved package insert, triptans are contraindicated in patients with CV, cerebrovascular, and peripheral vascular problems. This contraindication came about from purely theoretical reasoning rather than real-life experience. Triptans do in fact have mild vasoconstriction properties and it is possible that someone with severe occlusion of coronary or other blood vessels can have dangerous constriction of a blood vessel. There have been also reports of healthy people developing cardiovascular complications, but those are very rare. This new data indicates that triptans are safer than the alternatives most doctors prescribe. The two alternatives described in the report also carry significant risks of addiction, stomach ulcers, and bleeding. It is very likely, however, that doctors will continue to avoid prescribing triptans in... --- ### Another study confirms vascular safety of triptans - Published: 2022-06-04 - Modified: 2022-06-04 - URL: https://www.nyheadache.com/blog/another-study-confirms-vascular-safety-of-triptans/ - Categories: Chronic migraine, Headache medications Sumatriptan (Imitrex) and other triptans have been available without a prescription in all European countries for over a decade. A new study by Austrian researchers published in the current issue of Headache confirms the outstanding safety of these drugs. The study looked at 13,833 people over 50 years of age who were prescribed a triptan in 2011, the year before triptans became available over-the-counter. The comparison group included 41,400 triptan non-users. Of the 13,833, 19% were older than 65. The researchers established that 16% "overused" triptans, defined as getting more than 30 doses in a 90-day period, although the concept of "overuse" clearly lacks a scientific basis. They discovered that those who were taking triptans did not spend more time in a hospital. They also did not have a higher frequency of heart attacks, hypertension, irregular heartbeats (arrhythmias), strokes, circulation problems in their extremities, or other vascular problems. This was true even for those who "overused" triptans. These findings are consistent with the “Consensus Statement: Cardiovascular Safety Profile of Triptans in the Acute Treatment of Migraine” by the Triptan Cardiovascular Safety Expert Panel published in 2004. It states “The incidence of serious cardiovascular events with triptans in clinical trials and clinical practice appears to be extremely low “. Unfortunately, in the US triptans are available only by prescription. About 15 years ago, the FDA blocked an application by the American Home Products (a company that Pfizer later acquired) to launch over-the-counter sumatriptan. This greatly restricts access to a highly effective... --- ### Primary stabbing headache - Published: 2022-05-22 - Modified: 2022-05-22 - URL: https://www.nyheadache.com/blog/primary-stabbing-headache/ - Categories: Brain disorders, Headaches Primary stabbing headache is a rare disorder. Because it is rare, it is often misdiagnosed and not treated properly. This post was prompted by a patient with this condition I saw last week. She went undiagnosed for 45 years. This 57-year-old woman has been having intermittent headaches since age 12. Her headaches would occur in bouts lasting anywhere from a few days to a couple of weeks. She’s had periods of up to a year without any headaches. Her latest period of daily headaches has been the longest – it has lasted almost 4 weeks and was still ongoing. Her headaches were left-sided and localized to the temple. The pain was very severe in intensity (9 on a 1 to 10 scale), sharp and stabbing in character. The pain lasted only a second but occurred 1-2 times an hour. She was having difficulty working as her work involved being in a videoconference all day long. She had no associated tearing, nasal congestion, nausea, or sensitivity to light or noise. She was taking 400 to 800 mg of ibuprofen with modest relief. During one of her previous bouts, she had tried gabapentin, 100 mg three times a day, which helped initially, but then became ineffective and she stopped it. As is the case with all rare conditions, controlled treatment trials are very difficult to do. Anecdotally though, indomethacin, a strong anti-inflammatory drug, seems to be very effective. Gabapentin, which the patient tried in a small dose, has been also reported to... --- ### CGRP monoclonal antibodies in pregnancy - Published: 2022-05-09 - Modified: 2022-05-09 - URL: https://www.nyheadache.com/blog/cgrp-monoclonal-antibodies-in-pregnancy/ - Categories: Chronic migraine, Headache medications, injections, Migraine, New treatments Not surprisingly, none of the new migraine drugs have been tested in pregnant women. No new drug for any indication is ever tested for its safety in human pregnancy. They are always tested in pregnant animals, which helps weed out most drugs that are clearly dangerous. It takes decades to learn if a drug is safe. This happens through an accumulation of anecdotal reports and pregnancy registries that are usually run by drug manufacturers. Erenumab (Aimovig) was the first CGRP monoclonal antibody to be approved for the preventive treatment of migraines four years ago. It was tested in pregnant monkeys who were given 50 times higher doses (by weight) than the FDA-approved dose for humans. Even though some of the medicine crossed the placenta into baby monkeys, they had no developmental problems. In the current issue of Headache, University of Texas doctors published a report of a woman who continued to inject herself with erenumab throughout the duration of her pregnancy. She tried to stop the drug before planning to get pregnant but her severe migraines recurred. Her baby was born healthy and had normal development by the last evaluation at 6 months of age. This case report is the first very small but important step in the process of evaluating the safety of erenumab in pregnancy. In humans, the transfer of antibodies, which are large molecules, across the placenta is very limited before the 16th week of pregnancy and increases after the 22nd week. We still recommend stopping the... --- ### Rimegepant (Nurtec) is now approved in Europe - Published: 2022-05-02 - Modified: 2022-05-02 - URL: https://www.nyheadache.com/blog/rimegepant-nurtec-is-now-approved-in-europe/ - Categories: Headache medications, Migraine Rimegepant (Nurtec ODT) was just approved by the European Medicines Agency for marketing in 27 EU countries as well as Iceland, Liechtenstein, and Norway. It was approved for both the acute treatment of migraine with or without aura, and prophylaxis (prevention) of episodic migraine in adults who have at least four migraine attacks per month. The drug will be sold under the name VYDURA. --- ### Treating so-called medication overuse headache - Published: 2022-04-21 - Modified: 2022-04-21 - URL: https://www.nyheadache.com/blog/treating-so-called-medication-overuse-headache/ - Categories: Botox, Headache medications, Migraine If you are "overusing" acute migraine medications, preventive migraine treatments still work very well. This was the conclusion of a study that was just published in the journal of the American Academy of Neurology, Neurology. The concept of medication overuse headache (MOH) has remained controversial. The majority of headache specialists believe in its existence. And that is what it is, a belief. There are correlational studies showing that those who take acute migraine drugs tend to have them more often as time goes on. This obviously does not mean that the drug is responsible for the increase in frequency. It is more likely that people take drugs more often because their headaches have gotten worse. There is proof for the existence of MOH only for two drugs - caffeine and opioid (narcotic) pain drugs. Triptans and NSAIDs have no such proof and in my 30 years of experience, they rarely cause MOH. The daily use of triptans is the topic of my most popular post in the 15 years of writing this blog. It received about 400 comments. Many people commented how relieved they are that taking triptans daily can be safe and effective. They often lament that they can't get their doctors to prescribe a sufficient quantity of pills. I am not suggesting that taking triptans daily is the first or second option. It is always better to try Botox and non-drug approaches. Taking a triptan daily, however, is probably safer than taking FRA-approved epilepsy drugs such as topiramate... --- ### What to do if Emgality, Aimovig, and Ajovy do not last a full month - Published: 2022-04-14 - Modified: 2022-04-14 - URL: https://www.nyheadache.com/blog/what-to-do-if-emgality-aimovig-and-ajovy-do-not-last-a-full-month/ - Categories: Chronic migraine, Migraine, New treatments Yesterday I saw a 48-year-old man who has been suffering from migraine headaches since his teens. He did not respond to a wide variety of drugs and non-drug therapies, but Emgality has been very effective. The only problem is that the effect lasts three and a half weeks. During the week before the next shot, his migraine headaches become severe and frequent. Sumatriptan helps but his disability as measured by the MIDAS scale is in the moderate range. He is a high-level executive in a large corporation and needs better control of his migraines. He had tried the other two monoclonal antibodies for migraines - Aimovig and Ajovy - and they were less effective. Fortunately, there is a good solution to his problem. I advised him to take Emgality injections every three and a half weeks. This is a higher frequency than what is recommended by the FDA and some doctors and patients may have concerns about the safety. The one-month interval is based on averages derived from large studies. People, however, are not average. Some metabolize drugs faster or need a higher or a lower dose of a drug. Another reassuring fact about Emgality is that it is approved at a much higher dose for cluster headaches. For migraine, we give a 240 mg loading dose and then, 120 mg monthly. Patients with cluster headaches get monthly injections of 300 mg. I have patients who have the same problem of the short duration of effect with Aimovig and Ajovy... --- ### Headache after COVID vaccination - Published: 2022-04-04 - Modified: 2022-04-04 - URL: https://www.nyheadache.com/blog/headache-after-covid-vaccination/ - Categories: Chronic migraine, Migraine, Science of Migraine I recently saw a 32-year-old woman who never suffered from headaches until a year ago when she was given an injection of a COVID vaccine (J&J). Her headache started the day after vaccination and it has persisted unabated. Besides severe daily headaches, she developed profound fatigue, muscle aches, and brain fog, making her unable to work. Her headaches had all the features of chronic migraines and I recommended trying Botox injections along with a migraine medication that she has not yet tried. I've seen a few dozen patients who developed less devastating headaches or whose preexisting migraines worsened after vaccination. Some developed a headache after the first or second shot and a few had it only after the booster. I am not suggesting that people should avoid the COVID vaccine. I've had three shots myself. I am writing about this because of a study just published by European researchers in the Journal of Headache and Pain - "Headache onset after vaccination against SARS-CoV-2: a systematic literature review and meta-analysis. " They examined the results of 84 scientific reports that included 1. 57 million participants, 94% of whom received Pfizer or Oxford-AstraZeneca vaccines. They discovered that vaccines were associated with a doubling of the risk of developing a headache within 7 days from the injection compared to people who received a placebo injection. They did not find a difference between the two different vaccine types. Some people developed a headache within the first 24 hours. In approximately one-third of the cases,... --- ### Chiropractic for migraine - Published: 2022-03-28 - Modified: 2022-03-28 - URL: https://www.nyheadache.com/blog/chiropractic-for-migraine/ - Categories: Alternative Therapies, Migraine A patient recently asked me about trying chiropractic treatment for her migraines. This is a chapter on chiropractic from my last book, The End of Migraines: 150 Ways to Stop Your Pain. Chiropractors can also relieve migraines if they are skilled and talented. Norwegian researchers conducted a study of chiropractic manipulation for migraine headaches in 104 patients. They divided patients into three groups. One group received real chiropractic manipulation of the spine, another one received a sham treatment that consisted of just putting pressure over the shoulders and lower back, and the third group continued their usual medication. The real and sham chiropractic groups received 12 treatment sessions over 12 weeks. Patients were followed for a year. After 12 weeks patients in all three study groups reported improvement. However, a year later, only the chiropractic groups still felt better. On average, they had about four migraine days a month, down from six to eight before the treatment started. Patients who continued their medications lost all of their improvement and their migraine frequency was back where it was at the baseline. The results published in the European Journal of Neurology suggest that chiropractic is indeed effective in reducing migraine frequency. However, it also suggests that any hands-on treatment is equally effective. This probably explains the popularity of chiropractic, physical therapy, massage, reflexology, Reiki, energy therapies, and other hands-on treatments. The same word of caution applies to chiropractic as to yoga. Avoid having high-velocity adjustments – sudden upward pulling and twisting of... --- ### Attend RetreatMigraine, online or in person - Published: 2022-03-17 - Modified: 2022-03-17 - URL: https://www.nyheadache.com/blog/attend-retreatmigraine-online-or-in-person/ - Categories: Headaches, Migraine, New treatments, Psychology of headaches I am honored to speak (in person) at this patient advocacy event. My topic will be, When treatments stop working, what's next? Here is some information and a link: RetreatMigraine 2022: April 1-3 at Hilton Charlotte University Place RetreatMigraine is a conference specially designed by and for adults living with migraine disease. The multi-day event brings together patients, care partners and migraine experts to support and strengthen our community. In 2022 RetreatMigraine will be a hybrid event. In-person capacity is for 300+ attendees and virtual capacity is unlimited. The conference offers interactive sessions that provide disease and treatment education, advocacy training and complementary therapy experiences. This conference is organized by CHAMP - Coalition for Headache and Migraine Patients. --- ### Julie Mauskop at Shrine.nyc - Published: 2022-03-10 - Modified: 2022-03-10 - URL: https://www.nyheadache.com/blog/julie-mauskop-at-shrine-nyc/ - Categories: Alternative Therapies See Julie's solo show at Shrine. nyc, 179 East Broadway, New York, NY --- ### Relief for droopy eyelids caused by Botox - Published: 2022-03-05 - Modified: 2022-03-05 - URL: https://www.nyheadache.com/blog/relief-for-droopy-eyelids-caused-by-botox/ - Categories: Uncategorized 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... --- ### Migraine World Summit is on again and it offers a wealth of information - Published: 2022-02-24 - Modified: 2022-02-24 - URL: https://www.nyheadache.com/blog/migraine-world-summit-is-on-again-and-it-offers-a-wealth-of-information/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, Science of Migraine I am happy to announce that you can attend the Migraine World Summit free of charge. It is back on March 16-24, 2022 for its 7th annual virtual event. As one of the former presenters, I can tell you that you may greatly benefit from learning about the latest research on how to best manage migraine. Migraine World Summit is a 9-day event where 32 of the world’s leading experts on migraine and headache research are interviewed on topics voted on by real patients. These interviews are online and can be accessed from anywhere in the world, but are only available free during the 9-day event. Get your ticket today at MigraineWorldSummit. com --- ### Combining peripheral electrical stimulation with relaxation training to treat migraine headaches - Published: 2022-02-17 - Modified: 2022-02-17 - URL: https://www.nyheadache.com/blog/combining-peripheral-electrical-stimulation-with-relaxation-training-to-treat-migraine-headaches/ - Categories: Alternative Therapies, Migraine, New treatments, Psychology of headaches Nerivio, an electrical stimulation device was cleared by the FDA to treat acute migraine attacks in adults almost three years ago. It was recently also cleared to treat migraines in adolescents. A new study sponsored by Theranica, the manufacturer of Nerivio shows that combining this device with relaxation and education improves its efficacy. Remote electrical neuromodulation (REN) is the official term for passing an electrical current through the arm in order to treat migraine headaches. Theoretically, other painful conditions can be also treated by electrical stimulation applied outside of the area of pain. Currently, however, there is only only one such device, Nerivio, and it is used to treat migraine headaches. I've prescribed this device (and it still needs a prescription) to hundreds of patients. About half of them find it effective and continue using it. Some of my patients have remarked that not only their migraine improves, but they also feel more relaxed. I was a bit surprised because they are supposed to crank up the current to the point just below where it becomes painful. But even if you don't feel relaxed, it makes sense for all patients to try to relax during this treatment which typically takes 45 minutes. Theranica sponsored a trial that combined electrical stimulation with what they call Guided Intervention of Education and Relaxation (GIER). This consisted of a 25-minute video played on the user’s smartphone during the treatment. It trains patients in three relaxation techniques: diaphragmatic breathing, progressive muscle relaxation, and guided imagery.... --- ### Internet-delivered cognitive and behavioral interventions help chronic pain - Published: 2022-02-05 - Modified: 2022-02-05 - URL: https://www.nyheadache.com/blog/internet-delivered-cognitive-and-behavioral-interventions-help-chronic-pain/ - Categories: Alternative Therapies, Pain, Pain Research, Psychology of headaches My previous post described a study that found no difference in efficacy among different types of psychosocial interventions for the treatment of chronic back pain. A recent 2020 Cochrane review concluded that there is strong evidence that face-to-face treatments based on cognitive behavioral therapy (CBT) have a small beneficial effect on reducing pain, disability, and distress in people with chronic pain. A meta-analysis just published in the journal Pain examined the efficacy of CBT delivered via the internet. Australian researchers examined 36 studies with 5778 participants. Most participants were female, and most studies recruited participants from community settings through online advertisements in Western countries. They concluded that "internet-delivered cognitive and behavioural interventions can result in small significant improvements in interference/disability, depression, anxiety, pain intensity, self-efficacy and pain catastrophizing. Guided interventions may result in greater treatment effects for key outcomes in pain management, including interference/disability, anxiety and pain intensity. " The meta-analysis showed that guidance by a clinician improves the results. However, this guidance varied across the studies in terms of how it was provided (e. g. , via secure email, SMS messages, telephone calls), the timing and frequency with which it is provided (e. g. , weekly, on demand, or at set time points), the amount provided (e. g. , brief versus extended), and the professional qualifications and experience of those providing it (e. g. , students-in-training, registered psychologists, non-health professionals). There was no difference between the traditional CBT and ACT (acceptance-commitment therapy), confirming the results described in my previous... --- ### What is best - cognitive therapy, mindfulness-based stress reduction, or behavioral therapy? - Published: 2022-01-30 - Modified: 2022-01-30 - URL: https://www.nyheadache.com/blog/what-is-best-cognitive-therapy-mindfulness-based-stress-reduction-or-behavioral-therapy/ - Categories: Uncategorized 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... --- ### Intranasal ketamine for cluster headaches - Published: 2022-01-20 - Modified: 2022-01-20 - URL: https://www.nyheadache.com/blog/intranasal-ketamine-for-cluster-headaches/ - Categories: Alternative Therapies, Cluster headaches, Headache medications, New treatments Cluster headaches are considered to cause the worst pain imaginable. We have a variety of medications - both acute and preventive - that help relieve the pain of cluster headaches. For some, none of these treatments work and we do need additional medications. Ketamine could be one such drug. Ketamine has been in use for over 50 years. Its main indication is intravenous anesthesia. Recently, the FDA approved ketamine nasal spray for depression. It is also being widely used intravenously and by mouth for depression, chronic pain, and migraine headaches. A group of researchers at the Danish Headache Center in Glostrup, Denmark tested the efficacy of ketamine nasal spray for the acute treatment of cluster headaches. Anja Petersen and her colleagues selected 20 cluster patients whose attacks did not respond sufficiently well to sumatriptan or oxygen - the two most effective acute therapies for cluster headaches. Patients treated a single cluster attack with 15 mg of intranasal ketamine. They could repeat this dose every 6 minutes, for up to 5 times. Four patients took another medication after 15 minutes. Of the 16 remaining ones, 11 had a drop in pain severity by an average of four points, to four or lower on a one to 10 scale. Half of the patients preferred ketamine to oxygen and/or sumatriptan injection. No patient had any serious side effects from ketamine during the trial. Ketamine nasal spray that is approved for depression is a more potent version of ketamine called esketamine (Spravato). It is... --- ### Marijuana increases the risk of car accidents - Published: 2022-01-13 - Modified: 2022-01-13 - URL: https://www.nyheadache.com/blog/marijuana-increases-the-risk-of-car-accidents/ - Categories: Alternative Therapies, Brain disorders, Migraine, New treatments, Pain I've been prescribing medical marijuana (MM) since 2016 when it became legal in New York. We still lack controlled clinical trials of MM for the treatment of migraines. Most of my patients who find MM useful report that it relieves nausea or anxiety, helps them go to sleep and sometimes relieves pain. Others find that taking it daily prevents migraines. CBD alone can be also helpful, but most patients need a combination of CBD and THC as well in order to obtain a therapeutic effect. Like any other drug, MM can have side effects. One of them is cognitive impairment. A study just published in the New England Journal of Medicine describes the effect of recreational marijuana legalization in Canada on injuries to car drivers. The researchers studied drivers treated after a motor vehicle collision in four British Columbia trauma centers from 2013 through 2022. They discovered that after legalization, the number of moderately injured drivers with a THC level above the legal limit doubled. The largest increase was seen in older and male drivers. This is relevant to the users of MM as well. From now on, I will caution my patients not to drive after taking any THC-containing products. Just like with alcohol, you don't need to have a blood level above the legal limit to slow your reflexes. --- ### Pandemic worsens headaches in children - Published: 2022-01-06 - Modified: 2022-01-07 - URL: https://www.nyheadache.com/blog/pandemic-worsens-headaches-in-children/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Pain, post-traumatic headache, Psychology of headaches, Science of Migraine Worsening of headaches in children is one of many deleterious effects of the pandemic and measures to control it. A survey of children in a headache clinic at the Children's National Hospital in Washington DC by Dr. DiSabella and his colleagues showed that 46% of children had worsening of their migraine headaches during the pandemic. They also reported much higher rates of anxiety, depression, and stress. Two-thirds of children reported that they exercised less. This could be one of the contributing factors since exercise has been shown to reduce the frequency and the severity of headaches. What this survey did not explore is the effect of family stress and the presence of child abuse. Reports of child abuse have actually declined during the pandemic because most of these reports come from teachers. Chronic migraines and chronic pain are much more common in patients with a history of being physically, emotionally, or physically abused. PTSD from other causes has a similar predisposing effect and many children and adults have been traumatized by the pandemic. Some children (as well as adults) report improvement of their headaches during the pandemic. My patients tell me that because they do not have to commute, they have more time to exercise, meditate, cook healthy meals, and get more sleep. I see this in a small proportion of patients. A larger group did worse with additional factors being worsening of headaches due to COVID and in a very small number, COVID vaccines. --- ### If you are having surgery and have had migraines, read this! - Published: 2021-12-28 - Modified: 2021-12-28 - URL: https://www.nyheadache.com/blog/if-you-are-having-surgery-and-have-had-migraines-read-this/ - Categories: Brain disorders, Chronic migraine, Migraine, Science of Migraine There is a new and surprising connection between postoperative nausea and vomiting (PONV) and migraines. It offers a very effective treatment that will relieve the suffering of tens of thousands of patients. Many migraine patients tell me that they develop a severe migraine following surgery. Possible reasons include the stress of the operation, fasting before surgery, the effect of anesthetic drugs, pain medicines given after surgery, an awkward head position, and caffeine withdrawal. But some patients report severe nausea and vomiting that occurs without a headache. PONV affects about 30% of all patients undergoing surgery under general anesthesia. Some patients develop intractable vomiting that does not respond to typical nausea medications even though there are more than a dozen such medications. This often requires hospital admission when surgery is done in an ambulatory (outpatient) setting. Admissions for PONV are more common than for surgical or cardiovascular complications. Intractable PONV can cause opening of the sutured wound, aspiration pneumonia, bleeding, and other complications. It appears that patients who suffer from migraines or have had migraines in the past are more prone to develop intractable PONV. I learned about this last month while participating in a headache conference in Zurich. Dr. Leander Sakellaris, a Swiss anesthesiologist and pain specialist, told me about his Masters degree thesis on this topic. He allowed me to share its full text - MasterThesis-PONV. His thesis describes ways to reduce the risk of PONV. If possible, ask for surgery to be done under regional and not general... --- ### Repetitive transcranial magnetic stimulation relieves migraines - Published: 2021-12-18 - Modified: 2021-12-18 - URL: https://www.nyheadache.com/blog/repetitive-transcranial-magnetic-stimulation-relieves-migraines/ - Categories: Alternative Therapies, Headaches, Migraine, neurostimulation, New treatments Magnetic stimulation with a single pulse has been shown to be effective in aborting a migraine attack with the eNeura Spring TMS device. Repetitive magnetic stimulation (rTMS) of the brain has been shown to relieve depression. A pilot study just published in the journal Brain Stimulation examined the effectiveness of repetitive magnetic brain stimulation for the prevention of migraine attacks. German and Moldovan researchers conducted a double-blind, randomized controlled study in patients with episodic migraine. They compared real and sham stimulation in 60 patients. Participants received six treatment sessions over two weeks. The primary outcome measure was the number of patients whose migraine days dropped by 50% or more. The frequency and intensity of migraine attacks over a 12-week period were also assessed. Real rTMS produced at least a 50% reduction in migraine days in 42%. This number was 26% in the sham group. The mean migraine days per month decreased from 7. 6 to 4. 3 days in the real rTMS group and from 6. 2 to 4. 3 days in the sham rTMS group. The reduction in migraine attack frequency was also higher in the real rTMS compared to the sham group. No serious adverse events were observed. There are a couple of practical issues with this treatment approach. The rTMS equipment is already being used for depression, which in theory should make it easy to adapt for migraines. However, this treatment is time-consuming and expensive and is not likely to be covered by insurance. Another problem, which... --- ### Sublingual ketamine for pain - Published: 2021-11-28 - Modified: 2021-11-28 - URL: https://www.nyheadache.com/blog/sublingual-ketamine-for-pain/ - Categories: Headache medications, Headaches, Migraine, Pain Ketamine was approved by the FDA in 1970 and was originally used for the induction of anesthesia. It has been shown to relieve depression and is also widely used to treat pain. For depression, it is approved by the FDA in a nasal spray form. For severe pain, it is often given intravenously. Oral ketamine is probably the least effective. In a recent study, Australian researchers compared the pain-relieving effect of oral and sublingual ketamine in 16 patients. The study was double-blind. Sublingual administration of ketamine resulted in a faster onset of pain relief - 7 minutes with sublingual and 13 with oral. Side effects were also more common with the sublingual route. In all other measures, sublingual and oral administration produced similar pain-relieving effects. Oral and sublingual ketamine are not available at regular pharmacies. It is, however, easily made up by compounding pharmacies. The sublingual ketamine is available as a lozenge which is also called troche. I usually prescribe ketamine infusions or troches only after a wide variety of other treatments do not provide relief. Ketamine is a controlled drug with a potential for misuse. It can also cause psychiatric side effects such as hallucinations, disinhibition, delusional thinking, and depression. --- ### Zürich headache conference - Published: 2021-11-08 - Modified: 2021-11-08 - URL: https://www.nyheadache.com/blog/zurich-headache-conference/ - Categories: Chronic migraine, Cluster headaches, Headache medications, Headaches, Migraine With Swiss colleagues Drs. Caterina Podella, Livia Granata, and Reto Agosti at the headache conference held on November 4, 2021, in Zürich. Dr. Podella presented a very comprehensive approach to the treatment of migraine headaches. Dr. Granata expertly covered the topic of cluster headaches. I spoke about the challenges of treating refractory migraine headaches and Dr. Agosti provided a lively and insightful discussion of all these topics. --- ### Men with migraine and cluster headaches can also have hormonal issues - Published: 2021-10-31 - Modified: 2021-10-31 - URL: https://www.nyheadache.com/blog/men-with-migraine-and-cluster-headaches-can-also-have-hormonal-issues/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Cluster headaches, Pain, Science of Migraine The influence of estrogen on migraines in women is well established - women often experience migraines before or during menstruation and ovulation and their migraines usually subside during pregnancy and menopause. According to a new study published this month by Dutch researchers, men who suffer from migraines often have a deficiency of male hormones. Gisela Terwindt and her collaborators evaluated a possible deficiency of androgens or male hormones in 534 men with migraine and 437 men with cluster headaches. These men were compared to 152 healthy controls. Two validated questionnaires were used to measure androgen deficiency scores. The researchers controlled for age, weight (BMI), smoking, and lifetime depression. They also measured four sexual symptoms (beard growth, morning erections, libido, and sexual potency). These four symptoms have been shown to differentiate between hormonal deficiency from anxiety and depression. They did not perform blood tests to measure hormone levels. Patients reported more severe symptoms of clinical androgen deficiency compared with controls. Both patient groups were more likely to suffer from any of the specific sexual symptoms compared to controls (18% migraine, 21% cluster headache, 7% controls). The findings in men with cluster headaches are not surprising. Prior reports have documented low testosterone levels in this population. A small study by Dr. Mark Stillman suggested that those cluster patients who have low testosterone levels could benefit from hormone replacement therapy. There are also reports of low testosterone levels in men with chronic migraines but the connection is less established. This study may prompt... --- ### If you see a friend respond to treatment, you are more likely to respond as well - Published: 2021-10-21 - Modified: 2021-10-21 - URL: https://www.nyheadache.com/blog/if-you-see-a-friend-responds-to-treatment-you-are-more-likely-to-respond-as-well/ - Categories: Alternative Therapies, Headache medications, Migraine, Pain, Pain Research, Psychology of headaches The placebo effect is a bane of clinical trials. It is, however, a great tool in clinical practice. It is unethical to prescribe an actual placebo but there is no reason not to try to enhance the placebo effect when prescribing any treatment, pharmacological or non-drug. A new and unique study that was just published in Pain, a journal of the International Association for the Study of Pain, suggests that looking at others who respond to treatment makes people more likely to respond to that treatment as well. German researchers decided to study what is called social observational learning (SoL). This was a double-blinded randomized controlled clinical trial in 44 patients with chronic low-back pain (CLBP). They compared the effects of observing positive treatment outcomes in a sham or pretend patient versus hearing the same sham patient report neutral effects. In the SoL group, the sham patient told study patients about his improved pain due to amitriptyline and he also demonstrated his improved mobility by bending forwards and sideways. The same sham patient told the control group only that he was taking amitriptyline. The researchers collected data before and after the intervention and two weeks later. After the intervention, pain decreased in both groups with no difference between groups. The SoL group, however, showed a significantly larger decrease in perceived disability. The authors concluded that "The CLBP patients’ direct observation of positive treatment outcomes in the sham patient appears to have enhanced the treatment effects, while indirect verbal reports of... --- ### Dr. Mauskop to speak on refractory migraines in Zurich, Switzerland - Published: 2021-10-14 - Modified: 2021-10-14 - URL: https://www.nyheadache.com/blog/6358-2/ - Categories: Chronic migraine, Headaches, Migraine, New treatments I am honored to participate in a symposium on headache management, “THE CHALLENGE OF MIGRAINE AND CLUSTER HEADACHES”. The title of my presentation is The challenge of migraine: new perspectives in refractory cases This interactive neurological conference will be held in-person on Thursday, November 4, 2021 at the Zurich Marriott Hotel, Zurich, Switzerland --- ### Response to drugs is influenced by psychological factors - Published: 2021-10-11 - Modified: 2021-10-11 - URL: https://www.nyheadache.com/blog/response-to-drugs-is-influenced-by-psychological-factors/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Psychology of headaches To gain FDA approval a drug has to be shown to be better than a placebo. The placebo effect is a well-established psychological contributor to the efficacy of most treatments. A group of Italian researchers just published an interesting study looking at other psychological factors that might influence the response to treatment. They evaluated chronic migraine patients who were treated with erenumab (Aimovig). Erenumab is a monoclonal antibody that targets CGRP, a neurotransmitter involved in the development of migraine attacks. Monthly erenumab injections were given for one year to 75 patients with chronic migraine who had already failed at least three other oral preventive drugs. A full psychological evaluation assessed personality disturbances, mood and anxiety disorders, as well as childhood traumas, and ongoing stressors. After 12 months of treatment, 53 patients had at least a 50% drop in the number of headache days per month. The other 22 did not. When compared to responders, non-responders were more likely to have personality disorders with anxious-fearful, avoidant, dependent, and obsessive-compulsive features. Non-responders were also more likely to suffer anxiety disorders and had a higher number of current major stressors. A very practical application of these findings is that doctors need to address anxiety when treating migraine and chronic pain patients. I've seen a number of patients whose migraines improved with an SSRI antidepressant such as fluoxetine (Prozac) or escitalopram (Lexapro). SSRIs do not possess pain-reliving properties. However, they are good at relieving anxiety and so can indirectly improve migraines. Most of the... --- ### FDA approves Qulipta (atogepant), a new preventive migraine drug - Published: 2021-10-02 - Modified: 2021-10-02 - URL: https://www.nyheadache.com/blog/fda-approves-qulipta-atogepant-a-new-preventive-migraine-drug/ - Categories: Chronic migraine, Headache medications, Migraine Atogepant (Qulipta) is a new migraine drug that was just approved by the FDA for the preventive treatment of migraines. It is the third drug in the family of gepants. Gepants block the CGRP receptor. CGRP is a chemical released during a migraine attack. In the past three years, the FDA approved four injectable preventive migraine drugs that also block CGRP. Gepants are taken by mouth. The dose of atogepant is 10 mg, 30 mg or 60 mg taken daily, once a day. The primary efficacy endpoint in clinical trials was the change from baseline in mean monthly migraine days over the 12-week treatment period. There was a drop of 3. 7, 3. 9, and 4. 2 in the number of mean monthly migraine days in the 10 mg, 30 mg, and 60 mg doses, respectively. Side effects - assessed in almost 2,000 patients - were infrequent and mild. Nausea occurred in 5%, 6%, and 9% on 10 mg, 30 mg, and 60 mg respectively, constipation in 6% on all three doses, and fatigue or somnolence in 4%, 4%, and 6%. Ubrogepant and rimegepant, two other gepants, were first approved to be taken as needed, whenever a migraine strikes. Rimegepant recently was also approved for the prevention of migraines. Even though gepants are very similar they often differ in how they work in an individual patient. Some of my patients find that ubrogepant works much better than rimegepant while for others the opposite is true. I am certain that some... --- ### A large study shows that the weather affects pain - Published: 2021-09-27 - Modified: 2021-09-27 - URL: https://www.nyheadache.com/blog/a-large-study-shows-that-the-weather-affects-pain/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, Pain, Pain Research Many migraine sufferers report that their migraines are brought on by the weather. High humidity, high temperatures, and changes in barometric pressure are the most commonly reported triggers. I've seen some patients for whom changes in the weather is the only trigger. Research studies looking at this connection, however, have been contradictory. A very large study just published in Pain, the journal of the International Association for the Study of Pain examined a possible connection between the weather and pain tolerance. The data from 18,000 Norwegians aged 40 years or older from the general population were examined. All of them underwent pressure pain tolerance (PPT) test using a blood pressure cuff and cold pain tolerance (CPT), tested by immersing the dominant hand in cold water. The results showed a clear seasonal variation in CPT. Cold pain tolerance was worse during the warmer times of the year compared with January. There was no seasonal variation in PPT. The authors also found that temperature and barometric pressure have "a causal and dynamic effect on pain tolerance, which supports the common belief that weather affects pain. " There is not much you can do about the weather except for moving to a place with an unchanging and mild climate. Some of my patients with barometric pressure-induced headaches do respond to acetazolamide (Diamox). This is a diuretic that prevents mountain sickness in climbers. Patients do not need to constantly check the weather forecast. For more information on acetazolamide, see my previous blog post. --- ### Migraines are less common in people with diabetes - Published: 2021-09-18 - Modified: 2021-09-18 - URL: https://www.nyheadache.com/blog/migraines-are-less-common-in-people-with-diabetes/ - Categories: Uncategorized 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. --- ### Julie Mauskop on David Zwirner’s Platform - Published: 2021-09-11 - Modified: 2021-09-11 - URL: https://www.nyheadache.com/blog/julie-mauskop-on-david-zwirners-platform/ - Categories: Alternative Therapies Patients coming to the New York Headache Center have enjoyed seeing my daughter Julie's artwork since she was 11. This was not just a childhood interest - Julie graduated from the Rhode Island School of Design with a degree in painting. She has continued to work hard as a painter and her perseverance and talent have led to wider recognition. Julie is represented by a New York City gallery, SHRINE. A few days ago, her work was selected for Platform, a new online initiative by David Zwirner. You can see more of Julie's work on her Instagram page. --- ### A new, better DHE nasal spray is approved for acute migraines - Published: 2021-09-06 - Modified: 2021-09-06 - URL: https://www.nyheadache.com/blog/a-new-better-dhe-nasal-spray-is-approved-for-acute-migraines/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine, New treatments Trudhesa is a new formulation of dihydroergotamine (DHE) nasal spray just approved by the FDA. It appears to be more effective than the original DHE nasal spray (Migranal) that was introduced in 1997. Ergotamine, the first migraine-specific drug was developed in 1926. It is still available in tablet form but is not widely used because it causes nausea, constriction of blood vessels, and other side effects. DHE, approved in 1946, was the first synthetic migraine drug. It was derived from ergotamine in an attempt to reduce side effects. DHE is not effective when taken by mouth and was originally approved for intravenous use. It is still being used now - 75 years later - intravenously, intramuscularly, and subcutaneously. DHE injection is a very effective medicine, often used when no other migraine drug provides relief. It does cause nausea and vomiting in a significant number of patients. This is why it is often given along with an anti-nausea drug such as ondansetron (Zofran), prochlorperazine (Compazine), or metoclopramide (Reglan). The original DHE nasal spray has been a relative disappointment. It is not very effective, although there are some patients for whom it works well. Despite being on the market for over 20 years, it is still very expensive - $100 a dose. The manufacturer of Trudhesa, which is a better product than Migranal, is promising to make their product more affordable. Nasal delivery of DHE causes less nausea than an injection. Trudhesa is more effective despite delivering a smaller dose of DHE... --- ### Placebo really works, even if you know it's placebo - Published: 2021-08-30 - Modified: 2021-08-30 - URL: https://www.nyheadache.com/blog/placebo-really-works-even-if-you-know-its-placebo/ - Categories: Alternative Therapies, Headache medications, Headaches, Migraine, Pain, Pain Research, Psychology of headaches The placebo effect is a bane of clinical trials. A drug is considered ineffective if it is only as good as a placebo. And placebo can be quite good. Intriguingly, the placebo effect in clinical trials has been getting stronger over the past few decades. Lately, placebo has been receiving a lot of attention from researchers. A rigorous study just published in the journal Pain looked at the effect of a placebo when patients were clearly told that they are taking a placebo. These patients were compared to those who were given a placebo in a double-blind study of peppermint oil capsules for irritable bowel syndrome (IBS). These two different types of placebo were compared to a control group of patients who were not given any pills. Participants treated with an open-label placebo and a double-blind placebo reported similar and clinically meaningful improvements in IBS symptoms. These improvements were significantly greater than in those who were not given any pills. The results were statistically significant for the primary outcome measure (IBS Symptom Severity Scale) as well as for mean global improvement scores. Twice as many patients in the double-blind placebo group had side effects (mostly gastrointestinal, such as heartburn) than those in the open-label placebo. It is probably because the first group was told about the possible side effects of peppermint oil. The authors concluded that an open-label placebo "could play a role in the management of patients with refractory IBS". Just like migraines, IBS involves central sensitization and hypersensitivity... --- ### Another review of The End of Migraines: 150 Ways to Stop Your Pain - Published: 2021-08-22 - Modified: 2021-08-22 - URL: https://www.nyheadache.com/blog/another-review-of-the-end-of-migraines-150-ways-to-stop-your-pain/ - Categories: Chronic migraine, Migraine, Science of Migraine It is gratifying to know that my colleagues consider my new book, The End of Migraines: 150 Ways to Stop Your Pain, to be useful for patients with migraines as well as doctors who treat them. Dr. Uwe Reuter of Charité Universitätsmedizin Berlin, Germany has published a review in the latest issue of the journal of the International Headache Society, Cephalalgia. He concludes his review, "I am happy to encourage everybody who is interested in migraine to read this e-book. " Dr. Allan Purdy published a review of my book in May in the journal of the American Headache Society, Headache. His review was much longer and so was the conclusion: "I would recommend this book to anyone who has migraine or cares for people with migraine and wants a broad and sometimes detailed overview of the treatments. Available in the e-book format, it represents a lot of work for one person, but his passion, occasional humor, and historical perspectives are evident in this work. You don’t have to agree or accept everything the author says to enjoy and benefit from this “book,” and I know he would want people to be critical and skeptical where warranted. However, you will find more than you would usually need to know from this banquet of 150 ways to help your migraines! Enjoy, I did very much. Read it through once and save as reference. " If you do read this book, please write a short review on Amazon. com. --- ### More of the omega-3 and less of omega-6 fatty acids helps migraines - Published: 2021-08-08 - Modified: 2021-08-08 - URL: https://www.nyheadache.com/blog/more-of-the-omega-3-and-less-of-omega-6-fatty-acids-helps-migraines/ - Categories: Alternative Therapies, Migraine Migraine can be triggered by many foods, including sugar, chocolate, smoked, pickled, cured, dried, and fermented foods. There are also foods that can help with migraines. These are magnesium-rich dark leafy vegetables and whole grains. Omega-3 fatty acids that are known to have anti-inflammatory properties is another option. The British Medical Journal just published a randomized controlled trial of omega-3 and omega-6 fatty acids in the prevention of migraines. The same group of North Carolina researchers published a similar smaller study in 2013. The new trial included 182 participants who had migraines on 5-20 days per month. They were divided into three groups. One group was supplemented with omega-3 fatty acids (eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The second group was also given the same amount of EPA and DHA but their diet also had a reduced amount of linoleic acid, an omega-6 fatty acid. The third group served as control. Compared with the control diet, the first two diets decreased total headache hours per day, moderate to severe headache hours per day, and headache days per month. The diet that increased omega-3s and reduced omega-6 had a greater decrease in headache days per month than the diet that was only supplemented with omega-3s. Supplementation also resulted in an improvement of inflammatory markers in the blood, a change that was not seen in the control group. If eating more salmon or other fish rich in omega-3s is not practical, taking a good-quality supplement is a good alternative. To reduce... --- ### Magnesium can reduce the risk of aneurysm formation and rupture - Published: 2021-08-02 - Modified: 2021-08-02 - URL: https://www.nyheadache.com/blog/magnesium-can-reduce-the-risk-of-aneurysm-formation-and-rupture/ - Categories: Alternative Therapies, Brain disorders Many patients with headaches are concerned about having a brain aneurysm. It is rare for an aneurysm to cause ongoing headaches. An aneurysm usually causes one very severe headache when it ruptures and causes a brain hemorrhage. Half of the patients with a ruptured aneurysm die and many of those who survive have persistent neurological problems. This is why detecting and treating an aneurysm before it ruptures is the goal. Because aneurysms have a genetic component we do angiograms in close relatives of someone with a ruptured or unruptured brain aneurysm. About 2% of the population has brain aneurysms. It would be prohibitively expensive to subject everyone to a screening angiogram. Aneurysms are the result of an outpouching of a weak spot in an artery. This process is very gradual and aneurysms tend to get bigger with age. People with small aneurysms and high blood pressure are advised to control their blood pressure in the hope that this will prevent or slow down the growth of the aneurysm. Small aneurysms rarely rupture. If an aneurysm is larger than 5 millimeters in diameter, however, the risk of rupture becomes significant and surgery or non-surgical obliteration is recommended. Until now, there have been no interventions proven to reduce the risk of aneurysm formation and rupture. In the current issue of Neurology, a group of Swedish researchers published a rigorous study entitled, Association of Serum Magnesium Levels With Risk of Intracranial Aneurysm. They provided evidence showing that higher serum magnesium concentrations reduce the... --- ### Naratriptan is the most effective triptan? - Published: 2021-07-26 - Modified: 2021-07-26 - URL: https://www.nyheadache.com/blog/naratriptan-is-the-most-effective-triptan/ - Categories: Chronic migraine, Headache medications, Migraine In the US, we are lucky to have seven different triptans available in the pharmacies. Five of them - sumatriptan, rizatriptan, zolmitriptan, eletriptan, and almotriptan are considered to be more effective than the other two - naratriptan and frovatriptan. Frovatriptan has the longest duration of effect because its half-life is 26 hours. Its initial efficacy, however, is not as good as that of other triptans. Naratriptan has a half-life of 6 hours, while the leading five triptans, only 2-4 hours. Naratriptan is also considered to be less effective but it could be because the marketed dose is too low. In an article in the latest issue of Cephalalgia Peer Tfelt-Hansen argues that naratriptan is as effective as sumatriptan. In fact, if you inject an adequate dose of naratriptan it works better than an injection of sumatriptan. Naratriptan, however, is not available as an injection, only sumatriptan is. Naratriptan (Amerge) was introduced by the same company that made sumatriptan (Imitrex), the very first triptan. They decided to market it as a "gentle" triptan and selected a relatively low dose of 2. 5 mg that had as few side effects as the placebo. In clinical trials, 2. 5 mg of oral naratriptan is less effective than 100 mg of oral sumatriptan. However, clinical trials have shown that 10 mg of naratriptan has similar efficacy to 100 mg of sumatriptan. Naratriptan, 10 mg had slightly fewer side effects than sumatriptan, 100 mg. The author also mentions the conclusion of the 2004 review by... --- ### Chronic pain causes cognitive decline - Published: 2021-07-17 - Modified: 2021-07-17 - URL: https://www.nyheadache.com/blog/chronic-pain-causes-cognitive-decline/ - Categories: Brain disorders, Chronic migraine, Pain, Pain Research Many patients with chronic migraines complain of memory, word-finding, and other cognitive difficulties. I tell them that once we find an effective treatment for their migraines, their cognitive abilities should improve. I explain that the barrage of pain messages disrupts the normal flow of information in the brain. "Association between chronic pain and long-term cognitive decline in a population-based cohort of elderly participants" is the title of a study published in a recent issue of the journal Pain. The French researchers followed elderly chronic pain patients for up to 15 years. They concluded that "Chronic pain is associated with a higher cognitive decline, particularly in processing speed. This result reinforces the importance of actively treating chronic pain with pharmacological and nonpharmacological strategies to prevent its consequences, including cognitive consequences. " This also applies to chronic migraines. Fortunately, we have many new and not so new highly effective pharmacological and non-drug therapies that can provide relief to well over 90% of chronic migraine suffers. Check out my new book, The End of Migraines: 150 Ways to Stop Your Pain. --- ### Occipital nerve stimulation relieves chronic cluster headaches - Published: 2021-07-10 - Modified: 2021-07-10 - URL: https://www.nyheadache.com/blog/occipital-nerve-stimulation-relieves-chronic-cluster-headaches/ - Categories: Alternative Therapies, Cluster headaches, neurostimulation The pain of cluster headaches is considered to be the worst of all headaches. Hence the moniker, suicide headaches. Thankfully, it is a rare condition. Episodic cluster headaches affect a little over 0. 1% of the population or approximately 400,000 Americans. Of these, about 15% suffer from chronic cluster headaches. The division of cluster headaches into chronic and episodic is arbitrary, just like it is with migraines. Cluster headache attacks occurring for one year or longer without remission, or with remission periods lasting less than 3 months are considered to be chronic. Patients often go from episodic into chronic and back into episodic. The term cluster comes from the fact that headaches occur daily or several times a day for a few weeks or months and then stop for a year or so. The attacks are always one-sided and the pain is localized around the eye. It can be associated with tearing, droopy eyelid, and nasal congestion on the side of pain. Some patients also have redness of the eye, sweating of the face, and tenderness in the back of the head. These headaches are often misdiagnosed as migraine or sinus headaches. It can take several years before a patient receives the correct diagnosis and appropriate treatment. The only FDA-approved preventive treatment is monthly injections of galcanezumab (Emgality). It came Verapamil, a calcium channel blocker used for hypertension, is another very effective drug. The dose of verapamil for cluster headaches is much higher than for hypertension - up to 960... --- ### Mindfulness-based stress reduction helps migraines - Published: 2021-06-28 - Modified: 2021-06-28 - URL: https://www.nyheadache.com/blog/mindfulness-based-stress-reduction-helps-migraines/ - Categories: Alternative Therapies, Chronic migraine, Migraine, Psychology of headaches It's been a few years since I wrote about meditation. There is little doubt that it helps migraine sufferers. Unlike drugs, meditation is harder to test in clinical trials. However, we do have many imaging studies showing the effect of meditation on the brain and specifically on pain. Mindfulness-based stress reduction (MBSR) is based on the practice of meditation. It is more structured and usually consists of a fixed number of sessions. This makes it easier to study in research trials. The results of such a clinical trial were recently published in JAMA Internal Medicine. The researchers compared MBSR with headache education. The study included 89 adults who experienced between 4 and 20 migraine days per month. The participants and the researchers analyzing the data were blinded as to which group patients were assigned to. MBSR or headache education was delivered in groups that met for 2 hours each week for 8 weeks. Most participants were female and the mean number of migraine days per month was 7. They had severe migraine-related disability. The follow-up period was 36 weeks. While MBSR did not improve migraine frequency more than headache education, it did improve disability, quality of life, self-efficacy, pain catastrophizing, and depression for up to 36 weeks. MBSR courses are widely available online. However, you can also learn to meditate by reading a book. My favorite one is Mindfulness in Plain English by B. Gunaratana. In-person classes are also becoming again (after COVID) widely available. Tara Brach is a psychologist... --- ### Dividing migraines into chronic and episodic was a costly mistake - Published: 2021-06-17 - Modified: 2021-06-17 - URL: https://www.nyheadache.com/blog/dividing-migraines-into-chronic-and-episodic-was-a-costly-mistake/ - Categories: Botox, Chronic migraine, Headaches, Migraine, Science of Migraine The international classification of headache disorders lists many different types of migraines - migraine with aura, hemiplegic, retinal, chronic, and others. Chronic migraine is present if a person has a headache on 15 or more days each month. If the headache is present on fewer than 15 days, the condition is called episodic migraine. The division into chronic and episodic migraine is not based on any scientific evidence. Research by Dr. Richard Lipton and his colleagues showed that patients often cycle from chronic into episodic migraines and back. This happens even without any treatment. An international group of headache experts (some of whom participated in the decision to split migraines into chronic and episodic) just published a repudiation of this arbitrary designation. They concluded: "Our data suggest that the use of a 15 headache day/month threshold to distinguish episodic and chronic migraine does not capture the burden of illness nor reflect the treatment needs of patients. " One damaging aspect of having a category of chronic migraine as it applies to clinical practice is the fact that Botox is approved only for chronic migraines. I know from 25 years of experience injecting Botox that it works very well for some patients who have as few as four migraines a month. Unfortunately, insurance companies do not pay for Botox unless you have chronic migraine. This deprives many patients of this very effective and safe treatment. The second very costly effect is on the research of new preventive drugs. The FDA requires... --- ### Erenumab relieves trigeminal neuralgia - another case series - Published: 2021-06-07 - Modified: 2021-06-07 - URL: https://www.nyheadache.com/blog/erenumab-relieves-trigeminal-neuralgia-another-case-series/ - Categories: Headache medications, Headaches, Pain, Trigeminal and other neuralgias Trigeminal neuralgia (TN) is an extremely painful and often debilitating condition. Many people respond to the standard therapy with epilepsy drugs such as carbamazepine (Tegretol) or oxcarbazepine (Trileptal). Botox injections can be helpful as well. A significant minority of patients, however, do not respond to these treatments and sometimes require brain surgery. Fortunately, we have a new class of drugs that has allowed some of my patients to avoid having an operation. These drugs are CGRP monoclonal antibodies (mAbs). They have been approved by the FDA only for the prevention of migraine headaches, so their use for TN is considered to be "off-label". The first case series was reported in 2019 by the Cleveland Clinic doctors. They found that six out of eight TN patients had a good response to erenumab (Aimovig). A group of Israeli physicians published another case series in the current issue of Neurology. They found that nine out of ten TN patients obtained very good relief from erenumab. Erenumab was the first CGRP mAb. It was approved in May of 2018. Another two, galcanezumab (Emgality) and fremanezumab (Ajovy) were approved about six months later. These are given by a monthly subcutaneous injection. About a year ago, an intravenous CGRP mAb, eptinezumab (Vyepti) was also approved. These four drugs are very similar. However, some patients find one to be more effective than others. I've found this to be true not only in migraine patients but also in those with TN. Erenumab is slightly different in its mechanism... --- ### Dr. Allan Purdy's review of my new book - Published: 2021-06-02 - Modified: 2021-06-02 - URL: https://www.nyheadache.com/blog/dr-allan-purdys-review-of-my-new-book/ - Categories: Alternative Therapies, Blocks, Botox, Chronic migraine, Headache medications, Headaches, injections, Migraine, post-traumatic headache, Psychology of headaches, Science of Migraine A publication of the American Headache Society, Headache, The Journal of Head and Face Pain, has just published Dr. Allan Purdy's most generous review of my new book, The End of Migraines: 150 Ways to Stop Your Pain. I am very grateful to Dr. Purdy and to my many colleagues who wrote endorsements for this book. Self-publishing allows me to set a low price of $3. 95 for the ebook version. It also makes it easy for me to regularly update it. Self-publishing, however, means that, unlike my previous three books, this one does not have the promotional help of a big publisher. If you read the book, please write a review on Amazon and spread the word to other migraine sufferers. --- ### Nurtec is the first drug approved for acute and preventive treatment of migraines. - Published: 2021-05-27 - Modified: 2021-05-27 - URL: https://www.nyheadache.com/blog/nurtec-is-the-first-drug-approved-for-acute-and-preventive-treatment-of-migraines/ - Categories: Chronic migraine, Headache medications, Migraine, New treatments Biohaven, the manufacturer of rimegepant (Nurtec ODT) just received FDA approval to market this drug for the prevention of migraines. Rimegepant was approved in January of 2020 for the acute treatment of migraine headaches. It is the first drug to be approved for both acute and preventive therapy of migraines. Rimegepant is one of six drugs that block the action of calcitonin gene-related peptide (CGRP). CGRP has many important functions in the body but the release of excessive amounts of it in the brain can trigger a migraine. Four of the CGRP migraine drugs are given by injection and they are used only for the prevention of migraine attacks. Rimegepant and ubrogepant (Ubrelvy) are taken by mouth as needed, whenever a migraine strikes. These are truly novel drugs that have dramatically improved the lives of many migraine sufferers. Rimegepant stays in the body longer - it has a half-life of 10-12 hours, while ubrogepant's half-life is 7-8 hours. Another difference is that rimegepant dissolves in your mouth (ODT after Nurtec stands for orally disintegrating tablet), while ubrogepant is a solid tablet that is swallowed. In clinical trials, rimegepant was noticed to provide relief of migraine that persisted for up to 48 hours. Because of this sustained effect, the researchers decided to test this drug for the prevention of migraine attacks by giving it every other day. And rimegepant passed this test. The official FDA-approved label says that for the prevention of migraines, one tablet of rimegepant should be taken every... --- ### Predicting success of surgery for trigeminal neuralgia. - Published: 2021-05-23 - Modified: 2021-05-23 - URL: https://www.nyheadache.com/blog/predicting-success-of-surgery-for-trigeminal-neuralgia/ - Categories: Brain disorders, Pain, Trigeminal and other neuralgias Trigeminal neuralgia (TN) is an extremely painful condition. Patients describe the pain as electric shocks going through the face. The most common or classic form of TN is caused by the compression of the trigeminal nerve as it exits the brainstem by a blood vessel. TN can also be caused by multiple sclerosis (MS). The pain of TN can be debilitating. Some people are unable to eat because of pain and become malnourished. The pain can interfere with speech. In some, it occurs unprovoked. In many, it leads to depression. The first-line treatment is epilepsy drugs. These include carbamazepine (Tegretol) and oxcarbazepine (Trileptal). We also use Botox injections and the new preventive migraine drugs - CGRP monoclonal antibodies. If drugs and Botox fail, radiofrequency destruction of the nerve can be of help. When none of this helps, surgery can be very effective. The so-called microvascular decompression surgery involves opening the skull and placing a Teflon patch between the nerve and the blood vessel which presses on the nerve. Since TN in people with MS is not caused by the compression of the nerve, surgery is rarely undertaken. This is a very delicate surgery and should be performed by a neurosurgeon who has done many of such operations (yes, it's a conundrum - how do surgeons become experienced if nobody wants to be one of their early cases). Sometimes, even if surgery is performed well, the pain persists. Fortunately, a group of Canadian researchers found a way of predicting who is... --- ### The pendulum swings and hits hard patients on opioid drugs - Published: 2021-05-17 - Modified: 2021-05-17 - URL: https://www.nyheadache.com/blog/the-pendulum-swings-and-hits-hard-patients-on-opioid-drugs/ - Categories: Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Pain, Pain Research The opioid epidemic has claimed many lives. Overprescribing by doctors has certainly played a role. The push to use opioids more liberally started in the late 1980s. This promotion by many pain experts even led to pain being adopted as the fifth vital sign. One impetus for this push was the mistaken belief in the low rates of addiction when opioids are used to treat pain. Another was the results of surveys of patients being discharged from hospitals. Poor pain control was the main complaint of 40% of such patients. Centers for Medicare & Medicaid Services (CMS) got into the act as well and included good pain control as one of the measures required for the recertification of hospitals. In January 2018, however, the three survey questions about pain management were replaced by three questions about communication about pain. In October of 2019, even these three items about communication about pain were completely removed from the CMS' HCAHPS Survey. So hospitals and doctors no longer need to worry about relieving pain and the suffering that goes with it. Doctors have to worry more about losing their license or even being put into jail. I've testified in front of a disciplinary panel on behalf of a doctor who was at risk of losing his license. An adult patient's mother complained to the state health department about her son getting prescriptions for opioid drugs. In this case, the doctor was exonerated but the financial and the emotional toll will certainly make him... --- ### ER treatment of posttraumatic headaches - Published: 2021-05-09 - Modified: 2021-05-09 - URL: https://www.nyheadache.com/blog/er-treatment-of-posttraumatic-headaches/ - Categories: Brain disorders, Head trauma, Headache medications, Headaches, Migraine Almost 1. 5 million Americans visit emergency rooms every year for the treatment of head trauma. Headache, not surprisingly, is one of the most common symptoms of head trauma. What is very surprising is that until now, there have been no controlled studies of acute therapies for posttraumatic headaches. Dr. Benjamin Friedman and his colleagues at the Montefiore Hospital in the Bronx just published a "Randomized Study of Metoclopramide Plus Diphenhydramine for Acute Posttraumatic Headache" in the journal Neurology. Emergency rooms often use metoclopramide (Reglan) as the first-line drug for the treatment of migraines. Diphenhydramine (Benadryl) was added to reduce the chance of side effects from metoclopramide. These side effects of restlessness and involuntary movements can be very unpleasant. The study involved 160 patients. Their pain severity was measured on a 0 to 10 verbal scale. Patients who received a placebo reported a mean improvement of 3. 8, while those receiving two medications improved by 5. 2 points. Side effects occurred in 43% of patients who received medications and 28% of patients who received placebo. My recent post was devoted to a study that showed dramatic similarities between migraines and posttraumatic headaches. The outcome of Friedman's study, therefore, is not unexpected. The overall efficacy of metoclopramide is fairly modest. It provides only partial relief that often does not last. And some patients get no relief at all. It also causes unpleasant side effects. It is puzzling why emergency room doctors are not using a migraine-specific drug, sumatriptan for both migraines... --- ### Skipping breakfast, lack of greenery, and other factors that may predispose kids to headaches. - Published: 2021-05-02 - Modified: 2021-05-02 - URL: https://www.nyheadache.com/blog/skipping-breakfast-lack-of-greenery-and-other-factors-that-may-predispose-kids-to-headaches/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Headaches in children, Science of Migraine We know that physical emotional, and sexual abuse in childhood increases the risk of developing chronic pain and migraines later in life. Dutch researchers looked at several other potential predisposing factors. The results of their study were published in the May issue of the journal Pain. This study was a part of the Dutch Prevention and Incidence of Asthma and Mite Allergy birth cohort study. It included 3,064 children who were evaluated at the ages of 11, 14, 17, and 20. The researchers assessed headache prevalence and incidence in girls and boys and explored associations with early life, environmental, lifestyle, health, and psychosocial factors. From age 11 to 20 years, the prevalence of headaches increased from 9% to 20% in girls and remained in 6% to 8% range in boys. Eighty-eight percent of the girls and 76% of boys with headaches also reported at least one of the following at age 17: sleeping problems, asthma, hay fever, musculoskeletal complaints, fatigue, low mental health, or worrying. They also found that lower educational achievement, skipping breakfast on two or more days per week, and in boys, exposure to tobacco smoke in infancy, increased the risk of developing headaches. In girls, sleeping problems and musculoskeletal complaints were associated with a higher chance of having headaches. Interestingly, residential greenness reduced the chance of developing headaches. The risk factors are usually divided into modifiable and non-modifiable. Sex, age, and genetic factors are some of the non-modifiable ones. The factors mentioned in the study, except for... --- ### Post-traumatic headaches are mostly migraines - Published: 2021-04-24 - Modified: 2021-04-24 - URL: https://www.nyheadache.com/blog/post-traumatic-headaches-are-mostly-migraines/ - Categories: Brain disorders, Chronic migraine, Head trauma, Migraine Post-traumatic headaches (PTH) are classified as a distinct category of headaches. There is growing evidence, however, that headaches that develop after a head injury are migraines. A study just published in Cephalalgia by Dr. Ann Scher, her colleagues at the Uniformed Services University, and other researchers, showed that PTH and migraines are very similar. The only difference they found was that headaches occurring after a head injury tend to be more severe. They studied 1,094 soldiers with headaches. 198 were classified as having PTH. These headaches were compared to those in the other soldiers. They looked for the presence of 12 migraine features: Unilateral location, photophobia, phonophobia, nausea, exacerbation of headache by routine physical activity, pulsatility, visual aura, sensory aura, pain level, continuous headache, allodynia (sensitivity to touch), and monthly headache days. Soldiers with post-traumatic headache had a greater endorsement of all 12 headache features compared to the soldiers with non-concussive headaches. The authors concluded that post-traumatic headaches differ from non-concussive headaches only by severity and not by any other symptoms. Another study published in 2020 by Dr. Håkan Ashina and his Danish colleagues showed similar results. They performed a detailed evaluation of 100 individuals with persistent PTH following a mild traumatic brain injury. They found that 90 of the 100 patients had migraines or migraines as well as tension-type headaches. The rest had only tension-type headaches. These findings have important treatment implications. These patients should be treated like other patients with chronic migraine. Assigning these patients the diagnosis of... --- ### The description of neuropathic pain predicts response to Botox - Published: 2021-04-18 - Modified: 2021-04-18 - URL: https://www.nyheadache.com/blog/the-description-of-neuropathic-pain-predicts-response-to-botox/ - Categories: Botox, Brain disorders, Pain, Pain Research The goal of personalized medicine will be achieved through the exponential growth of computing power. Epigenetics, pharmacogenomics, and machine learning are some of the approaches that are being driven by our ability to process massive amounts of data. Unfortunately, it may take another decade or two before we can offer our patients truly personalized medicine. Until then, we still have to rely on clinical skills. In a study just published in the journal Pain, D. Bouhassira and his colleagues were able to predict the response of neuropathic pain to Botox injections. The prediction was based on a specific combination of symptoms and signs. They used the Neuropathic Pain Symptom Inventory (NPSI) in 628 patients to identify three distinct clusters of patients. The first group had a more severe pinpointed pain, the second one had more evoked pain, and the third had a higher score for deep pain. The study included adult patients who had experienced pain for at least three months with a mean pain intensity three or greater on a 0 to 10 numerical rating scale. In more than 85% of the patients, neuropathic pain was due to a traumatic or surgical nerve injury. In the rest, it was due to postherpetic neuralgia (shingles). The researchers used these three groupings to predicting treatment response through the analysis of their two previous controlled trials of Botox. They found significant effects of Botox compared to placebo in clusters 2 and 3, but not in cluster 1. They also developed and performed... --- ### Magnesium enhances the migraine prevention effect of valproate - Published: 2021-04-10 - Modified: 2021-04-10 - URL: https://www.nyheadache.com/blog/magnesium-enhances-the-migraine-prevention-effect-of-valproate/ - Categories: Chronic migraine, Headache medications, Migraine This blog has many posts about the role of magnesium in the prevention of migraines and clinical trials of magnesium. Another study was just published by Iranian doctors in The Journal of Headache and Pain. Unfortunately, like other studies, this one has a major flaw. Magnesium was given to all migraine sufferers, whether they were deficient in magnesium or not. If you are not deficient, taking extra magnesium will not help. For those who are deficient, however, the effect can be dramatic. Another problem with this and several previous studies is the use of poorly absorbed salts of magnesium. In this case, magnesium oxide. Patients in this study were divided into three groups. One group was given valproate (200 mg twice a day), the second group, valproate with magnesium oxide (250 mg twice a day), and the third group, magnesium oxide alone (also 250 mg twice a day). There were 82, 70, and 70 patients in each group, respectively. Patients in the two groups that included valproate did better than those in the group taking magnesium alone. The combination of valproate with magnesium was more effective than valproate alone. Surprisingly, the authors mention nothing about side effects. Valproate is one of the last drugs I use in migraine patients. It has many potential side effects, including weight gain, hair loss, tremor, nausea, and others. The majority of migraine sufferers are women of childbearing age and up to half of the pregnancies in the US are unplanned. So, another major reason... --- ### Dramatic weight loss with a diabetes drug; may help migraines and other neurological problems - Published: 2021-04-01 - Modified: 2021-04-12 - URL: https://www.nyheadache.com/blog/dramatic-weight-loss-with-a-diabetes-drug-may-help-migraines-and-other-neurological-problems/ - Categories: Alternative Therapies, Chronic migraine, Headaches, injections, Migraine, Science of Migraine Weight loss in overweight migraine sufferers - including that produced by bariatric surgery - leads to a reduction in the frequency of migraine attacks. In a previous post and in my new book I mentioned the use of metformin, a diabetes drug that helps weight loss, in migraine patients. A study published in the February 10 issue of The New England Journal of Medicine definitively confirmed that weekly injections of another diabetes drug, semaglutide (Ozempic) can lead to an average of 15% weight loss in obese individuals. Seventy percent of participants lost at least 10% of weight. This was a double-blind, placebo-controlled trial that included 1,961 participants. Individuals in both the placebo and the active group were counseled every four weeks to encourage maintenance of a reduced calory diet and increased physical activity. Semaglutide is very similar to dulaglutide (Trulicity). Other drugs that are used for weight loss produce an average of 4% to 6% weight loss and tend to have more side effects. Nausea and diarrhea were the most common adverse events with semaglutide. They were typically transient and mild-to-moderate in severity and subsided with time. Only 4. 5% of participants on semaglutide stopped taking the drug due to side effects. Obesity is a risk factor not only for diabetes and increased frequency of migraines but also strokes, idiopathic intracranial hypertension (pseudotumor cerebri), obstructive sleep apnea, hypertension, and others. This trial should lead to the FDA approval of semaglutide for weight loss in obese individuals without diabetes. Hopefully, the... --- ### Bidirectional association between loneliness and pain - Published: 2021-03-21 - Modified: 2021-03-21 - URL: https://www.nyheadache.com/blog/bidirectional-association-between-loneliness-and-pain/ - Categories: Brain disorders, Pain, Pain Research, Psychology of headaches COVID-related lockdowns have saved many lives. We don't yet fully appreciate, however, the other side of the ledger - the harms the lockdowns have caused. These include delays in diagnosing cancers, alcohol and drug abuse, depression, anxiety, deprivation of schooling and socialization in children, and worsening of pain and headaches. The latter not only because of lack of access to care but also due to the effect of loneliness. Prior studies have shown that loneliness is consistently associated with pain. A study by British researchers published in the current issue of the journal Pain examined the question of whether loneliness worsens pain or pain leads to loneliness. Drs. Anna Loeffler and Andrew Steptoe studied 4,906 men and women (mean age was 65) over a period of four years. They also looked at the role of inflammation in these people. Pain was defined by reports of being often troubled by pain at a moderate or severe intensity. Loneliness was measured using a standard scale. The researchers took into account age, sex, ethnicity, educational attainment, wealth as a marker of socioeconomic resources, marital status, physical activity, degree of mobility, and depressive symptoms. They found that baseline loneliness was associated with pain four years later. Similarly, baseline pain independently predicted loneliness four years later. The likelihood of pain was increased when at the baseline loneliness was accompanied by an increase in an inflammation marker, C-reactive protein (CRP). On the other hand, inflammation did not predict future loneliness. Both pain and loneliness are distressing... --- ### Low cerebrospinal fluid pressure headache - Published: 2021-03-13 - Modified: 2021-03-13 - URL: https://www.nyheadache.com/blog/low-cerebrospinal-fluid-pressure-headache/ - Categories: Brain disorders, Chronic migraine, Headaches, Science of Migraine The headache of low cerebrospinal fluid (CSF) pressure can be very severe. Its main feature is that it gets worse on sitting or standing and improves upon lying down. Sometimes, this change is quick but occasionally the headache slowly gets worse as the day goes on and is mildest or absent upon awakening in the morning. Low CSF pressure often results from the needle going in too far during an epidural steroid injection for low back pain or epidural anesthesia during delivery or surgery. This results in the spinal fluid leaking into the soft tissues of the back. The loss of fluid causes sagging of the brain which normally floats in a thin layer of CSF. Spinal fluid leaks usually seal on their own but sometimes require a “blood patch”– injecting the patient’s blood into the area of the leak. The injected blood clots and seals the leak. If a CSF leak happens after a diagnostic spinal tap or an epidural procedure, it is better to have the blood patch sooner rather than later. I recommend doing it if the headache persists for more than a couple of days. Rarely, a spinal fluid leak occurs spontaneously after straining or without an obvious trigger. This condition is called spontaneous intracranial hypotension (SIH). A review of scientific reports of SIH involving over 2,000 patients by a British physician Dr. Manjit Matharu and his colleagues provides a good description of this condition. Headache was present in 99% of patients. In 2% the headache... --- ### Postural orthostatic tachycardia syndrome (POTS) and migraine - Published: 2021-03-06 - Modified: 2021-03-06 - URL: https://www.nyheadache.com/blog/postural-orthostatic-tachycardia-syndrome-pots-and-migraine/ - Categories: Chronic migraine, Headaches, Migraine, Science of Migraine The term postural orthostatic tachycardia means that the heart rate becomes very fast upon standing up. POTS is a disorder of the autonomic nervous system that is associated with abnormal blood flow regulation. Almost all patients with POTS suffer from migraines. POTS can present with a bewildering variety of additional symptoms besides headaches (see below). This is why the diagnosis is often missed. Unfortunately, there are very few effective treatments for POTS. Making the correct diagnosis, nevertheless, is very important. It explains the cause of symptoms that are often dismissed as psychological and in some patients, treatment can lead to a dramatic improvement. This blog was prompted by a positive study of a drug, ivabradine, to treat POTS that was published by Dr. Pam Taub and her colleagues. Ivabradine (Corlanor) is approved by the FDA to treat heart failure, so its use for POTS is "off-label". This means that insurance companies are not likely to cover an unapproved use of a drug that costs $500 a month. With additional trials confirming that ivabradine works and with a lot of persuasion by the doctor, insurers might cover it if other treatments fail. Currently, the drugs that are used to treat POTS include beta-blockers, midodrine, fludrocortisone, and others. Increased intake of salt and fluids, exercise, dietary changes, and correction of nutritional deficiencies such as vitamin B12 and magnesium cal also help. Here is how the Cleveland Clinic website describes POTS: POTS symptoms can be uncomfortable and frightening experiences. Patients with POTS usually... --- ### Cyclic vomiting, a migraine variant - Published: 2021-02-25 - Modified: 2021-02-25 - URL: https://www.nyheadache.com/blog/cyclic-vomiting-a-migraine-variant/ - Categories: Chronic migraine, Headaches, Headaches in children, Migraine, 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... --- ### Low dietary intake of magnesium increases the risk of migraines - Published: 2021-02-18 - Modified: 2021-02-18 - URL: https://www.nyheadache.com/blog/low-dietary-intake-of-magnesium-increases-the-risk-of-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Science of Migraine 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. --- ### Transient global amnesia and migraines - Published: 2021-02-12 - Modified: 2021-02-12 - URL: https://www.nyheadache.com/blog/transient-global-amnesia-and-migraines/ - Categories: Brain disorders, Chronic migraine, Science of Migraine 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... --- ### In a new study prednisone relieves cluster headaches - Published: 2021-02-01 - Modified: 2021-02-01 - URL: https://www.nyheadache.com/blog/in-a-new-study-prednisone-relieves-cluster-headaches/ - Categories: Blocks, Cluster headaches, Headache medications Cluster headaches are considered to cause the most severe pain of any type of headache. Once the cluster period begins, headaches occur once or several times a day with each attack lasting 1-3 hours. We do have a new preventive treatment for cluster headaches - monthly injections of a drug that was first approved for migraines, galcanezumab (Emgality). This drug, however, does not help everyone. Even when it does, it can take up to a week to begin helping. For quick relief, we continue to use a 10-14 day tapering course of steroid medicine, prednisone. Prednisone often works only while the patient is taking it. It is a powerful drug with many potential side effects. This is why it is mostly used for a short time to serve as a bridge that allows another preventive drug to begin working. The most popular preventive medicine for cluster headaches besides Emgality is a blood pressure drug, verapamil. German researchers just published the results of a double-blind controlled study of prednisone for cluster headaches. They started half of the 116 patients with cluster headaches on placebo and the other half, on 100 mg of prednisone. After five days on 100 mg, they reduced the dose by 20 mg every 3 days. At the same time, all patients were started on verapamil. In the first week, those on prednisone had a mean of 7. 1 attacks, while those on placebo had 9. 5 attacks. Statistically, this was a highly significant difference. Having 2-3 fewer... --- ### Just published - The End of Migraines: 150 Ways to Stop Your Pain - Published: 2021-01-17 - Modified: 2021-01-29 - URL: https://www.nyheadache.com/blog/just-published-the-end-of-migraines-150-ways-to-stop-your-pain/ - Categories: Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, neurostimulation, Science of Migraine 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. --- ### Prompt treatment could restore the loss of smell due to COVID - Published: 2021-01-14 - Modified: 2021-01-14 - URL: https://www.nyheadache.com/blog/prompt-treatment-could-restore-the-loss-of-smell-due-to-covid/ - Categories: Brain disorders The loss of the sense of smell is the second most common presenting symptom of COVID. It occurs in 65% of patients. Fatigue occurs in 68% and headache, in 43%. Severe loss of the sense of smell was still present in 11% of patients after one month and in 7% after two months. A study published by French researchers in Neurology, reports on the likely cause of the loss of smell. They obtained MRI scans in 20 patients with COVID-related loss of smell. Nineteen out of 20 had complete occlusion of the olfactory clefts due to swelling. The clefts are two narrow vertical passages at the upper part of the nasal cavity. They are lined with the olfactory epithelium containing olfactory receptors. They found a correlation between the degree of olfactory impairment and the degree of occlusion of the olfactory cleft. The logical conclusion is that treating the swelling could help improve the sense of smell and possibly reduce the chance of permanent impairment. In the discussion section of the paper, the authors state that most treatments for virus-induced inflammation do not work. However, the only reference they provide is a study of 34 patients who were given the equivalent of 10-15 mg of prednisone. The majority of published trials of oral steroids for chronic sinusitis used 30 to 60 mg. Sudden hearing loss and Bell's palsy are very different conditions but are also thought to involve swelling and inflammation and are treated with a short course of prednisone, typically... --- ### Prolonged postconcussion headaches after mild head injury - Published: 2021-01-08 - Modified: 2021-01-08 - URL: https://www.nyheadache.com/blog/prolonged-postconcussion-headaches-after-mild-head-injury/ - Categories: Chronic migraine, Head trauma, Headaches Persistent post-traumatic headache (PTH), paradoxically, is more common after a mild traumatic brain injury (TBI) than after a severe one. In a recently published study, researchers in Indiana examined possible factors that may predispose people to a persistent headache after a mild TBI. They recruited 44 adult patients with mild TBI in an emergency department of a trauma center. Participants completed a variety of psychological questionnaires and underwent tests to measure innate pain control mechanisms. Participants were classified into persistent PTH and nonpersistent PTH groups based on the 4-month data. The results showed that patients with mild TBI who developed persistent PTH had significantly reduced pain inhibitory capacity, higher rates of depression and pain catastrophizing following injury compared to those who did not develop persistent PTH. They also found that headache pain intensity at 1–2 weeks and pain inhibitory capacity at 1–2 weeks predicted persistent PTH at 4 months after the injury. The authors concluded that persistent PTH is more likely in people with impaired endogenous pain modulatory function and psychological processes such as depression and catastrophizing. Catastrophizing is defined as having irrational thoughts about pain being uncontrollable, leading to disability, loss of a job, partner, ruined life, etc. Catastrophizing can be measured by questions such as “I feel it is never going to get better”, “I can’t stand it anymore”, and others. Catastrophizing has been shown to predict the degree of pain and disability in chronic low back pain and other painful conditions. The good news is that cognitive-behavioral... --- ### Nerivio relieves migraine in adolescents - Published: 2021-01-03 - Modified: 2021-01-03 - URL: https://www.nyheadache.com/blog/nerivio-relieves-migraine-in-adolescents/ - Categories: Alternative Therapies, Headaches in children, Migraine Nerivio device is approved by the FDA for the acute treatment of migraine attacks in adults. A study just published in the journal Headache indicates that it may be effective in the treatment of migraine in adolescents, aged 12 to 17. This study was open-label, which means that it was not as rigorous as the one done to get FDA approval in adults. There was no placebo arm and it was not blinded. Forty-five participants, out of 60 who were enrolled, performed at least one treatment. There was one device-related adverse event in which a temporary feeling of pain in the arm was felt. Pain relief and pain-free status were achieved by 71% (28/39) and 35% (14/39) of participants, respectively. At 2 hours, 69% (23/33) of participants had improvement in functional ability. Nerivio is a remote electrical neuromodulation, or REN device. It is applied to the upper arm and the current is turned up to produce a strong sensation below the pain level. It works by stimulating endogenous pain-relieving mechanisms. A recent review of various neurostimulation methods found REN to be the only one clearly proven to be effective. Nerivio requires a prescription from a health care provider. If you don't have one, you can consult one at a telemedicine startup, Cove (I am a consultant for Cove). It is a disposable device that costs $99 for 12 treatments. Some insurance companies pay for it. --- ### New daily persistent headache (NDPH) is an unhelpful myth - Published: 2020-12-26 - Modified: 2020-12-26 - URL: https://www.nyheadache.com/blog/new-daily-persistent-headache-ndph-is-an-unhelpful-myth/ - Categories: Chronic migraine, Headaches, Headaches in children, Science of Migraine 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... --- ### Stiff from too much time at a computer? Feldenkrais to the rescue. - Published: 2020-12-20 - Modified: 2020-12-20 - URL: https://www.nyheadache.com/blog/stiff-from-too-much-time-at-a-computer-feldenkrais-to-the-rescue/ - Categories: Alternative Therapies Feldenkrais method can appear magical but it is rooted in good science. It has withstood the test of time. Moshe Feldenkrais, a prominent Israeli physicist, developed his method over 70 years ago. You can read more about the science behind this method in my blog post from three years ago. I continue to recommend it to patients with neck, back, and other pains. You can watch me do some of the exercises here, here and here. You can find a local practitioner at Feldenkrais. com but these days you can see one virtually from anywhere. What prompted this blog post is a flier I came across in my files from the now-defunct Feldenkrais Institute. From reading it you can see that anyone can practice Feldenkrais method - it requires no physical strength or major effort. And, it cannot hurt you. Awareness Through Movement: Keys for Success Feldenkrais exercises are called Awareness Through Movement® lessons. Awareness Through Movement® works by changing the messages that your brain sends to your musculature, creating new options for movement, health, and vitality. Contrary to popular belief, your brain and nervous system—not your muscles—determine the health of your posture, and the ease and comfort of your movement. When you do Awareness Through Movement®, your brain has the opportunity to discover the most efficient and comfortable way to organize your movement. You will enjoy relief from pain, tension, and discomfort, and enhance your flexibility, ease of movement, relaxation, and posture. Following these simple guidelines will ensure that... --- ### What to try first, Botox or CGRP mAbs? - Published: 2020-12-13 - Modified: 2020-12-13 - URL: https://www.nyheadache.com/blog/what-to-try-first-botox-or-cgrp-mabs/ - Categories: Botox, Chronic migraine, Headache medications, Migraine This is a common question I get from patients. Botox was first approved by the FDA in 1989. The CGRP monoclonal antibodies (mAbs), in 2018. Long-term safety of Botox is well established. I've treated many pregnant women, children as young as 8, and one patient who reached 100. Botox acts locally and has no systemic effects. It means that it cannot affect your kidneys, liver, heart, or any other organ. Injections of CGRP mAbs appear to be safer than most old medications taken by mouth. But they do have some systemic side effects and we don't know if there are any long-term side effects. We have some 5-year safety data but only in a small number of patients. We will know more in a few years, after these drugs have been in use in a large population of patients. Long-term safety is the main reason why I recommend trying Botox before mAbs. Another reason to prefer Botox was presented at the 62nd annual meeting of the American Headache Society. It was conducted by Allergan, the manufacturer of Botox, so bias could be a factor. They looked at a relatively large number of patients - 1,976. Of these, 333 (17%) were treated with Botox first. Another 1134 (57%) were started on erenumab (Aimovig), 298 (15%) initiated fremanezumab (Ajovy), and 211 (11%) started galcanezumab (Emgality). More patients (75%) who were started on Botox were still receiving it 6 months later compared to patients who were first given a CGRP mAb (erenumab: 47%;... --- ### 100 Migraine Drugs, A to Z: zonisamide - Published: 2020-12-09 - Modified: 2020-12-09 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-zonisamide/ - Categories: Chronic migraine, Headache medications, Migraine Zonisamide (Zonegran) is an epilepsy drug similar to topiramate in its mechanism of action. Unfortunately, it shares its side effects as well. These include fatigue, difficulty with concentration and memory, nausea, and other. However, because they are not identical drugs, some patients tolerate zonisamide better than topiramate. One study showed that 44% of 172 patients who did not respond to topiramate did respond to zonisamide with 13% having an excellent response. A similar study in 63 patients who did not respond to topiramate also showed benefit from zonisamide as did 34 patients in another study. Zonisamide also helped 8 out of 12 children who did not respond to other medications. The dose of zonisamide ranges from 50 to 400 mg a day, but most patients need 100-200 mg. --- ### Migraine device, Cefaly no longer requires a prescription - Published: 2020-12-03 - Modified: 2020-12-03 - URL: https://www.nyheadache.com/blog/migraine-device-cefaly-no-longer-requires-a-prescription/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, neurostimulation Cefaly is a neurostimulation device that was approved by the FDA in 2014. Until October of this year, it required a prescription. Several clinical trials proved the device to be not only effective but also very safe. Now it can be purchased without a prescription from the manufacturer's website - Cefaly. com. Cefaly is used for both prevention and acute treatment of migraine. It is applied to the middle of the lower forehead with an adhesive electrode. For acute therapy, the device is used for 60 minutes. For prevention, it is used daily for 20 minutes. Some of my patients find it effective on its own while others use it in conjunction with medications. As far as side effects, the device is very safe. It can cause skin irritation from the adhesive or from the electrical current. Some of my patients reported worsening of their headaches. This tends to happen to patients who develop allodynia during their migraine attack. Allodynia means increased skin sensitivity. It can be so severe that sometimes a patient cannot even wear glasses or have a ponytail. An electrical stimulation device that is better tolerated by patients with allodynia is Nerivio. It is applied to the upper arm for 45 minutes as needed. Nerivio requires a prescription but it is sometimes covered by insurance while Cefaly is not. --- ### 100 Migraine Drugs, A to Z: zolmitriptan - Published: 2020-11-28 - Modified: 2020-11-28 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-zolmitriptan/ - Categories: Chronic migraine, Headache medications, Migraine Zolmitriptan (Zomig, Zomig ZMT, Zomig NS) is one of seven triptans sold in the US. It is available in tablets, orally disintegrating tablets, and nasal spray. The nasal spray is approved for children 12 and older. Both tablets and the spray are available in 2. 5 mg and 5 mg strength. The maximum daily dose is 10 mg. However, it is washed out of the body within a few hours. This means that taking three 5 mg tablets spread out over 24 hours poses no danger. Three doses a day is the approved limit for rizatriptan (Maxalt). There is no reason why this should not apply to zolmitriptan and other triptans except for the long-lasting frovatriptan. Fortunately, it is uncommon that a patient requires three doses in one day. And if a patient does need to take a triptan more than twice a day, we usually try a different drug that may work with a single dose. One advantage of the nasal spray is that it tends to have a faster onset of action. Another advantage is that can be taken when severe nausea or vomiting precludes the use of oral medications. My impression is that zolmitriptan spray is more effective than the original sumatriptan spray. The amount of fluid in a single dose of Zomig is less than that in sumatriptan and the spray droplets are of smaller size. This leads to better retention of fluid in the nasal passages and better absorption. The new version of sumatriptan spray,... --- ### Virtual reality for pain relief - Published: 2020-11-22 - Modified: 2020-11-22 - URL: https://www.nyheadache.com/blog/virtual-reality-for-pain-relief/ - Categories: Alternative Therapies, Headaches, Migraine, Pain Many studies have shown that virtual reality experience can relieve pain. The first such study in burn patients was published 20 years ago. A comprehensive review of this topic, Immersive Virtual Reality and Virtual Embodiment for Pain Relief was published last year by Italian researchers. A different group of Italian researchers tested the effects of visual distraction on pain in chronic migraine patients. They compared a classical hospital waiting room with an ideal room with a sea view. Both were represented in virtual reality (VR). They measured pain and brain responses induced by painful laser stimuli in healthy volunteers and patients with chronic migraine. Pain was induced in the hand of sixteen chronic migraine patients and 16 healthy controls. This was done during a fully immersive VR experience, where two types of waiting rooms were simulated. Patients with migraine showed a reduction of laser pain rating and brain responses during the sea view simulation. Control subjects experienced the same level of pain in both types of simulated rooms. An older study of 30 patients with chronic pain showed that 20 patients had pain relief during a VR session. Ten of them reported complete pain relief. Of the 20 who had relief, 10 had continued relief after the VR session. A combination of VR with biofeedback resulted in lasting benefits in 9 of 10 children with chronic headaches who completed 10 training sessions. About 5% to 10% of people who try VR get cybersickness. This is a feeling of dizziness or... --- ### 100 Migraine Drugs, A to Z: verapamil - Published: 2020-11-14 - Modified: 2020-11-14 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-verapamil/ - Categories: Chronic migraine, Headache medications, Migraine Verapamil (Calan, Isoptin) is an effective drug for the prevention of cluster headaches. It is sometimes used for migraines as well. However, the evidence for its efficacy is weak. A double-blind crossover trial by Dr. Glen Solomon and his colleagues in Ohio examined the effect of 320 mg of verapamil on 12 migraine patients. The drug was more effective than the placebo. Other small studies also suggested that it might help some patients. Verapamil has a reputation among headache specialists as being effective for the prevention of frequent migraine auras and other neurological symptoms that occur with migraines. Unfortunately, there are no controlled trials to support this impression. The starting dose of verapamil is 120 mg a day with a possible escalation up to 480 mg. For cluster headaches, the starting dose is 240 mg and the maximum dose is as high as 960 mg. Verapamil can cause arrhythmia (irregular heartbeat), especially at higher doses. I recommend an electrocardiogram before every increase of the dose above 240 mg. The two most common side effects of verapamil are constipation and swelling of the feet. In some of my patients, constipation was severe and resistant to treatment. They had to stop taking the drug. --- ### Botox for migraines in pregnancy - Published: 2020-11-06 - Modified: 2020-11-07 - URL: https://www.nyheadache.com/blog/botox-for-migraines-in-pregnancy/ - Categories: Botox, Migraine Fortunately, migraines improve during pregnancy in the majority of women. None of the preventive drugs for migraine are approved by the FDA for pregnant women. The only medicine that is considered safe is a beta-blocker, metoprolol. Other drugs are either labeled as dangerous (e. g. topiramate and valproate) or as not having enough information about their effect on the fetus. Most women obviously would rather not take any drugs. However, having frequent and severe migraines can be also detrimental to the fetus. It is not only the distress caused by severe pain but also the dehydration from vomiting that can have a negative effect. A group of British doctors collected data over a 9-year period and have found 45 patients who became pregnant while receiving Botox for chronic migraines. All patients had received Botox within 3 months prior to the date of conception. 32 patients wished to continue treatment during pregnancy while the remaining 13 stopped treatment. There was one miscarriage in the treatment group. All other patients had full-term healthy babies of normal birth weight and no congenital malformations. A recent poster presentation at the last annual meeting of the American Headache Society by neurologists at the Medstar Georgetown University Hospital in Washington, DC described 9 women treated with Botox during 10 pregnancies. All babies were born healthy. This is a small number of patients and we cannot make any conclusions about the safety of Botox in pregnancy. Other reports, however, also suggest that Botox is safe. In my... --- ### Dry eyes and migraine - Published: 2020-11-01 - Modified: 2020-11-01 - URL: https://www.nyheadache.com/blog/dry-eyes-and-migraine/ - Categories: Alternative Therapies, Migraine People who suffer from migraines often have a variety of visual symptoms. These include seeing an aura prior to the onset of headache, blurred vision, difficulty reading on screens or even on paper, and eye pain. Patients with migraines often have reduced visual quality of life (QoL). This is according to a study published in Headache by doctors at the University of Utah. They assessed the visual quality of life, headache impact, aura, dry eye, and photophobia in migraine patients. The researchers concluded that "Dry eye seems to be the most important symptom that reduces visual quality of life and worsens headache impact. " Research has consistently shown that dry eye disease has a significant impact on several aspects of patients’ QoL, including pain, vitality, ability to perform certain activities requiring sustained visual attention (e. g. , reading, driving), and productivity in the workplace. Some people may not be aware that their eyes are dry. Their eyes might just feel fatigued or irritated. Ophthalmologists perform the Schirmer test to detect dry eye disease. It is done by placing a strip of filter paper under the lower eyelid and measuring the length of the strip that gets wet. It is not clear if treating dryness of the eyes will help migraine headaches but it is very likely to improve visual functioning and QoL. Some of the treatments for dry eyes include artificial tears, tear stimulation, and anti-inflammatory therapy. --- ### 100 Migraine Drugs, A to Z: venlafaxine - Published: 2020-10-24 - Modified: 2020-10-24 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-venlafaxine/ - Categories: Chronic migraine, Headache medications, Migraine Venlafaxine (Effexor) is the first drug in the serotonin-norepinephrine reuptake inhibitors (SNRI) class. It was approved by the FDA for the treatment of depression in 1993. At low doses, venlafaxine works as a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine (Prozac). SNRIs are considered to be effective for the treatment of pain and migraine headaches. SSRIs are not. A review of studies that involved a total of 418 patients showed that SNRIs are effective for the prevention of migraines. The class of SNRIs includes duloxetine (Cymbalta), desvenlafaxine (Pristiq), milnacipran (Savella), and levomilnacipran (Fetzima). Milnacipran is the only SNRI that is approved by the FDA for the treatment of fibromyalgia rather than depression. In treating migraines, a 60-patient trial showed that the 150 mg dose is more effective than 75 mg. Another double-blind crossover study comparing venlafaxine with amitriptyline showed them to be equally effective. Venlafaxine had fewer side effects than amitriptyline. Venlafaxine is started at 37. 5 or 75 mg dose. After a week or two, the dose is increased to 150 mg. The maximum daily dose of venlafaxine is 450 mg. Potential side effects include insomnia, drowsiness, fatigue, nausea, dizziness, suicidal thoughts in depressed children and young adults, and others. Just like with other SNRIs, sudden discontinuation of venlafaxine can cause withdrawal symptoms. These may include one or more of the following: dizziness, headache, nausea, diarrhea, paresthesia (pins-and-needles), irritability, vomiting, insomnia, anxiety, sweating, and fatigue. SNRIs are stopped after a slow and gradual reduction of the dose. --- ### Find out what a hangover headache feels like - Published: 2020-10-18 - Modified: 2020-10-18 - URL: https://www.nyheadache.com/blog/find-out-what-a-hangover-headache-feels-like/ - Categories: Headaches, Migraine, Science of Migraine 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... --- ### 100 Migraine Drugs, A to Z: tramadol - Published: 2020-10-11 - Modified: 2020-10-11 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-tramadol/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine, Pain Tramadol (Ultram) is a mild narcotic (opioid) pain killer. Just like other opioids it is not a good choice to treat an acute migraine attack. Besides its addiction potential, it does not work well for most migraine patients, can cause nausea, and can lead to rebound or medication overuse headaches. Tramadol is also available in combination with acetaminophen (Ultracet). This combination was tested in a study published in Headache, Tramadol/Acetaminophen for the Treatment of Acute Migraine Pain: Findings of a Randomized, Placebo-Controlled Trial. 305 patients took tramadol/APAP (75 mg/650 mg) or placebo for a typical migraine with moderate or severe pain. Subjects in the tramadol/APAP group were more likely than those in the placebo group to be pain-free at 2 hours (22% vs. 9%), 6 hours (43% vs. 25%), and 24 hours (53% vs. 38%) Side effects caused by the active drug included nausea, dizziness, vomiting, and somnolence. Tramadol alone or in combination with acetaminophen is worth trying only if the first-line classes of drugs are ineffective or contraindicated. These include NSAIDs, triptans, and gepants. --- ### Marijuana protects brain in trauma - Published: 2020-10-05 - Modified: 2020-10-05 - URL: https://www.nyheadache.com/blog/marijuana-protects-brain-in-trauma/ - Categories: Alternative Therapies, Brain disorders, Head trauma Frequent use of marijuana has a negative effect on the developing brain. Researchers at Tulane and Dartmouth medical schools looked at the possible protective effect of marijuana in severe head injury. The results were recently published in an article, Preinjury Use of Marijuana and Outcomes in Trauma Patients. They examined records of adults who presented to two large regional trauma centers between 2014 and 2018. They included patients who had detectable levels of delta-9-tetrahydrocannabinol (THC) in the blood. They excluded those who had other illicit drugs present. Of the 4849 patients, 1373 (28. 3%) had THC present in the blood. These patients tended to be younger, more likely to be males, and more likely to be injured by "penetrating mechanism" than those who did not have THC present. Patients with THC had a shorter hospital stay, shorter need for ventilation, and a shorter stay in the intensive care unit. The mortality rate was somewhat lower in the THC-positive group (4. 3% versus 7. 6%) but this difference did not reach statistical significance. The mechanism could be related to the anti-inflammatory effects of marijuana mentioned in the previous post. Head trauma is known to trigger an immune response that leads to inflammation that in turn worsens brain damage. The researchers did not measure any inflammatory markers so this is just a speculation. It is also possible that the THC-positive group did better because it was significantly younger than the THC-negative group. In another very large chart review study that looked at... --- ### Anti-inflammatory effect of cannabis - Published: 2020-10-01 - Modified: 2020-10-01 - URL: https://www.nyheadache.com/blog/anti-inflammatory-effect-of-cannabis/ - Categories: Alternative Therapies, Migraine, Pain Cannabis has known anti-inflammatory properties. A group of researchers from UCSD published a study, Recent cannabis use in HIV is associated with reduced inflammatory markers in CSF and blood. They measured a variety of inflammation markers in the blood and cerebrospinal fluid (CSF) of people with HIV. They showed that "Recent cannabis use was associated with lower levels of inflammatory biomarkers, both in CSF and blood, but in different patterns. These results are consistent with compartmentalization of immune effects of cannabis. The principal active components of cannabis are highly lipid soluble and sequestered in brain tissue; thus, our findings are consistent with specific anti-neuroinflammatory effects that may benefit HIV neurologic dysfunction. " Translating this into English, smoking pot reduces inflammation not only in the body but also in the brain. Not all substances reach the brain because of the so-called blood-brain barrier. But the two main ingredients of marijuana - THC and CBD - easily dissolve in fat which allows their entry into the brain. Obviously, not all of the effects of marijuana are beneficial. The most harmful is the inhalation of smoke which causes lung damage. Vaping medical-grade marijuana or taking it by mouth is much safer. I've been prescribing medical marijuana for the past 6 years since it became legal in NY. In NY patients have a choice of capsules taken by mouth, tincture drops placed under the tongue, or vaping. I find it particularly useful for symptoms associated with migraines more than the actual pain - nausea,... --- ### 100 Migraine Drugs, A to Z: topiramate - Published: 2020-09-26 - Modified: 2020-09-26 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-topiramate/ - Categories: Headache medications, Migraine Topiramate (Topamax) is one of the most popular preventive drugs for migraine. This is not because it is more effective than other approved drugs. It is because it can cause weight loss. The drug manufacturer tried to get it approved for weight loss. The FDA, however, felt that while the side effects may be acceptable when treating epilepsy or migraines, they are not acceptable when treating obesity. You can argue that obesity is as serious a disorder but the FDA decision underscores the fact that the drug can have serious side effects. Cognitive side effects can be obvious to most patients but for some, they are not. People begin to attribute their memory and word-finding difficulties to stress, lack of sleep, early-onset dementia, and other reasons. They have told me that they feel stupid on this drug, hence the moniker, Dopamax. Topiramate can also cause irritability, depression, fatigue, osteoporosis, glaucoma, and in 20%, kidney stones (10% with symptoms and 10% without). Like the other FDA-approved epilepsy drug, valproate, it is contraindicated in pregnancy because it can cause birth defects. I urge patients who are taking these drugs to be very vigilant about contraception. In large clinical trials, 55% of patients had relief and were able to tolerate the drug. Postmarketing studies show that 40% of epilepsy patients stop the drug. Of these, one-fifth stop it because of lack of efficacy, almost half due to side effects, 12% due to both, and the rest for other reasons. It is likely that... --- ### An update on the Nerivio device - Published: 2020-09-20 - Modified: 2020-09-20 - URL: https://www.nyheadache.com/blog/an-update-on-the-nerivio-device/ - Categories: Alternative Therapies, Migraine, neurostimulation It's been a year since the introduction of Nerivio, an electrical stimulation device for the acute treatment of migraines. One of the unique features of the device is that it is controlled by a smartphone app. This allows Theranica, the manufacturer of Nerivio, to collect data on its use. They just published real-world data on the use of Nerivio in the first 6 months after its introduction. 59% or 662 out of 1,123 patients treated by headache specialists and 74% or 23 out of 31 patients treated by non-headache specialists reported pain relief at two hours in at least half of their treated attacks. Complete pain freedom was achieved by 20% of the patients in the first group and 36% in the second group in at least half of their treated attacks. Only 0. 5% of the patients reported device-related adverse events. The number of patients treated by non-headache specialists is small. Nevertheless, because headache specialists tend to see patients who are more severely affected by their migraines, it is likely that the device will be more effective in the hands of non-headache specialists, or rather on the arms of patients treated by such doctors. Nerivio is a disposable device that is placed on the upper arm for 45 minutes. My subjective impression correlates with this published data. Some of my patients use it along with their abortive medications such as triptans or NSAIDs. One patient finds that the stimulation not only relieves pain but is also very relaxing. Even... --- ### Benign paroxysmal positional vertigo - another benefit of vitamin D - Published: 2020-09-16 - Modified: 2020-09-17 - URL: https://www.nyheadache.com/blog/benign-paroxysmal-positional-vertigo-another-benefit-of-vitamin-d/ - Categories: Alternative Therapies, Migraine Vitamin D deficiency predisposes to or worsens many different medical problems. I've written at least a dozen blog posts on vitamin D. A group of South Korean researchers just published in the journal Neurology a study, Prevention of benign paroxysmal positional vertigo with vitamin D supplementation. A randomized trial. They selected 518 patients with confirmed BPPV who were successfully treated with canalith repositioning maneuvers (Epley maneuver) and who had a vitamin D level below 20. The primary outcome measure was the annual recurrence rate. Patients in the intervention group were given vitamin D 400 IU and 500 mg of calcium carbonate twice a day for 1 year. Patients in the observation group were assigned to follow-ups without further vitamin D evaluation or supplementation. The intervention group had a significant reduction in the treatment group compared to the observation group. The authors concluded that supplementation of vitamin D and calcium may be considered in patients with frequent attacks of BPPV, especially when serum vitamin D is subnormal. BPPV, dizziness, vertigo, difficulty with balance are more common in people with migraines. Keeping your vitamin D level at least in the middle of the normal range may help prevent all these symptoms as well as migraines and other neurological problems. --- ### Melatonin for migraines - Published: 2020-09-11 - Modified: 2020-09-11 - URL: https://www.nyheadache.com/blog/melatonin-for-migraines/ - Categories: Alternative Therapies, Migraine, New treatments Melatonin is a hormone produced by the pineal gland located in the brain. The release of melatonin helps us fall asleep. Melatonin supplements have been used to treat insomnia. The results of clinical trials, however, are contradictory. This may be because a wide variety of doses have been used. One study suggests that 3 mg of melatonin – a common dose sold in stores – is less effective than 0. 3 mg. I usually recommend 0. 3 mg (300 mcg) for both insomnia and jet lag. Melatonin has been tested for the prevention and acute treatment of migraines. Melatonin was not effective in a study by Norwegian doctors. They gave 2 mg of extended-release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo in a double-blind crossover trial. Migraine frequency did improve from an average of 4. 2 a month to 2. 8 in both the melatonin and the placebo groups. Another blinded trial was done in Brazil by Dr. Mario Peres and his colleagues. It compared 3 mg of immediate-release melatonin with a placebo and with 25 mg of amitriptyline. The study involved 196 patients. The number of headache days dropped by 2. 7 days in the melatonin group, 2. 18 for amitriptyline, and 1. 18 for placebo. Melatonin significantly reduced headache frequency compared to placebo. Amitriptyline did not. Not surprisingly, melatonin was much better tolerated than amitriptyline. Considering its safety and very low cost, it is worth considering... --- ### 100 Migraine Drugs, A to Z: tizanidine - Published: 2020-09-04 - Modified: 2020-09-04 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-tizanidine/ - Categories: Headache medications, Migraine Tizanidine (Zanaflex) is a muscle relaxant that has been shown to relieve chronic migraines in a 200-patient double-blind study by Dr. Joel Saper and his colleagues. It may be particularly effective in people with neck and shoulder muscle spasm and pain. The majority of migraine sufferers have such muscle pains. It is also a good choice when you have insomnia along with migraines. The main side effect of tizanidine is drowsiness and dizziness. This is why it is usually taken at night. The starting dose is 4 mg. It can be gradually increased to 8, and then 12 mg. In the double-blind study, the median dose was 18 mg. Some patients went up to 24 mg with 8 mg taken three times a day. Very few of my patients can take that much tizanidine during the day. At most, they will take 2-4 mg twice during the day and a higher dose at night. --- ### Oxygen for migraines - Published: 2020-08-29 - Modified: 2020-08-29 - URL: https://www.nyheadache.com/blog/oxygen-for-migraines/ - Categories: Alternative Therapies, Migraine People who live at high altitudes tend to have lower oxygen levels in their blood. A higher percentage of them suffer from migraines than people who live at sea level. Oxygen is effective for a significant percentage of patients with cluster headaches. It is much less effective for the treatment of migraines. Two small studies showed that oxygen under normal pressure is ineffective for the acute treatment of migraine but oxygen under pressure, or hyperbaric oxygen, is. The first study had 10 patients, the second, only eight. Norwegian researchers conducted a double-blind, placebo-controlled study to assess the prophylactic effect of hyperbaric oxygen therapy on migraine. The effect of three daily sessions of hyperbaric oxygen was compared to the effect of three hyperbaric air treatments. Oxygen under pressure appeared to be more effective. However, because the number of patients was small – 19 in the oxygen and 15 in the air group – no statistical significance was found. Even if proven effective, using hyperbaric oxygen for the acute treatment of migraines, is highly impractical. There are few hyperbaric chambers to be found. It is also a very expensive treatment. --- ### 100 Migraine Drugs, A to Z: timolol - Published: 2020-08-23 - Modified: 2020-08-23 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-timolol/ - Categories: Chronic migraine, Headache medications, Migraine Timolol (Blocadren), is the second of the two beta-blockers approved by the FDA for both hypertension and the prevention of migraines. Among the dozen or so beta-blockers, it is not very popular for either hypertension or migraine. An ophthalmic solution of timolol is often used for glaucoma. A study of 107 migraine patients compared prophylactic treatment with timolol, 20 to 30 mg per day with matching placebo. The study was a double-blind crossover study that lasted 20 weeks. Timolol was significantly better than the placebo in decreasing the frequency of headaches, numbers of patients who had a 50% reduction in headache frequency, global response, and patient preference. The overall response was 65% with timolol compared with 40% with placebo. The severity and duration of headaches that occurred were unchanged. Few side effects were reported with either timolol or placebo. Another study compared timolol, 10 mg twice a day with propranolol, 80 mg twice a day, and with placebo in 83 migraine patients. Timolol and propranolol were equally effective and had a similar rate of side effects. The side effects of timolol are typical of all beta-blockers - chest discomfort, tiredness, lightheadedness, dizziness, fainting, shortness of breath, slow or irregular heartbeat. The usual dose of timolol is 10 mg twice a day. You can read about the use of timolol eye drops to treat acute migraines in a previous post. --- ### Histamine and migraine - Published: 2020-08-17 - Modified: 2020-08-17 - URL: https://www.nyheadache.com/blog/histamine-and-migraine/ - Categories: Alternative Therapies, Headache medications, Headaches, injections, Migraine Histamine is best known as a part of the defense against allergies. But it is also an important neurotransmitter – a brain chemical involved in arousal, anxiety, the stress-related release of hormones, activation of the sympathetic nervous system, pain relief, and other functions. Increased sensitivity to histamine may lead to an excessive allergic reaction which is relieved by anti-histamine drugs. It can also increase pain. One strategy thought to reduce this over-reaction is desensitization – injecting small amounts of histamine which can lead to a reduced reaction. This approach seems to help some migraine and cluster patients. It was first reported in 1941 by a Mayo clinic doctor, Bayard Horton in an article entitled The use of histamine in the treatment of specific types of headaches. Another article, Intravenous histamine in the treatment of migraine was published in 1946 by W. A. Thomas and S. Butler. A group of Mexican doctors compared subcutaneous (under the skin) injections of small doses of histamine to injections of placebo in 60 patients. They found histamine to be more effective. The same group of doctors conducted three more double-blind trials of histamine injections. A double-blind study of 90 migraine patients compared twice-weekly injections of histamine with 100 mg of oral topiramate, which is an FDA-approved treatment for migraines. These treatments were equally effective. They then compared twice-weekly injections of histamine to 500 mg of valproate, which is also an FDA-approved migraine drug in 92 migraine patients. Histamine was superior to valproate. They compared histamine... --- ### Acetyl-leucine may help dizziness, vertigo and migraines - Published: 2020-08-12 - Modified: 2020-08-12 - URL: https://www.nyheadache.com/blog/acetyl-leucine/ - Categories: Alternative Therapies, Chronic migraine, Head trauma, Headache medications, Headaches, Migraine, New treatments, Uncategorized Acetyl-leucine (Tanganil) is an amino acid that has been available in France for over 60 years as a prescription drug. It is approved for the treatment of low blood pressure and dizziness. However, there are no published studies of this product for either low blood pressure or dizziness. There are some animal studies suggesting that acetyl-leucine works on brain cells responsible for the balancing of the body and motor control. It was also tested in animals whose inner ear balancing organ was destroyed on one side. A group of German doctors, whom I know and respect, found it to be very effective in a prospective study of 10 patients with migraines. The dose was 5 grams daily. The usual recommended dose for dizziness and hypotension is up to 2 grams. I occasionally recommend it to desperate patients with severe and persistent dizziness and vertigo that has resulted from a concussion or vestibular migraine. While acetyl-leucine is not proven to be effective, it does not cause any side effects. Acetyl-leucine is also being tested for some rare hereditary neurological disorders such as Niemann-Pick disease. --- ### 100 Migraine Drugs, A to Z: Low-dose naltrexone - Published: 2020-08-06 - Modified: 2020-08-06 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-low-dose-naltrexone/ - Categories: Alternative Therapies, Chronic migraine, Pain, Pain Research Naltrexone is similar to naloxone, a drug used to reverse the effect of narcotic (opioid) overdose. Naltrexone is not used to reverse the effect of an overdose, but to treat opioid and alcohol dependence. (LDN) and is given as a monthly injection or a daily pill. Naltrexone blocks the body’s own endogenous morphine (endorphin) receptors. In theory, this should make the pain worse. However, low-dose naltrexone (LDN) seems to have the opposite effect. It is possibly explained by the fact that a small amount of naltrexone blocks the endorphin receptors for a short time, during which the body begins to make more endorphins in an attempt to overcome this block. After the effect of naltrexone wears off, this extra amount of endorphins provides relief of pain and by blocking other receptors (such as Toll-like receptor 4) and reducing inflammation, potentially produces other beneficial effects, most of which are not scientifically proven. Inflammatory bowel disease (Crohn’s disease and ulcerative colitis) do seem to respond to LDN. A study of 27 patients with chronic central pain syndromes at the Stanford Pain Management Clinic published in The Journal of Pain concluded that “The significant findings of decreased average pain scores and depression and improved physical function after prescribing this well-tolerated, inexpensive medication provides justification for larger, controlled trials in patients with central sensitivity syndromes. ” Some of these central sensitivity syndromes include migraine, fibromyalgia, irritable bowel syndrome, chronic back pain, and other. Naltrexone is available only in a 50-mg tablet, while LDN is... --- ### 100 Migraine Drugs, A to Z: sumatriptan - Published: 2020-07-30 - Modified: 2020-07-30 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-sumatriptan/ - Categories: Headache medications, Migraine Sumatriptan (Imitrex, Imigran) is by far the most popular triptan because it was the first one on the market. Because it came out a long time ago, many manufacturers make generic copies of this drug. This has reduced its price. Sumatriptan is available in combination with naproxen (Treximet). This combination is more effective than either drug alone. The drug is available in 25, 50 and 100 mg strength. The starting dose for most patients is 100 mg. If after two hours one tablet has not relieved your migraine, take a second dose. In Europe, 50 mg tablets of sumatriptan have been sold without a prescription for over a decade. The nasal spray of sumatriptan is not as effective as the tablets but the newer forms of nasal sumatriptan (Onzetra, Tosymra) are work better. However, the newer forms are much more expensive. Sumatriptan injection is the most effective abortive migraine treatment. Over 80% of patients respond to it. Unfortunately, the injections are highly underutilized. The doctors are not very familiar with them, forget to offer them, and are afraid to prescribe them. The perception is that the side effects are common or they think that patients will not be receptive to the idea of injections. The injection begins to work within 10-15 minutes and can quickly restore people to normal functioning. They are particularly useful for people for whom tablets are not likely to work well or work fast enough. People who wake up with a severe migraine, have a rapid... --- ### WTF? Do we need another study of swearing for the relief of pain? - Published: 2020-07-25 - Modified: 2020-07-25 - URL: https://www.nyheadache.com/blog/wtf-do-we-need-another-study-of-swearing-for-the-relief-of-pain/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Pain, Pain Research, Psychology of headaches, Science of Migraine 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... --- ### 100 Migraine Drugs, A to Z: rizatriptan - Published: 2020-07-21 - Modified: 2020-07-21 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-rizatriptan/ - Categories: Chronic migraine, Headache medications, Headaches, Migraine Rizatriptan (Maxalt, Maxalt MLT) is one of the seven triptans approved in the US. Along with zolmitriptan, it is one of the two triptans available in an orally disintegrating form - it melts in your mouth and does not require water to take it. This is important for those migraine sufferers who are so nauseous that they cannot drink even a small amount of fluid without throwing it up. It also means that you can take it when water is not immediately available. This is important since the earlier you take an abortive drug the better the results. Another unique feature of rizatriptan is that the FDA-approved dose is up to three 10-mg tablets a day (it is also available in 5-mg tablets), while all other triptans have a limit of 2 a day. This does not mean that there is any significant difference in how different short-acting triptans are processed in your body or that taking sumatriptan three times in one day is dangerous. Unfortunately, many doctors blindly follow the rules and sternly warn patients not to exceed the FDA-recommended dose. The 5 most effective triptans (this excludes naratriptan and especially frovatriptan) have a half-life of 2-3 hours, which means that half of a single dose is gone from your body in 2-3 hours and after 6-8 hours, almost all of it is washed out. Naratriptan has a half-life of 6 hours and frovatriptan, 26 hours. Even if you were to take narartriptan three times a day it would... --- ### 100 Migraine Drugs, A to Z: lisinopril - Published: 2020-07-16 - Modified: 2020-07-16 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lisinopril/ - Categories: Chronic migraine, Headache medications, Migraine Lisinopril (Prinivil, Zestril) is a blood pressure medicine in the family of angiotensin-converting enzyme inhibitors (ACEI). At 20 mg a day it was effective in the prevention of migraine headaches, according to a double-blind cross-over study of 60 patients. Three patients stopped the drug due to cough. An open-label study of 5 mg of lisinopril in 21 patients was also positive but 3 patients stopped it because of cough. ACEIs but not angiotensin receptor blockers (ARBs) which are similar to ACEIs can cause cough. The occurrence of cough is not dose-dependent. A review of a large database of prescriptions showed that patients taking ACEIs or ARBs were getting 50% fewer prescriptions for abortive migraine drugs compared to those taking a diuretic, which is another type of drug to treat hypertension. The advantage of ACE inhibitors and ARBs over beta-blockers such as propranolol is that they do not lower the heart rate, which can make exercise difficult. Both can cause fatigue and dizziness due to the lowering of blood pressure, but the weight gain and depression, occasionally seen with propranolol does not happen with ACEIs and ARBs. On the other hand, beta-blockers can sometimes help reduce anxiety and palpitations. --- ### Botox for brain tumor headaches? - Published: 2020-07-12 - Modified: 2020-07-12 - URL: https://www.nyheadache.com/blog/botox-for-brain-tumor-headaches/ - Categories: Botox, Brain disorders, Headaches Two patients treated at MD Anderson Cancer Center for brain tumors were given Botox injections for their tumor-related headaches. The report at the recent meeting of the American Headache Society describes two patients, one with a meningioma ("extensive meningiomatosis") and the second one with metastatic breast cancer. The first patient completed 14 treatments with Botox over 4 years and the second, 9 treatments over 2 years. Both patients had sustained improvement in their headache intensity, duration, headache-free days, and quality of life. The recurrence of headaches often began 90 days after each treatment, which is the usual duration of the effect of Botox. Botox is approved by the FDA for the preventive treatment of chronic migraine headaches, which are defined as headaches occurring on at least 15 days each month. However, most headache specialists I know use it for other types of headaches as well. Cluster headaches, hemicrania continua, post-traumatic headaches, numular headaches, trigeminal neuralgia have all been reported in the medical literature to respond to Botox. I've also successfully treated patients with these types of headaches, as well as a large number with episodic migraines (less than 15 headache days a month) and a few with chronic tension-type headaches. Neuropathic pain also seems to respond to Botox and I've treated patients with post-herpetic neuralgia (shingles), stump pain after amputation, post-surgical scar pain, and other pain types. It is not surprising that Botox could help headaches caused by a brain tumor. The brain itself is not pain-sensitive - neurosurgeons can... --- ### 100 MIgraine drugs, A to Z: lamotrigine - Published: 2020-07-07 - Modified: 2020-07-07 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lamotrigine/ - Categories: Headache medications, Migraine Lamotrigine (Lamictal) is an epilepsy drug that is also approved as a mood stabilizer in bipolar disorders. Its exact mechanism of action is not well understood. There are no good controlled trials of lamotrigine in migraines, but an open long-term study by European neurologists suggests that 100 mg of lamotrigine is effective not only in reducing the frequency of migraines but also in reducing the frequency and the duration of visual auras. There are also case reports of lamotrigine relieving complicated auras with visual and sensory symptoms. The main side effects of lamotrigine are dizziness, drowsiness, upset stomach, and rash. The rash can be serious and in very rare cases fatal (Stevens-Johnson syndrome), but it could be avoided by starting with a very low dose (25 mg) and increasing it by 25 mg every two weeks. For epilepsy, the dose goes up to as high as 600 mg a day. --- ### 100 Migraine Drugs, A to Z: promethazine - Published: 2020-07-01 - Modified: 2020-07-01 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-promethazine/ - Categories: Chronic migraine, Headache medications, Migraine Promethazine (Phenergan) is a phenothiazine drug that can be very effective for the treatment of migraine-induced nausea and vomiting. Like other phenothiazine drugs, it can have some direct effect on pain of migraine although it has not been studied as extensively as prochlorperazine or metoclopramide. A double-blind study in 216 patients comparing sumatriptan with promethazine with sumatriptan alone, showed that the combination was more effective in relieving pain, achieving pain-free state, and preventing recurrence of migraine. Promethazine is available as a tablet and injection as well as a rectal suppository which is very useful for patients with severe nausea and vomiting. Side effects of promethazine are similar to other phenothiazine drugs and include drowsiness, dizziness, and akathisia or restlessness. This restlessness can be very unpleasant but can be treated with oral or injected diphenhydramine (Benadryl). --- ### 100 Migraine Drugs, A to Z: prochlorperazine - Published: 2020-06-27 - Modified: 2020-06-27 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-prochlorperazine/ - Categories: Chronic migraine, Headache medications, Migraine Prochlorperazine (Compazine) belongs to the category of phenothiazine drugs. Chlorpromazine (Thorazine) was the first drug in this family and it was approved for the treatment of schizophrenia in 1950. Phenothiazine drugs have also been found to be effective for the treatment of nausea and vomiting, severe anxiety, and persistent hiccups. Prochlorperazine is mostly used for the treatment of nausea and vomiting and it is available in tablets, rectal suppositories, and injections. Prochlorperazine appears to be an effective drug not only for the treatment of nausea and vomiting of migraine, but also for head pain and other symptoms. Prochlorperazine was found to be more effective in treating all migraine symptoms than another antiemetic (nausea drug), metoclopramide (Reglan). In a study of children with migraine seen in an emergency department, intravenous prochlorperazine was more effective than an intravenous pain medication ketorolac (Toradol). The main side effect of prochlorperazine is restlessness or akathisia, which occurs in a large minority of patients who receive it intravenously. In many patients this symptom is mild but in some, it is severe and extremely unpleasant. Many describe the sensation as if wanting to crawl out of their skin. With regular long-term intake of phenothiazine medications, involuntary movements can be a very serious side effect. I do have patients for whom chlorpromazine works exceptionally well and with no side effects. Most of them need it not more than a few times a month and most use tablets and less often, suppositories. Suppositories work faster than tablets and are... --- ### 100 Migraine Drugs, A to Z: protriptyline - Published: 2020-06-24 - Modified: 2020-06-24 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-protriptyline/ - Categories: Chronic migraine, Headache medications, Migraine Protriptyline (Vivactil) is one of the tricyclic antidepressants (TCAs). It is rarely used, compared to amitriptyline and nortriptyline. This is probably because protriptyline has never been subjected to a controlled trial in migraines. However, even amitriptyline, which is the most popular and most studied TCA, is rated only as probably effective by the American Academy of Neurology and the American Headache Society guidelines. In the bad old days, very few drugs were tested in large double-blind trials and sometimes got approved without any testing. The reason to use protriptyline is that it tends to have fewer side effects when compared to other TCAs. If someone has good relief of migraines on amitriptyline but drowsiness is a problem, protriptyline is worth trying. Also, protriptyline is easier to titrate than other TCAs – the starting dose is 10 mg nightly and after a couple of weeks, it is increased to 20 mg and then, if needed and if tolerated, to 30 mg nightly. The most common side effects of all TCAs besides sedation are constipation, dry mouth, dizziness, sexual dysfunction. Some patients refuse to consider TCAs because of their potential for weight gain, although it tends to happen at higher doses and in a minority of patients. --- ### 100 Migraine Drugs, A to Z: pregabalin - Published: 2020-06-19 - Modified: 2020-06-19 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-pregabalin/ - Categories: Chronic migraine, Headache medications, Migraine Pregabalin (Lyrica) is an epilepsy drug that is also approved by the FDA for the treatment of neuropathic (nerve) pain associated with diabetes, spinal cord injury, shingles (herpes zoster), and fibromyalgia. It is a controlled drug with a low risk of addiction and abuse, although it is often combined with other illicit drugs. Common side effects include dizziness, drowsiness, difficulty thinking clearly, weight gain, sexual dysfunction, and dry mouth. It also has many other less common side effects. There are no large controlled trials of pregabalin for migraines only case series and anecdotal reports. However, because it does relieve pain and because two other epilepsy drugs, topiramate (Topamax, Trokendi, Qudexi) and divalproex sodium (Depakote) relieve migraines, at least theoretically it should be also effective for migraines. However, despite the few anecdotal reports, it does not appear to be very effective and often does cause side effects. I rarely prescribe it and have very few patients who benefit from it without side effects. --- ### High CRP level is a modifiable risk factor for chronic migraine - Published: 2020-06-14 - Modified: 2020-06-14 - URL: https://www.nyheadache.com/blog/high-crp-level-is-a-modifiable-risk-factor-for-chronic-migraine/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine A large population-based 11-year long study just published by Norwegian researchers confirmed that an elevated level of an inflammatory marker C-reactive protein (CRP) is associated with an increased risk of developing chronic migraine. Inflammation is a well-established part of the pathophysiology of migraine. Pro-inflammatory aspects of obesity are thought to underly the correlation between excessive weight and the frequency of migraines. While it is not clear how high CRP leads to chronification of migraines, there are several ways to lower this marker. CRP is also a well-documented marker of risk for cardiovascular disease. Statins, such as atorvastatin (Lipitor) lower CRP levels independently of their lipid-lowering effect. Metformin is another drug that can lower CRP levels. There are several ways to lower CRP without drugs including lifestyle changes such as regular exercise, a healthy diet, and moderate alcohol consumption. A Japanese study of over 2,000 people showed that blood levels of vitamin C are inversely correlated with CRP levels. A review of 12 published studies of the effect of vitamin C on CRP showed that vitamin C lowers CRP levels. A meta-analysis of 12 published studies showed that vitamin E (alpha-tocopherol or gamma-tocopherol) is another vitamin that lowers CRP levels. --- ### 100 Migraine Drugs, A to Z: propranolol - Published: 2020-06-13 - Modified: 2020-06-13 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-propranolol/ - Categories: Chronic migraine, Headache medications, Migraine Propranolol (Inderal) belongs to the beta-blocker family of medications and it was approved by the FDA in 1967 for the treatment of high blood pressure. About a decade later it became the first drug to be approved by the FDA for the preventive treatment of migraine headaches. Propranolol is also used for essential tremor, performance anxiety, fast heart beating (tachycardia), angina, and other conditions. In 1988, a British scientist Sir James Black was awarded the Nobel Prize for the discovery of propranolol. Propranolol is a very effective drug, but because it can lower blood pressure, side effects such as fatigue, lightheadedness, and fainting can occur. Because it slows down the heart rate it can also make it difficult to exercise, which is one of the best ways to prevent migraines. Propranolol can sometimes worsen pre-existing asthma but newer beta-blockers do not have this problem. If someone along with migraines has a rapid heartbeat, anxiety, or difficulty making public presentations, this drug can provide dual benefits. A typical starting dose of propranolol is 60 mg of the long-acting formulation. The dose is then increased to 80, 120, and 160 mg, if needed and if tolerated. --- ### A large study confirms that yoga helps migraines - Published: 2020-06-08 - Modified: 2020-06-08 - URL: https://www.nyheadache.com/blog/a-large-study-confirms-that-yoga-helps-migraines/ - Categories: Alternative Therapies, Chronic migraine, Migraine If you’ve ever tried doing yoga as I have (I love hot yoga, but it’s not for everyone), you will not need convincing that it may very well help prevent migraine headaches along with giving you many other benefits. A study just published by Indian researchers in the leading neurological journal, Neurology examined the effect of yoga as an add-on therapy to conventional medical treatment of migraine headaches. It was a “prospective, randomized, open-label superiority trial with blinded endpoint assessment carried out at a single tertiary care academic hospital in New Delhi”. 160 patients with episodic migraine were randomly assigned to medical and yoga groups. A total of 114 patients completed the trial. Compared to medical therapy, the yoga group showed a significant reduction in headache frequency, headache intensity, disability as measured by the headache impact test (HIT-6) and migraine disability assessment (MIDAS) scores, and in the number of pills taken. The authors justifiably concluded that “Yoga as an add-on therapy in migraine is superior to medical therapy alone. It may be useful to integrate a cost-effective and safe intervention like yoga into the management of migraine. ” A word of caution though. Since migraine sufferers are more prone to a dissection of their neck arteries avoid extreme twisting of your neck. Forcing your neck into an extreme flexion or extension positions (which some teacher urge you to do) can also cause herniation of a disc in your spine. I’ve tried and have found standing on my head strangely pleasant,... --- ### 100 Migraine Drugs A to Z: propofol - Published: 2020-06-04 - Modified: 2020-06-04 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-propofol/ - Categories: Chronic migraine, Headache medications, injections, Migraine Propofol (Diprivan) was originally developed for general anesthesia during surgery. Smaller amounts were found to work well for "conscious sedation" to induce a semiconscious state for minor procedures such as colonoscopies. In small doses, propofol appears to be effective for the treatment of migraines. A 2019 review of nine studies and case reports showed that "Propofol may be an effective rescue therapy for patients presenting to the ED for acute migraine, but its place in therapy based on the limited available evidence is unknown. " Propofol was also tested for the emergency room treatment of 66 children with migraines. It was found to be as effective as the standard therapy but those give propofol had a lower rate of headache recurrence within 24 hours. Propofol is a drug of abuse that was in part responsible for the death of Michael Jackson (it was one of several drugs found in his body). Because it is given only intravenously and is not easy to get, most of the cases of addiction reported occurred in healthcare professionals. Propofol is administered only intravenously and at anesthetic doses it can have serious side effects such as a drop in blood pressure. However, it appears very safe for conscious sedation and is probably even safer at small doses used for migraines. It should be considered when a patient does not respond to other intravenous therapies such as ketorolac, metoclopramide, and dihydroergotamine. --- ### I've tried Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant) - Published: 2020-05-30 - Modified: 2020-05-30 - URL: https://www.nyheadache.com/blog/ive-tried-ubrelvy-ubrogepant-and-nurtec-odt-rimegepant/ - Categories: Chronic migraine, Headache medications, Migraine, New treatments My migraines respond very well to sumatriptan, but I do like to try new treatments that I recommend to my patients. A few months ago two new abortive drugs to treat acute migraine attacks were approved by the FDA. Ubrelvy (ubrogepant) and Nurtec ODT (rimegepant) block CGRP, a substance released during a migraine attack. They work in a similar way to four injectable drugs used for the prevention of migraines - erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti). I've tried erenumab and fremanezumab with some relief, but stopped both because sumatriptan works well and I don't really need any preventive medications. Because the two injectable drugs did help, I expected the two new oral medications to work as well. Alas, neither one had any effect. This suggests that CGRP is not very operational in my case. The fact that sumatriptan, a drug that works on serotonin receptors works so well indicates that the serotonin system is dominant in producing my migraines. Migraine is a very heterogeneous disorder with a variety of clinical presentations and with dozens of identified genetic abnormalities that predispose one to migraines. This means that we are not likely to have a drug that works for all migraine patients. What we do expect, is the advent of personalized medicine - having tests that predict which drug will work for which patient. --- ### Eye exercises for head trauma and headaches - Published: 2020-05-22 - Modified: 2020-05-22 - URL: https://www.nyheadache.com/blog/eye-exercises-for-head-trauma-and-headaches/ - Categories: Alternative Therapies, Head trauma, Headaches, Migraine We recently started using RightEye eye-tracking equipment which can help our patients who are suffering from visual difficulties due to migraines, concussion, or traumatic brain injury (TBI). Many brain disorders can impair the control of eye movements. This can lead to incorrect information being passed from the eyes to the brain, which can worsen brain dysfunction. Eye strain can also contribute to migraines and post-concussion headaches. The RightEye computer has a built-in infrared eye-tracking device that can accurately diagnose different abnormal eye movements. It tests smooth pursuit, vertical and horizontal saccades, reading, reaction time, and other functions. A recent study, Vertical smooth pursuit as a diagnostic marker of traumatic brain injury showed a correlation between moderate and severe TBI and abnormal eye movements. Eye movement problems after TBI were also reported in a study published in the Journal of Neurotrauma , Eye Tracking Detects Disconjugate Eye Movements Associated with Structural Traumatic Brain Injury and Concussion. A study in the journal Brain showed that eye movement difficulties were still present 3 to 5 months after the concussion and that they were not affected by the presence of depression or degree of intellectual ability. Compared with neuropsychological tests, eye movements were more likely to be markedly impaired in patients with many postconcussion symptoms. While there are no studies showing that migraines improve with eye exercises, there is some evidence that symptoms of concussion which can include migraine headaches, do improve. A review of several published studies of vision therapy for post-concussion symptoms... --- ### More on vitamin D and COVID-19 - Published: 2020-05-14 - Modified: 2020-05-14 - URL: https://www.nyheadache.com/blog/more-on-vitamin-d-and-covid-19/ - Categories: Uncategorized 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)... --- ### 100 Migraine Drugs, A to Z: phenelzine - Published: 2020-05-13 - Modified: 2020-05-14 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-phenelzine/ - Categories: Chronic migraine, Headache medications, Migraine Phenelzine (Nardil) is an antidepressant which was approved by the FDA for the treatment of depression in 1961. It belongs to the family of monoamine oxidase (MAO) inhibitors and it is a very effective antidepressant. However, it is rarely used because of its potential to cause side effects and serious drug and food interactions. There have been no good trials of phenelzine for the treatment of migraines. One small study compared phenelzine with and without a beta blocker, atenolol. Atenolol is known to help migraines and lowers blood pressure, so it could prevent an increase in blood pressure from phenelzine. Phenelzine worked well with and without atenolol. Another report described 11 patients with refractory (not responding to usual drugs) migraines. Ten of the 11 patients had a greater than 50% reduction in the number of headache attacks. Two patients developed low blood pressure and one, high pressure, which was easily controlled. There was also a case report of dramatic improvement in a patient with chronic and treatment-resistant migraines. Phenelzine can interact with other antidepressants, appetite suppressants, drugs for attention deficit disorder, some epilepsy drugs, muscle relaxants, certain blood pressure medications, some opioid (narcotic) medications, and other. Foods that can interact with phenelzine include aged cheeses, aged/dried/fermented/salted/smoked/pickled/processed meats and fish, fava beans, Italian green beans, broad beans, overripe or spoiled fruits, packaged soups, sauerkraut, red wine, and some other types of alcohol. An adverse interaction with these drugs and foods can cause a sudden increase in blood pressure or serotonin syndrome,... --- ### 100 Migraine Drugs, A to Z: ondansetron - Published: 2020-05-06 - Modified: 2020-05-06 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ondansetron/ - Categories: Headache medications, Migraine Ondansetron (Zofran) is not a migraine drug per se, but it is used for the treatment of nausea that often accompanies a migraine attack. It belongs to a different class of nausea drugs than the older drugs such as prochlorperazine (Compazine), promethazine (Phenergan) or metoclopramide (Reglan). which are effective for both nausea and pain of migraine. There are no good studies of ondansetron for the treatment of migraines, but the impression of most headache specialists is that it is helpful only for the treatment of nausea of migraine and not the pain. However, one large observational study does suggest that it may help more than just nausea, at least in children. Observational studies are much less reliable than double-blind placebo-controlled ones, however, the large size of this study provides some compensation for this deficiency. The researchers looked at the records of 32,124 children with migraine who presented to the emergency room. One fifth received ondansetron and it was as effective in preventing a return visit to the ER as metoclopramide, while prochlorperazine was a bit more effective. The advantage of ondansetron is that it does not cause neurological symptoms of restlessness (akathisia) and drowsiness, which can occur with metoclopramide and prochlorperazine. Ondansetron is available in a tablet, an orally disintegrating tablet, and as an injection, but not as a suppository. Rectal suppositories of prochlorperazine and promethazine work fast and are very useful for patients who are vomiting and cannot hold down a tablet. --- ### Tonight you can watch a live Facebook event on exercise and migraines - Published: 2020-04-30 - Modified: 2020-04-30 - URL: https://www.nyheadache.com/blog/tonight-you-can-watch-a-live-facebook-event-on-exercise-and-migraines/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine Tonight at 6 PM (EST), Dr. Mauskop will speak at the Weekly Wellness with the American Migraine Foundation. He will discuss the role of exercise in the management of migraine headaches and the results of scientific clinical trials, as well as practical information about various types of exercise such as aerobic (cardiovascular), isometric, high-intensity interval testing, and the Feldenkrais method. He will also provide advice on how to avoid exercise-induced and exertional headaches. You can log in to see this event and ask questions here - https://www. facebook. com/events/730534437480323/ --- ### 100 Migraine Drugs, A to Z: metoclopramide - Published: 2020-04-19 - Modified: 2020-04-19 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metoclopramide/ - Categories: Headache medications, injections, Migraine Metoclopramide (Reglan) is an anti-nausea drug that has been in use since 1979. Controlled studies have shown that metoclopramide stops not only nausea and vomiting that often accompany migraine attacks, but also relieves the pain. The American Headache Society (AHS) and the European Federation of Neurological Societies (EFNS) guidelines on the management of adults with acute migraine recommend intravenous metoclopramide as an effective and recommended treatment in the management of acute migraine. While intravenous (IV) administration is preferred, intramuscular (IM), subcutaneous (SC) and oral routes are also effective. These guidelines were based on many high-quality blinded studies such as one comparing 10 mg of IV metoclopramide with 600 mg of ibuprofen in which metoclopramide was clearly superior. A meta-analysis of 13 studies of intravenous metoclopramide involving 655 patients showed that "Metoclopramide is an effective treatment for migraine headache. . " and that "Given its non-narcotic and antiemetic properties, metoclopramide should be considered a primary agent in the treatment of acute migraines in emergency departments". Another emergency room study that was done after this meta-analysis was published, compared IV metoclopramide with IV ketorolac (an NSAID pain drug) and IV valproate, (an epilepsy drug approved in a pill form for the prevention of migraines) in 330 patients. Metoclopramide was the most effective of the three. We give IV metoclopramide in the office and prescribe it in a tablet form. However, this drug is not free of side effects. Drowsiness is one of the common side effects, but a much more unpleasant side... --- ### Covid-19 and headaches - Published: 2020-04-10 - Modified: 2020-04-10 - URL: https://www.nyheadache.com/blog/covid-19-and-headaches/ - Categories: Botox, Chronic migraine, Migraine It is hard to think or write about anything other than Covid-19, so here is some information on Covid-19 and headaches. The bad news is that the long-suffering headache patients are suffering more. Most hospitals consider Botox injections, nerve blocks, and other procedures to treat headaches as "nonessential". Yes, our patients will not die like some of those with Covid-19, but a more nuanced approach than just canceling all "nonessential" procedures should've been possible. My NYC colleagues are not needed to treat Covid-19 patients and they are just sitting around worrying about their patients and their own futures. We are a private headache clinic and are continuing to see patients in our office (with all the precautions) for Botox and other procedures, although the number of patients we are treating has dropped by three quarters. Most are understandably concerned about contracting the virus and are staying home. As far as the relationship between Covid-19 and headaches, it appears that this virus can sometimes invade the brain. This is not surprising because many viruses that affect the respiratory system can also affect the brain. The brain symptoms of Covid-19 are similar to those seen with other brain infections, including headaches (at times with nausea and vomiting), seizures, and disturbed consciousness. Loss of sense of smell is very characteristic of Covid-19 and it happens because of the damage to olfactory nerves. These nerve endings line the nasal cavity and they are directly connected to cell bodies of neurons in the brain. This... --- ### Nerivio, a drug-free treatment for acute migraines - Published: 2020-04-04 - Modified: 2020-04-04 - URL: https://www.nyheadache.com/blog/nerivio-a-drug-free-treatment-for-acute-migraines/ - Categories: Alternative Therapies, Migraine, New treatments Nerivio is a smartphone-controlled wireless device that provides electrical stimulation of the type that is similar to TENS units widely used in physical therapy for musculoskeletal disorders. It was approved by the FDA last year for the treatment of acute migraines. Nerivio was proven to be effective in a double-blind, sham-controlled study of 252 adults with migraine headaches. It was applied for 40 minutes on the upper arm and the strength of the current is gradually increased to a strong but non-painful intensity level. Active stimulation was more effective than sham stimulation in achieving pain relief (67% vs 39%), pain-free state (37% vs 18%), and relief of the most bothersome symptom such as nausea sensitivity to light or noise (46% vs 22%) at 2 hours post-treatment. The pain relief and pain-free superiority of the active treatment was sustained 48 hours post-treatment. The device was very well tolerated with only a few patients reporting local irritation. This device is controlled by a smartphone which allows the manufacturer to collect data about its use (with patients' permission and without identifying individual patients). After 6 months of my prescribing this device to a couple of hundred of patients, 62% of my patients reported having pain relief after 2 hours and 24% reported to be pain free after 2 hours. These numbers are comparable to the results seen with migraine drugs such as triptans (sumatriptan or Imitrex and other) as well as the new class of abortive migraine drugs, gepants (ubrogepant or Ubrelvy and... --- ### Vitamin C is another supplement to consider for pain, immune system (Covid?), connective tissue - Published: 2020-03-29 - Modified: 2020-03-29 - URL: https://www.nyheadache.com/blog/vitamin-c-is-another-supplement-to-consider-for-pain-immune-system-covid-connective-tissue/ - Categories: Alternative Therapies, Migraine Vitamin C or ascorbic acid (AA) was discovered by Albert von Szent-Györgyi for which he received the 1937 Nobel Prize in Medicine. Linus Poling, one of only 4 people to win the Nobel prize twice, devoted many years of his life to researching AA. A wealth of information on AA is available on Oregon State University's Linus Pauling Institute website. Many studies have shown that AA is important in collagen formation. It is also important for the proliferation of stem cells. A study of 1210 hospitalized patients showed that intravenous infusion of AA in doses of 3–10 grams/day reduced the mortality of critically ill patients. AA also plays a vital role in the functioning of the immune system as well as inflammation. This post was prompted not only by thoughts of how to boost your immunity and increase your resistance to viral infections but also by a recent paper with a catchy title, Dietary ascorbic acid restriction in GNL/SMP30-knockout mice unveils the role of ascorbic acid in regulation of somatic and visceral pain sensitivity. The authors conclude "our data unveil the critical role of ascorbic acid in regulating somatic and visceral pain sensitivity and support accumulating clinical evidence for the usefulness of ascorbic acid in pain management. " Another example of a basic science study of the role of AA in pain modulation is Evidence for the involvement of glutamatergic system in the antinociceptive effect of ascorbic acid. And what about migraines? Surprisingly, nobody has done any studies of AA... --- ### Vitamin D is good for pain, immune system (think Coronavirus), brain, and body - Published: 2020-03-23 - Modified: 2020-03-23 - URL: https://www.nyheadache.com/blog/vitamin-d-is-good-for-pain-immune-system-think-coronavirus-brain-and-body/ - Categories: Alternative Therapies, Migraine Vitamin D level testing is no longer covered by many insurers and many doctors, NY Times, and other media consider taking vitamin D supplements of unproven benefit. I've written 10 blog posts over the past 12 years on vitamin D. These posts describe highly scientific studies of the role of vitamin D deficiency on the development of delirium in hospitalized patients, multiple sclerosis, major diseases and dying, and of course migraines. This morning, Dr. Leo Galland during his TV appearance mentioned the importance of supplements that can boost the immune system and reduce our susceptibility to viral diseases. He mentioned vitamin D and curcumin. Dr. Galland is a highly respected physician who often helps patients with problems that are difficult to diagnose and treat. I've reviewed one of his excellent books The Allergy Solution in a previous post. What prompted another post on vitamin D besides Dr. Galland's TV appearance, was a 593-patient Mayo Clinic study which reported increased severity of fibromyalgia in patients with vitamin D deficiency. Of these 593 patients, 122 or 21% had vitamin D deficiency. Patients with lower vitamin D levels also reported higher rates of anxiety and depression and were more likely to be overweight. If you do get your vitamin D level tested, check what the actual result is. The normal range in most laboratories is from 30 to 100. However, if you are at the bottom of the normal range, you may be deficient and be more predisposed to a variety of medical... --- ### 100 Migraine Drugs, A to Z: onabotulinumtoxinA - Published: 2020-03-16 - Modified: 2020-03-16 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-onabotulinumtoxina/ - Categories: Chronic migraine OnabotulinumtoxinA (Botox) is a most remarkable medicine. It was first approved by the FDA in 1989 for two eye conditions and since then it received approval for another dozen conditions as varied as excessive sweating, very frequent urination, spasm of muscles, and of course, migraines. An interesting chain of serendipitous discoveries led to its approval for migraines. A Vancouver ophthalmologist, Dr. Jean Carruthers started using Botox in 1987 to treat blepharospasm (forceful and uncontrollable blinking) and noticed that patients' wrinkles disappeared. She mentioned this to her husband-dermatologist Dr. Alastair Carruthers who began to inject it for cosmetic reasons. Then a plastic surgeon in California, Dr. William Binder who has been using Botox to treat wrinkles began hearing from his patient that their headaches went away along with their wrinkles. When Dr. Binder first presented his observation in the early 1990s, he was met with a lot of skepticism. How could Botox, which affects only superficial muscles and nerve endings, help migraine, which begins deep in the brain? And what does a plastic surgeon really know about headaches? I was also a bit skeptical but faced with many patients whose migraines would not respond to usual treatments, I decided to look into this. I discovered that by weight, Botox is the deadliest poison known to man. At the same time, it is safer than aspirin, ibuprofen, or acetaminophen because obviously any drug can become a poison depending on the amount you ingest. Thousands of people die every year from bleeding ulcers... --- ### Listen to podcast by Bottom Line - 7 New Treatments for Migraines - Published: 2020-03-09 - Modified: 2020-03-09 - URL: https://www.nyheadache.com/blog/listen-to-podcast-by-bottom-line-7-new-treatments-for-migraines/ - Categories: Alternative Therapies, Migraine, New treatments Sarah Hiner, President of BottomLineInc interviews me for The Bottom Line Advocator podcast - 7 New Treatments for Migraines Just Released — with Alexander Mauskop, MD --- ### Galcanezumab can start to improve migraines within a day - Published: 2020-03-08 - Modified: 2020-03-09 - URL: https://www.nyheadache.com/blog/galcanezumab-can-start-to-improve-migraines-within-a-day/ - Categories: Headache medications, Migraine Galcanezumab (Emgality) is one of the three injectable monoclonal antibodies approved for the prevention of migraines. Pharmacological studies show that it takes up to a week for these drugs to reach their highest concentration. However, it does not mean that it takes a week for them to start helping. Many of my patients report feeling better within a day. A new study of galcanezumab indicates that such a rapid onset of action is not just due to the placebo effect. The authors analyzed the results of two large studies of patients with episodic migraines that were submitted to the FDA to gain its approval. The first study enrolled 858 patients and the second, 915. Patients were given monthly injections of galcanezumab 120 mg (with 240 mg loading dose) or 240 mg or placebo for up to 6 months.  In both studies, the onset of effect was present the day after the injection.   I do tell my patients that they might start feeling better the day after they receive their first injection (the initial dose of two 120 mg injections), but it is more likely that they will begin to improve within a week or even later. Some patients notice only minimal relief even at the end of the first month and require 2 or 3 monthly shots before any significant improvement occurs. This is true for all three injectable CGRP monoclonal antibodies. Vyepti, the fourth drug in this family, which was just approved and will be available in a... --- ### Rimegepant, another very safe and effective drug receives FDA approval for the acute treatment of migraine headaches - Published: 2020-03-01 - Modified: 2020-03-01 - URL: https://www.nyheadache.com/blog/rimegepant-another-very-safe-and-effective-drug-receives-fda-approval-for-the-acute-treatment-of-migraine-headaches/ - Categories: Chronic migraine, Headache medications, Migraine, New treatments Rimegepant (NURTEC ODT) is the second gepant approved for the acute treatment of migraine headaches. It blocks the same CGRP pathway as the injectable monoclonal antibodies that are used for the prevention of migraine attacks (erenumab/Aimovig, fremanezumab/Ajovy, galcanezumab/Emgality, and eptinezumab/Vyepti).   It follows the recent introduction of a similar drug that also blocks the CGRP receptor, ubrogepant (Ubrelvy). Since there have been no head-to-head trials comparing these two gepants, it is had to say if one is better than the other. On average, they appear to be very similar, but this does not mean that they will be equally effective or cause the same side effects in a particular patient. We see this with triptans (drugs like sumatriptan, eletriptan, and other) - the top 5 show similar efficacy in trials, but some patients strongly prefer one over another. One difference is that rimegepant is an orally disintegrating tablet and does not require water, while ubrogepant is taken with water. This makes rimegepant easier to take on the go and could be easier to take for patients with severe nausea. Another minor difference is that the dose of rimegepant is 75 mg that is taken once a day, while ubrogepant comes in 50 and 100 mg tablets and either dose can be repeated for up to 2 tablets a day. This can be both an advantage and a disadvantage. The instructions are simple for rimegepant - take one tablet once on the day you have a migraine (and the earlier you... --- ### 100 Migraine Drugs, A to Z: nortriptyline - Published: 2020-02-26 - Modified: 2020-02-26 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-nortriptyline/ - Categories: Chronic migraine, Headache medications, Migraine Nortriptyline (Pamelor) is a tricyclic antidepressant approved by the FDA only for the treatment of depression. However, with the introduction of SSRI family of antidepressants such as fluoxetine (Prozac) which have fewer side effects, the use of tricyclic antidepressants for depression has declined. Tricyclic antidepressants are still in wide use, but mostly for the treatment of headaches and pain. Nortriptyline is very similar to amitriptyline (Elavil) and is thought to cause fewer and milder side effects, although this has not been proven. This could be due to the fact that amitriptyline is broken down into nortriptyline, which is the active metabolite. Amitriptyline tends to be more sedating, which can be useful in patients with insomnia. There are no good blinded studies of nortriptyline for the prevention of migraines and they are not likely to be done. We assume it is as good as amitriptyline, although studies of amitriptyline also lack in size and scientific rigor. There are many trials of amitriptyline and nortriptyline for various pain conditions, but they are also not up to our modern standards. Amitriptyline was approved in the US in 1961. Besides sedation, nortriptyline can cause dry mouth, constipation, urinary retention in older patients, and other side effects. The dose to treat migraines and pain is usually lower than the dose used to treat depression. Pain and headaches sometimes respond to as little as 10 or 25 mg while for depression, the dose goes up to 100 mg and higher. In short-term studies of major depression,... --- ### Vyepti - Another breakthrough in the prevention of migraines - Published: 2020-02-22 - Modified: 2020-02-22 - URL: https://www.nyheadache.com/blog/vyepti-another-breakthrough-in-the-prevention-of-migraines/ - Categories: Chronic migraine, Headache medications, Migraine Eptienzumab (Vyepti) was just approved by the FDA for the preventive treatment of migraine headaches. Eptinezumab is another monoclonal antibody that blocks the effect of CGRP, a chemical released during a migraine attack. It joins erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality), three other monoclonal antibodies approved for the preventive treatment of migraine headaches. Eptinezumab is different from the other three drugs in that it is administered intravenously. It is given every three months by an infusion over 30 minutes. The other three drugs are self-administered subcutaneously every month, although fremaezumab can be also given every 3 months. Eptinezumab may also have a faster onset of action because it is administered intravenously and quickly reaches its peak concentration in the blood. The other three drugs take up to a week to reach their maximum concentration. The reason for such a long delay (most drugs injected subcutaneously take less than an hour to peak) is that the monoclonal antibodies are large molecules and are distributed not by blood vessels, but the slow-moving lymphatic system. On the other hand, these are preventive therapies, so the speed of onset is less critical than for abortive drugs, such as NSAIDs, triptans, and gepants (ubrogepant, rimegepant). Theoretically, it is possible that eptinezumab could work for patients who do not respond to the other three drugs because of a better distribution of the drug and because these drugs are not identical. About 10% of my patients report significantly better response when switched from erenumab, which was... --- ### fMRI may offer the first accurate and objective way to diagnose migraines - Published: 2020-02-18 - Modified: 2020-02-18 - URL: https://www.nyheadache.com/blog/fmri-may-offer-the-first-accurate-and-objective-way-to-diagnose-migraines/ - Categories: Migraine, Science of Migraine 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. --- ### Acupuncture for migraines - worth a try - Published: 2020-02-14 - Modified: 2020-02-14 - URL: https://www.nyheadache.com/blog/acupuncture-for-migraines-worth-a-try/ - Categories: Alternative Therapies, Migraine Acupuncture has been subjected to a very large number of clinical trials for a variety of conditions, including migraine headaches. Dr. Zhang, a neurologist at Stanford and two of his colleagues have published a review of trials that compared acupuncture with standard pharmacological migraine therapy. The review included only scientifically rigorous trials that compared the efficacy of acupuncture with a standard migraine preventive medication in adult patients with a diagnosis of chronic or episodic migraine with or without aura. Out of the 706 published reports, 7 clinical trials, with a total of 1430 participants were of high quality. Modes of acupuncture and pharmacological treatments varied from trial to trial, which made it difficult to make any sweeping conclusions. However, several of the studies showed acupuncture to be more effective than the standard pharmacological treatments for migraine prevention. Even if acupuncture is only as effective as drugs, its safety makes it a superior choice. The major drawbacks of acupuncture are that it is time-consuming and relatively expensive when compared to generic prescription drugs. These are the reasons why I rarely perform acupuncture on my patients. If someone is interested in acupuncture, I do encourage them to try it and refer them to well-trained lower-cost non-physician providers.   --- ### 100 Migraine Drugs, A to Z: nebivolol - Published: 2020-02-10 - Modified: 2020-02-10 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-nebivolol/ - Categories: Headache medications, Migraine Nebivolol (Bystolic) is one of the newer, third generation beta-blockers, drugs used for the treatment of high blood pressure as well as migraine headaches. In Europe, it's been in use for over 20 years. In addition to beta-blockade, it may have additional beneficial effects on endothelium (blood vessel lining). It may also improve glucose metabolism by improving insulin sensitivity and other functions. Nebivolol has the advantage of having fewer side effects than other beta blockers. including lower rates of fatigue and shortness of breath. The majority of migraine sufferers are young women, many of who have low blood pressure, which predisposes them to side effects from beta blockers. However, in the US, nebivolol is relatively expensive ($160 for one month supply) since it is not yet available in a generic form. Many insurers will not pay for it unless the patient cannot tolerate the widely used and inexpensive beta blockers such as propranolol, metoprolol, or atenolol. --- ### Lasmiditan - another new drug for acute treatment of migraines. - Published: 2020-02-02 - Modified: 2020-02-02 - URL: https://www.nyheadache.com/blog/lasmiditan-another-new-drug-for-acute-treatment-of-migraines/ - Categories: Headaches, Migraine, New treatments Lasmiditan (Rayvow) is the first (and probably the last) drug in the class of ditans. Just like the triptans (sumatriptan or Imitrex and other), it works through the serotonin system. However, it activates 5-HT1F serotonin receptor, while triptans activate 5-HT1B and 5-HT1D receptors. This confers an advantage in that lasmiditan does not cause constriction of coronary arteries, which can happen with triptans . So patients with a history of a heart attack, angina or multiple risk factors for vascular disease who could not take triptans, now have another drug that is safe to use. The first acute migraine drug for this at-risk population, ubrogepant (Ubrelvy) became available a week ago. Lasmiditan will reach pharmacies in the next few days. I will also prescribe lasmiditan to patients for whom triptans and ubrogepant are ineffective, partially effective, or cause side effects, which constitutes a sizable minority of my patients. . Results of two large double-blind trials showed that 28-39% of patients achieved fast and complete elimination of migraine pain at two hours with lasmiditan as compared to 15% and 21% with placebo. 41-49% of patients achieved freedom from their most bothersome symptom of sensitivity to light, sensitivity to sound, or nausea at two hours with lasmiditan compared to 30% and 33% with placebo. Lasmiditan is available in 50 mg and 100 mg tablets and the recommended dose is 50, 100, or 200 mg taken once a day. Side effects were generally mild to moderate and the most frequent ones included dizziness, fatigue,... --- ### 100 Migraine Drugs, A to Z: naratriptan - Published: 2020-01-26 - Modified: 2020-01-26 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-naratriptan/ - Categories: Headache medications, Migraine Naratriptan (Amerge, Naramig) is a triptan with a longer duration of action of 6 hours, compared to sumatriptan, rizatirptan, zolmitriptan, eletriptan, and almotriptan, which work for 2-4 hours. The seventh triptan, frovatriptan has the longest half-life of 26 hours, but its overall efficacy is not as good as than that of other triptans. These numbers of 6, 2-4 and 26 hours actually refer to drug's half-life - the time it takes for the blood level of the drug to drop by half. The duration of the effect is not important for most migraine sufferers because a quick-acting and highly effective drug stops the migraine process and there is no need for it to remain in the body. However, in some patients sumatriptan or another short-acting triptan may relieve symptoms for 4-6 hours and then migraine returns. Taking a second dose often works well, but not always. Those patients can benefit from taking naratriptan. Naratriptan also tends to have fewer side effects. The longer half-life makes naratriptan better suited for "mini-prophylaxis" - taking a drug daily for several days to prevent a predictable menstrual migraine. However, sumatriptan has been also shown to work in this manner. Just like with other triptans, naratriptan can be combined with ibuprofen or naproxen for better efficacy. Many insurers limit the number of pills they will pay for to 6 or 9, but naratriptan, along with sumatriptan and rizatriptan is one of the cheaper triptans. This allows patients to buy additional quantities, although many doctors have... --- ### Light therapy with Allay lamp - Published: 2020-01-19 - Modified: 2020-01-19 - URL: https://www.nyheadache.com/blog/light-therapy-with-allay-lamp/ - Categories: Alternative Therapies, Migraine Light sensitivity is a common feature of migraine headaches and during an attack most people prefer being in the dark. According to a Harvard professor, Dr. Rami Burstein, exposure to pure green light may be better than being in complete darkness. Dr. Burstein is one of the world's most productive and creative headache researchers. His research has been published in such leading medical journals as Brain, Nature, Pain, Neurology, Journal of Neuroscience, and many other. This is to say that his research is of high quality and can be trusted. I've known Rami for over 20 years and he never ceases to surprise with a fresh look at old phenomena that have lead him to many breakthrough discoveries. While studying light sensitivity, he decided to look at the effect of different parts of the visible light spectrum on the brain of experimental animals as well as migraine sufferers.   According to his research published in Brain, white light as well as other colors of the spectrum worsen pain perception, but green light reduces pain. Blue light produces the strongest pain response and this is why some of my patients find relief from wearing orange-colored lenses that block the blue part of the spectrum. Another paper by Burstein and his colleagues published in the Proceedings of the National Academy of Sciences suggests that exposure green light also has a positive effect on mood and autonomic nervous system functions. Because of these findings Dr. Burstein developed a lamp that produces pure green... --- ### 100 Migraine Drugs, A to Z: naproxen - Published: 2020-01-14 - Modified: 2020-01-14 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-naproxen/ - Categories: Headache medications, Migraine Naproxen (Aleve, Anaprox, Naprosyn) is a popular over-the-counter and prescription non-steroidal anti-inflammatory drug (NSAID), which is often used for the treatment of migraine headaches. A combination of naproxen with sumatriptan (Treximet) is approved by the FDA for the treatment of acute migraine attacks. Naproxen alone, while not specifically approved for the treatment of migraines, is widely considered to be an effective drug. A review of several double-blind studies confirmed this observation. It has the advantage of having longer duration of effect when compared to ibuprofen or aspirin. Naproxen has been also studied and proven effective in a double-blind study for the prevention of migraine attacks.   In another double-blind study naproxen, 550 mg taken twice a day was also effective for the prevention of menstrual migraines. It also helped relieve premenstrual pain. Naproxen is rarely used for the long-term prevention of migraines because of the risk of stomach ulcers and stomach bleeding. NSAIDs carry a warning about the potential negative effects on the heart, but it should be of no concern to most migraine sufferers who tend to be young women with no risk factors for heart problems and who take naproxen only intermittently. There is a myth that NSAIDs (and triptans) can cause rebound or medication overuse headaches (MOH). There is no scientific proof that this happens and in fact, when someone suffers from MOH due to caffeine-containing drugs (Excedrin, Fioricet) or opiates, naproxen is often prescribed to help withdrawal headaches. --- ### Migraine comorbidities - Published: 2020-01-05 - Modified: 2020-01-06 - URL: https://www.nyheadache.com/blog/migraine-comorbidities/ - Categories: Migraine, Science of Migraine 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... --- ### 100 Migraine Drugs, A to Z: mirtazapine - Published: 2019-12-30 - Modified: 2019-12-30 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-mirtazapine/ - Categories: Migraine, Uncategorized Mirtazapine (Remeron) is a tetracyclic antidepressant similar to tricyclic antidepressants and like tricyclics may have pain-relieving properties. The three and four cycles refer to the chemical formulas of these drugs, which contain 3 or 4 rings. Mirtazapine tends to have fewer side effects than the tricyclic antidepressants, but its analgesic properties are much less proven than those of tricyclics. Only anecdotal reports suggest that it is effective in the preventive treatment of migraine headaches. In a small but well-conducted double-blind trial it was shown to provide good relief of tension-type headaches and a single case report described a patient whose cluster headaches consistently responded to mirtazapine. Although it does have fewer side effects than tricyclics such as amitriptyline (Elavil) or nortriptyline (Pamelor), it still can cause somnolence and that is why it is taken at night. In patients with insomnia this can be a beneficial side effect. Similarly, it can also cause dizziness, weight gain, constipation, and dry mouth. Mirtazapine has a narrower dose range (15 to 45 mg a day), which often means that it can be effective for depression as well pain. Tricyclics, on the other hand, often help pain at doses that are insufficient for the relief of depression. The average dose of amitriptyline and nortriptyline for the prevention of migraines and for the treatment of pain is between 25 and 75 mg, while for depression the dose goes up to 150 mg. One exception in the family of tricyclics is protriptyline (Vivactil), which is dosed at... --- ### Ubrogepant (Ubrelvy), a new type of drug to treat acute migraines is approved by the FDA - Published: 2019-12-23 - Modified: 2019-12-23 - URL: https://www.nyheadache.com/blog/ubrogepant-ubrelvy-a-new-type-of-drug-to-treat-acute-migraines-is-approved-by-the-fda/ - Categories: Headache medications, Migraine Ubrogepant (Ubrelvy) is the first oral anti-CGRP drug to be approved by the FDA for the acute treatment of migraine attacks. It was developed by Allergan, manufacturer of Botox, the safest and arguably the most effective preventive treatment for chronic migraines. Allergan took a risk and bought this drug from Merck after Merck ran into problems developing a similar drug, telcagepant. Fortunately, ubrogepant had none of telcagepant's problems and it was shown to be safe and effective in two large double-blind placebo-controlled trials. The FDA-approved package insert says that, UBRELVY is a calcitonin gene-related peptide receptor antagonist indicated for the acute treatment of migraine with or without aura in adults. The recommended dose is 50 mg or 100 mg taken as needed. If needed, a second dose may be administered at least 2 hours after the initial dose. The maximum dose in a 24-hour period is 200 mg. It can be taken with or without food. The most common side effects were nausea, seen in 2% of those receiving placebo, 2% of those on 50 mg of ubrogepant and 3% of patients taking 100 mg. The second most common side effect was somnolence, present in 1% of patients taking placebo, 2% of those taking 50 mg and 3% taking 100 mg. Such a low incidence of side effects is extremely rare with oral drugs, but we also see this with injectable anti-CGRP drugs that are used for the prevention of migraines. The second oral anti-CGRP drug, rimegepant which is awaiting... --- ### 100 Migraine Drugs, A to Z: milnacipran - Published: 2019-12-21 - Modified: 2019-12-21 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-milnacipran/ - Categories: Chronic migraine, Headache medications, Migraine Milnacipran (Savella) is a drug that is approved by the FDA for the treatment of fibromyalgia. Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. Milnacipran belongs to the category of selective serotonin and norepinephrine reuptake inhibitors (SNRIs), which are used to treat anxiety, depression, and pain. There are four other SNRIs that are approved for the treatment of anxiety and depression, and in case of duloxetine (Cymbalta) also for fibromyalgia, peripheral nerve damage due to diabetes and musculoskeletal pain. The manufacturer of milnacipran decided not to seek approval for the treatment of depression to avoid the stigma of being an antidepressant drug. Many patients feel that if they are prescribed an antidepressant, their pain is not perceived as real physical pain, but rather purely psychological. Milnacipran was tested for the preventive treatment of migraines only in one unblinded observational study. Not surprisingly, it was effective. We often use duloxetine and venlafaxine (Effexor) for the treatment of migraines. Fibromyalgia, back pain, and other pains are comorbid with migraines, meaning that if you have one condition, you are more likely to have the other as well. Such patients are ideal candidates for SNRIs, although tricyclic antidepressants such as amitriptyline also work well for any pain and migraines. Just like with other SNRIs, the most common side effects include nausea, headache, constipation, dizziness, insomnia, hot flushes, hyperhidrosis (excessive sweating), vomiting, palpitations, increased heart rate, dry mouth, and hypertension. Another common problem with these drugs is... --- ### 100 Migraine Drugs, A to Z: metoprolol - Published: 2019-12-15 - Modified: 2019-12-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metoprolol/ - Categories: Headache medications, Migraine Metoprolol (Toprol) is one of the beta-blockers, drugs used for the treatment of hypertension and other heart conditions. It is one of the three beta-blockers (the other two are propranolol and timolol) that are included in the American Academy of Neurology guidelines for the preventive treatment of migraines. A large double-blind study showed that metoprolol (200 mg/day) was more effective than aspirin (300 mg/day) in achieving 50% migraine frequency reduction (45% vs 30%). No significant side effects were reported in either group. A small study reported that metoprolol (50–150 mg/day) had similar efficacy to nebivolol (another beta-blocker), 5 mg/day in reducing migraine attacks. Metoprolol, unlike propranolol and timolol, is a selective beta-blocker, which means that it has a much lower chance of triggering an asthma attack in those who suffer from asthma or prone to occasional asthma attacks. Some of the side effects that can occur with all beta blockers, including metoprolol, are tiredness. , dizziness, constipation, blurred vision, chest pain, slowing of the heart rate, which can interfere with aerobic exercise, and other. Migraines are most common in young women many of whom have low blood pressure, which makes them more likely to develop dizziness and tiredness. It can also interfere with the best preventive treatment of migraines - regular exercise. I reserve beta-blockers for those with normal or high blood pressure, those with rapid heart beat, and anxiety. It helps physical but not mental manifestations of anxiety - sweating, shaky voice, and fast heart rate. Beta-blockers are proven... --- ### Triptans are woefully underutilized - Published: 2019-12-08 - Modified: 2019-12-08 - URL: https://www.nyheadache.com/blog/triptans-are-woefully-underutilized/ - Categories: Chronic migraine, Headache medications, Migraine When sumatriptan (Imitrex) was introduced in 1992 it was truly a breakthrough drug - the first drug specifically developed for the acute treatment of migraines. Sumatriptan and six other triptans have alleviated suffering of millions of people. Sumatriptan is considered to be the gold standard therapy for an acute migraine. Unfortunately, 27 years later many millions of migraine sufferers have not had a chance to try these drugs. A study by R. Lipton and his colleagues presented earlier this year surveyed 15,133 migraine sufferers. Only 37% had ever used a triptan and only 16% were using them at the time of the survey. Most patients used tablets, but 11% also tried either a nasal spray or an injection. Lack of efficacy (in 38%) and side effects (in 22%) were the most common reason for stopping the drug and the most common side effects were dizziness, nausea, and fatigue. My guess is that lack of efficacy is often due to the suboptimal dose of a triptan that is often prescribed. I see many patients who tell me that they've tried sumatriptan and it did not work, but many of them took 25 or 50 mg, while an effective dose for most patients is 100 mg. Most other triptans are also available in two different strengths and the lower, less effective dose is often prescribed. Another common problem is that patients who fail one triptan due to side effects or lack of efficacy are not prescribed a different triptan. Many of my... --- ### 100 Migraine Drugs, A to Z: methylergonovine - Published: 2019-11-29 - Modified: 2019-11-29 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-methylergonovine/ - Categories: Headache medications, Migraine Methylergonovine (Methergine) is used intravenously or in a tablet form after childbirth to help stop bleeding from the uterus. Methylergonovine belongs to the class of drugs known as ergot alkaloids. A drug in this class that is in wide use for the treatment of migraines is dihydroergotamine (DHE). DHE is one of the most effective drugs for the treatment of an acute migraine when given by injection. Methysergide (Sansert) was another drug in this class and in a tablet form was used for the prevention of migraine and cluster headaches. It was very effective, but because of a very rare but serious side effect was withdrawn from the market. This was unfortunate because a small group of patients for whom other drugs were ineffective were glad to take that risk in exchange for significantly improved quality of life. After the withdrawal of methysergide, the only oral ergot drug left on the market was methylergonovine and headache specialists continue to use it for their difficult to treat migraine and cluster patients. Methylergonovine was first reported to be effective for the treatment of migraines with medication overuse in an open-label trial of 60 patients in 1993. Of these 60 patients, 44 or 73% improved. Another uncontrolled trial of methylergonovine in 20 cluster headache patients also showed it to be very effective. Intravenous infusion of this drug given to 125 migraine patients presenting to the emergency room provided pain freedom after one hour in 74%. This was also an uncontrolled, open-label study, which... --- ### Vitamin B12 and migraines - Published: 2019-11-24 - Modified: 2019-11-24 - URL: https://www.nyheadache.com/blog/vitamin-b12-and-migraines/ - Categories: Alternative Therapies, Migraine Vitamin B12 (cyanocobalamin) deficiency has been long suspected to play a role in the development of migraines, but so far it has not been directly linked to migraines. A new study published in the latest issue of Headache compared vitamin B12 status in 70 migraine sufferers with 70 healthy people with similar demographics. Serum levels of vitamin B12 were found to be significantly lower in migraine patients than in healthy subjects. Vitamin B12 levels are notoriously inaccurate, so the authors confirmed this finding by testing for a more sensitive indicator of deficiency, methylmalonic acid (MMA), which goes up as the vitamin B12 levels go down. Patients with the B12 levels in the highest quartile had 80% lower chance of having migraines compared to those with levels in the bottom quartile. Patients in the highest quartile of MMA had more than 5 times increased risk of having migraines. In a study migraine sufferers with elevated homocysteine levels, which is another indicator of deficiency of vitamin B12 and other B vitamins, were given vitamins B12, folic acid and vitamin B6. Their homocysteine levels dropped and migraine-related disability improved. Elevated homocysteine level is suspected to be responsible for the increased risk of strokes in patients with migraines with aura, although that is still unproven. This latest study only shows correlation, but it does not prove that taking vitamin B12 and increasing your serum level will relieve migraines. Nevertheless, it makes sense to have your level at least in the middle of normal range... --- ### 100 MIgraine Drugs, A to Z: metformin - Published: 2019-11-16 - Modified: 2019-11-16 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-metformin/ - Categories: Headache medications, Migraine Metformin (Glucophage, Glumetza) is a drug for the treatment of diabetes and you will not find any scientific articles if you google "metformin and migraine". However, I've been prescribing metformin to some of my migraine patients with some success. In the absence of controlled trials to prove its efficacy, one can argue that those patients who improved are experiencing the placebo effect. However, there are two possible ways by which metformin can help prevent migraines. Obesity does not predispose one to migraines, but in those who do suffer from migraines increased weight is associated with an increased frequency and severity of migraine attacks. Since metformin is proven to help reduce weight, this could be one of the mechanisms by which it improves migraines. Weight loss due to metformin has been shown to be sustainable for up to 10 years. The second possible mechanism is metformin's direct effect on inflammation, which is one of the major mechanisms involved in migraines. I usually prescribe metformin to patients who are overweight and I prefer metformin to the most popular migraine preventive drug, topiramate (Topamax). Topiramate can cause difficulty with memory, kidney stones, osteoporosis, acute glaucoma and other serious side effects, while metformin only occasionally causes nausea. If nausea does occur, changing to a slow release form of metformin (metformin ER) usually helps. Metformin can also cause a drop in vitamin B12 level, so it is worth prescribing a vitamin B12 supplement along with metformin. Metformin should not be prescribed to patients with impaired... --- ### 100 Migraine Drugs, A to Z: clopidogrel - Published: 2019-11-10 - Modified: 2019-11-10 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clopidogrel/ - Categories: Headache medications, Headaches, Migraine Clopidogrel (Plavix) was not on my original list of 100 migraine drugs, but I decided to add it after another mention of this drug at the last congress of the International Headache Society in Dublin (since I keep adding drugs and new ones are being released, the list will exceed 100). Patients who suffer from migraines, especially those who have auras, have a higher incidence of a persistent opening between the left and the right side of their heart, called patent foramen ovale or PFO. PFO is found in 25% of the general population, is usually small and causes no symptoms. When it is large, it needs to be closed, which can be done through a vein in the groin. Unfortunately, studies that aimed to relieve migraines by closing the PFO did not show much benefit. However, blood thinners used after the procedure may have helped some patients. I first mentioned clopidogrel in a blog post from 2007 when describing a British doctor's experience with a few of his patients. In another blog post from 2015 I mentioned a study that showed that clopidogrel with aspirin was more effective in improving migraines than aspirin alone. A study comparing aspirin and clopidogrel showed them to be equally effective in improving migraines in patients with a PFO. In the study presented in Dublin by two Chinese doctors PFO was found in 151 out of 266 (57%) of all migraine patients, of whom 65 the opening was large. PFO was found in 59... --- ### 100 Migraine Drugs, A to Z: memantine - Published: 2019-11-04 - Modified: 2019-11-05 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-memantine/ - Categories: Chronic migraine, Headache medications, Migraine Memantine (Namenda) is an Alzheimer's drug that has been used for the treatment of pain and migraine headaches. This drug blocks the NMDA receptor in the brain, which is involved in the processing of pain messages and in other neurological conditions such as epilepsy, stroke and traumatic brain injuries. NMDA receptor antagonist dizocilpine, or MK801 was a drug with a potential to treat all these conditions, but unfortunately it had serious side effects and after spending hundreds of millions of dollars, Merck stopped its development. It is possible that strong inhibition of the NMDA receptor will always lead to serious side effects. We do have several other milder NMDA inhibitors, besides memantine - dextromethorphan, which is used as a cough suppressant and ketamine. Memantine, 10 to 20 mg a day was studied in 28 patients with migraines that were not responding to at least two standard medications and was found to be effective. A double-blind, placebo-controlled trial of 10 mg of memantine in 52 patients was also positive. Another double-blind placebo-controlled trial of 60 patients also showed some benefit. A review of case reports and two controlled studies concluded that memantine, 10 to 20 mg a day may be an effective treatment for the prevention of migraines. A study of 40 mg of memantine for chronic tension-type headaches did not show any efficacy, although women seemed to benefit more than men. The only side effects of this relatively high dose (the Alzheimer's dose is 20 mg) were nausea and dizziness.... --- ### Cove, a telemedicine startup for migraine sufferers - Published: 2019-10-30 - Modified: 2019-10-30 - URL: https://www.nyheadache.com/blog/cove-a-telemedicine-startup-for-migraine-sufferers/ - Categories: Alternative Therapies, Headache medications, Headaches, Migraine, New treatments Cove, a telemedicine startup provides medical care to people suffering from migraines. There are 40 million migraine sufferers in the US, only half of whom seek medical care. The other half may have mild migraines, not have access to medical care, or are under the impression that nothing can be done about their headaches. Only half of the half that go to a doctor receive a correct diagnosis of migraine. The other half, or about 10 million, are misdiagnosed as sinus, tension, or stress headaches and never receive effective treatment. Withcove. com is website where migraine sufferers can have a neurologist evaluate their symptoms and provide an accurate diagnosis and prescribe individualized treatment. It may seem that not seeing a doctor in person would be a major obstacle, but it is not. The patient completes a questionnaire and video is used for neurological examination. The doctor evaluates the information and prescribes migraine drugs, both for the acute treatment of an attack, as well for prevention. You don't even need to go to a pharmacy - the medicine is shipped to you. Cove also offers a variety of supplements, such as magnesium and CoQ10, which can be more effective and safer for the prevention of migraines than drugs. My colleague at the NY Headache Center, Dr. Sara Crystal and I are helping Cove with the design of proper evaluation tools, treatment algorithms, and other aspects of care. In addition to providing direct care, Cove is conducting some research as well. In... --- ### 100 Migraine Drugs, A to Z: meloxicam - Published: 2019-10-28 - Modified: 2019-10-28 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-meloxicam/ - Categories: Headache medications, Migraine Meloxicam (Mobic) is a non-steroidal anti-inflammatory drug (NSAID) which is approved for the treatment of rheumatoid arthritis and osteoarthritis in adults and juvenile rheumatoid arthritis in children older than 2 years. Meloxicam tends to be better tolerated than some other NSAIDs. The main side effects of NSAIDs are heartburn (reflux), stomach pain, and peptic ulcers. Although there have been no trials of meloxicam for the acute or prophylactic treatment of migraine headaches, it is probably as effective as other NSAID that have been tested for migraines. One advantage of meloxicam is that the effect of a single dose lasts all day. This makes it particularly suitable for the prevention of migraine attacks. It is also available in a liquid form, which can work faster than a solid tablet and speed of onset can be important when using it for acute therapy since faster acting drugs tend to be more effective. Meloxicam tablets are available in 7. 5 and 15 mg strength. An abstract presented at the recent meeting of the International Headache Society describes a new combination product in development for the acute treatment of migraines, which includes meloxicam, 20 mg with rizatriptan (Maxalt), 10 mg. This is a product similar to the combination of naproxen with sumatriptan (Treximet) and just like Treximet is likely to be more effective than either drug alone. However, being a branded drug it is likely to be much more expensive than generic drugs and not likely to be covered by most insurance plans. The... --- ### Thinking fast and slow when prescribing opioids - Published: 2019-10-20 - Modified: 2019-10-20 - URL: https://www.nyheadache.com/blog/thinking-fast-and-slow-when-prescribing-opioids/ - Categories: Brain disorders, Headache medications, Pain, Pain Research It is not surprising that when a doctor is tired or hurried he or she is more likely to make a mistake. A new study published in JAMA Network Open provides some hard data on doctor performance as it relates to the prescribing of opioid (narcotic) analgesics. Opioids are still overprescribed, especially for migraine headache patients. The researchers at the University of Minnesota discovered that doctors were 33% more likely to prescribe an opioid pain medicine at the end of the workday than in the beginning. If the doctor was running an hour or more behind schedule her or she was 17% more likely to prescribe an opioid. Prescribing of nonsteroidal anti-inflammatory drugs and referral to physical therapy did not display similar patterns. This was a very large study which means that the results are likely to be reliable. The study looked at 5,603 primary care practitioners who were involved in 678,319 primary care encounters for a painful condition. Prescribing an opioid seems like a quick fix for a problem that saves doctors time, but usually is not be the best treatment for the patient. Nobel Prize winner Daniel Kahneman in his book, Thinking Fast and Slow suggests that there are additional and easily correctable factors that may be contributing to poor decision making. Here are some quotes from the book. "The most surprising discovery made by Baumeister’s group shows, as he puts it, that the idea of mental energy is more than a mere metaphor. The nervous system consumes... --- ### More evidence that Botox relieves not only migraines, but also depression - Published: 2019-10-14 - Modified: 2019-10-14 - URL: https://www.nyheadache.com/blog/more-evidence-that-botox-relieves-not-only-migraines-but-also-depression/ - Categories: Alternative Therapies, Botox, Brain disorders, Chronic migraine, Migraine A large study confirms previous reports of the beneficial effect of onabotulinumtoxinA (Botox) injections on depression as well as anxiety. In my two previous blog posts from 2011 and 2014 I mentioned reports of cosmetic Botox injections relieving depression but those involved a relatively small number of patients. A study published in the Journal of Neurology, Neurosurgery, & Psychiatry under the title Effects of onabotulinumtoxinA treatment for chronic migraine on common comorbidities including depression and anxiety ,described the COMPEL trial (Chronic Migraine OnabotulinumtoxinA Prolonged Efficacy Open-Label). It was a multicenter, open-label, prospective study assessing the long-term safety and efficacy of 155 units of onabotulinumtoxinA (Botox) over nine treatments (108 weeks) in adults with chronic migraines. OnabotulinumtoxinA treatment was associated with sustained reduction in headache days and depression and anxiety scores in the 715 patients over 108 weeks. The anxiety and depression scores were significantly reduced at all time points in patients with clinically significant symptoms of depression and/or anxiety at baseline. By week 108, 78% and 82% had clinically meaningful improvement in depression and anxiety symptoms, respectively. Sleep quality and symptoms of fatigue also improved. In an earlier poster presentation of this data at a scientific conference the authors reported that the improvement in anxiety and depression was seen even in patients whose migraines did not improve with Botox. Even if that were true, we need a separate large study of Botox for anxiety and depression. The one study that treated patients with major depression in a double-blind, placebo-controlled trial... --- ### 100 Migraine Drugs, A to Z: mefenamic acid - Published: 2019-10-06 - Modified: 2019-10-06 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-mefenamic-acid/ - Categories: Headache medications, Migraine Mefenamic acid (Ponstel) is one the nonsteroidal antiinflammatory drugs (NSAIDs) and like all other NSAIDs it is being used for the treatment of acute migraine attacks. Mefenamic acid is popular for the treatment of menstrual migraines, which probably stems from the fact that in addition to the treatment of mild or moderate pain, it is also approved for the treatment of dysmenorrhea, or pain of menstruation. In a small study mefenamic acid was found to be specifically effective for the treatment of menstrual migraines, which can be more severe and more difficult to treat than non-menstrual attacks. Mefenamic acid was found to be superior to acetaminophen (called paracetamol in Europe), which is no surprise since acetaminophen has little antiinflammatory action and therefore does not reduce inflammation that occurs during a migraine attack. Ergotamine was the mainstay of migraine treatment before the introduction of triptans in 1992. A study comparing ergotamine with mefenamic acid was found them to be equally effective, but ergotamine caused more side effects, especially nausea, which is a common side effect of ergot derivatives. A small trial suggests that it can be also used for the prevention of migraines and it is as effective as propranolol. For the treatment of pain and primary dysmenorrhea, the initial dose is 500 mg, followed by 250 mg every 6 hours, as needed. Just like other NSAIDs, it can cause heartburn, stomach upset, bleeding ulcers, and other side effects. --- ### Caffeine and migraine headaches - Published: 2019-10-01 - Modified: 2019-10-01 - URL: https://www.nyheadache.com/blog/caffeine-and-migraine-headaches/ - Categories: Alternative Therapies, Headaches, Migraine Medication overuse headache (MOH) is not proven to occur from the frequent intake of triptans (Imitrex, or sumatriptan and other) or NSAIDs (ibuprofen, naproxen, and other). However, there is good evidence that caffeine (and opioid analgesics) which can help relieve an occasional migraine, can definitely make them worse if taken frequently. Caffeine withdrawal is a proven trigger of headaches, including migraines. While we know that caffeine withdrawal causes headaches, a study just published by Harvard researchers in The American Journal of Medicine addressed an unexamined question - does drinking coffee directly triggers a migraine? This was a rigorous prospective study of 98 adults with episodic migraine who completed electronic diaries every morning and evening for a minimum of 6 weeks. 86 participants were women and 12 were men, with mean age of 35 and the average age of onset of headaches of 16. Every day, participants reported caffeinated beverage intake, other lifestyle factors, and the timing and characteristics of each migraine headache. The researchers compared incidence of migraines on days with caffeinated beverage intake to the incidence of migraines by the same individual on days with no intake. In total, the participants reported 825 migraines during 4467 days of observation. There was a significant association between the number of caffeinated beverages and the odds of migraine headache occurrence on that day. This association was stronger in those who normally drank 1-2 cups of coffee daily - they were more likely to get a migraine on days when they drank 3... --- ### 100 Migraine Drugs, A to Z: lidocaine - Published: 2019-09-23 - Modified: 2019-09-23 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-lidocaine/ - Categories: Headache medications, Migraine Lidocaine (Xylocaine) is an old local anesthetic used by surgeons, dentists, and other doctors to numb parts of the body. Lidocaine drops given into the nostrils were compared to saline drops for the acute treatment of migraine attacks in a double-blind placebo-controlled 113-patient trial by Dr. Morris Meizels and his colleagues. This study showed that lidocaine nose drops were much more effective than saline drops, but relieved migraines in only about one third of patients. Another, but smaller (49 patients) study did not find a difference between lidocaine and saline. I've had a handful of patients with difficult to control migraines respond to an intravenous infusion of lidocaine and one of these patients continues to do well with a monthly infusion of lidocaine. There have been no double-blind studies of intravenous lidocaine for migraines, but an observational study of 68 hospitalized patients who failed to respond to other treatments, suggests that this treatment can be effective for some patients. Intravenous administration of lidocaine is usually done in a hospital or an outpatient facility that has cardiac monitoring because lidocaine can cause arrhythmias (irregular heart beat). Otherwise, lidocaine is safe and well tolerated. The widest use of lidocaine in migraine is for nerve blocks. An occipital nerve block has been scientifically proven to relieve an acute migraine attack. Combining blocks of occipital nerves (in the back of the head) with a block of supraorbital nerves (in the forehead) has been also shown to be more effective than injections of saline. We... --- ### - Published: 2019-09-15 - Modified: 2019-09-18 - URL: https://www.nyheadache.com/blog/3362-2/ - Categories: Migraine On September 12, 2019, Dr. Mauskop spoke on Advances and Controversies in Migraine at Charité – Universitätsmedizin Berlin, Europe’s largest university hospital. In the top photo Dr. Mauskop with Professor Uwe Reuter of Charité and Dr. Zoltan Medgyessy of Detmold Medicum. The middle photo shows the entrance to the renown Psychiatric and Neurologic Clinic at Charité. Bottom photo is of Dr. Mauskop in the lecture hall, where at the top you can see six portraits of physicians, who after 1933 were dismissed and persecuted for political or racial reasons. --- ### Vitamin D and migraine - Published: 2019-09-11 - Modified: 2019-09-11 - URL: https://www.nyheadache.com/blog/vitamin-d-and-migraine/ - Categories: Alternative Therapies, Migraine, Science of Migraine 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. --- ### 100 Migraine Drugs, A to Z: levetiracetam - Published: 2019-09-03 - Modified: 2019-09-07 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-levetiracetam/ - Categories: Headache medications, Migraine Levetiracetam (Keppra) is an epilepsy drug that has been reported to help some patients with migraines. However, unlike divalproex sodium (Depakote) and topiramate (Topamax, Trokendi, Qudexy), the evidence for its efficacy in migraines is weak. This evidence consists mostly of uncontrolled observational studies without a comparison to placebo. One small double-blind placebo-controlled study compared 500 mg of levetiracetam (27 patients) to 500 mg of divalproex sodium (32 patients) and to placebo (26 patients). Both epilepsy drugs were superior to placebo. In one of the reports the mean dose of levetiracetam was 1,125 (and up to 2,000), while the maximum dose for epilepsy is 3,000). It is possible that the drug may work better at a higher dose. However, with an increase in the dose there is an increase in side effects. These include weakness, drowsiness, dizziness, anxiety, depression, irritability and aggressive behavior, and other. Since this drug is not proven to be effective and can have serious side effects, I never prescribe this drug. --- ### Migraine Associated With Dementia, Alzheimer’s in Women - Published: 2019-08-26 - Modified: 2019-08-26 - URL: https://www.nyheadache.com/blog/migraine-associated-with-dementia-alzheimers-in-women/ - Categories: Alternative Therapies, Brain disorders, Migraine An alarming study entitled Association Between Migraine Headaches and Dementia in More than 7,400 Patients Followed in General Practices in the United Kingdom was just published in the Journal of Alzheimer's Disease. The researchers found that the risk for ALzheimer's and other dementias is increased only in women with migraines and not in men. The first large study to discover an association between migraines and dementia was done in Taiwan. Interestingly, a follow-up study in Taiwan discovered that people who used traditional Chinese medicine (mostly herbal products Jia-Wei-Xiao-Yao-San and Yan-Hu-Suo) had lower risk of dementia than those who did not. There is no need to panic since other studies have found no such association and there is a wide range of preventive measures that are proven effective. Controlling ones blood pressure, blood glucose, cholesterol level, and avoiding smoking are extremely important in lowering the risk of Alzheimer's. The single most effective preventive measure is regular physical exercise, which is more effective than mental exercise. Engaging in mental activities, such as learning languages, solving crossword puzzles, and playing bridge (which adds the benefit of social contacts) can also help. Dancing and tai chi combine physical and social benefits. Meditation appears to be effective in preventing shrinkage of the brain, which used to be thought a normal part of aging. This was confirmed in more than one study. In addition to Chinese herbal products mentioned above, there are several other supplements that are also less proven but are safe and may help... --- ### 100 Migraine Drugs, A to Z: ketorolac - Published: 2019-08-19 - Modified: 2019-08-19 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketorolac/ - Categories: Headache medications, Migraine Ketorolac (Toradol) is one of many nonsteroidal anti-inflammatory (NSAID) pain medications used to treat migraine headaches. In a tablet form it is no more effective than ibuprofen, naproxen or any other NSAID, but has more side effects and its use is limited to 5 days. On the other hand, ketorolac in an injection is a unique and very useful drug. It provides pain relief comparable to that of opioid (narcotic) drugs without the side effects or addiction potential of those drugs. Intravenous ketorolac has been proven to be an effective drug for the treatment of severe migraine attacks. A study done by Dr. B. Friedman and his colleagues at the emergency department of the Montefiore Medical Center in the Bronx compared intravenous infusion of 30 mg of ketorolac with an infusion of 10 mg of metoclopramide (Reglan) and 1,000 mg of valproate (Depacon). There were over 100 patients in each group, making this a highly reliable study. Ketorolac and metoclopramide were more effective than valproate, but metoclopramide caused severe restlessness in 6 (6%) of patients. This is a well known side effect of metoclopramide and a similar drug, prochlorperazine (Compazine). This side effect is extremely unpleasant, but can be relieved by diphenhydramine (Benadryl). Intramuscular injection of 60 mg of ketorolac was compared to intravenous infusion of 25 mg of chlorpromazine (Thorazine) and they were found to be equally effective. Just like prochlorperazine, chlorpromazine carries a risk of restlessness, as well as involuntary movements and sedation. These two drugs belong to... --- ### tDCS, which we are testing for migraines, may relieve depression - Published: 2019-08-12 - Modified: 2019-08-12 - URL: https://www.nyheadache.com/blog/tdcs-which-we-are-testing-for-migraines-may-relieve-depression/ - Categories: Alternative Therapies, Chronic migraine, Migraine Transcranial direct current stimulation (tDCS) has been definitively shown to alter brain connectivity and function. We are still enrolling patients in our double-blind study of tDCS for the prevention of migraines, so please contact us if you are interested. A group of Iranian researchers used tDCS to treat "treatment-resistant major depression". The results of this double-blind randomized sham-controlled trial were published in Clinical EEG and Neuroscience. Patients with less than 50% decrease in the intensity of depression after 8 weeks of treatment with selective serotonin reuptake inhibitors (drugs like Prozac or fluoxetine, Lexapro or escitalopram, and other) were included in the trial. 16 women and 14 men were randomly allocated to an active group, which received 2-mA stimulation for 20 minutes per session, or the sham group. The Hamilton Depression Rating Scale was used to measure the severity of depression. There were statistically significant differences in the mean Hamilton scores in favor of the active treatment compared to the sham group. The difference in improvement persisted for a month after the treatment ended. The authors' conclusion that "tDCS is an efficient therapy for patients with resistant major depression, and the benefits would remain at least for 1 month" may be premature because of the small sample size. However, other studies have also indicated that tDCS may be effective in depression. Considering its low cost and very high safety, tDCS may be worth trying in patients with depression. The same may apply to patients with migraines since several small studies have... --- ### Migraine does not increase the risk of strokes in postmenopausal women - Published: 2019-08-10 - Modified: 2019-08-10 - URL: https://www.nyheadache.com/blog/migraine-does-not-increase-the-risk-of-strokes-in-postmenopausal-women/ - Categories: Brain disorders, Migraine Migraine with and without aura carries an increased risk of strokes and heart attacks, according to several large studies. Most migraine sufferers are young women and until now there have been no studies looking at postmenopausal women. At the last annual scientific meeting of the American Headache Society, Dr. Pavlovic and her colleagues at the Albert Einstein College of Medicine in the Bronx presented data of their study of over 70,000 postmenopausal women who were followed annually for 22 years. Ten percent of them had a history of migraines (compared to 18% seen in surveys of all women). Surprisingly, those with a history of migraine did not have a higher risk for strokes or heart attacks. This somewhat contradicts another study mentioned on this blog last year. Doctors in South Carolina established that people with migraine with aura who were 60 or older, were more likely to have atrial fibrillation (a type of arrhythmia, or irregular heart beat), a condition that increases the risk of strokes. Despite some inconsistencies in various studies, the practical implications are that those with migraines (and those without) should try to control modifiable risk factors. These include smoking, high blood pressure, diabetes, high cholesterol. If atrial fibrillation is present, a blood thinner is usually indicated as it may prevent strokes. Control of modifiable risk factors includes not only medications, but also regular exercise, healthy diet, stress management, and good sleep habits. --- ### Probiotics for migraine - Published: 2019-08-03 - Modified: 2019-08-03 - URL: https://www.nyheadache.com/blog/probiotics-for-migraine/ - Categories: Alternative Therapies, Chronic migraine, Migraine Many migraine sufferers have gastro-intestinal problems, such as irritable bowel syndrome, constipation, sensitivity to gluten, dairy, and other types of foods. Nausea and vomiting and gastric stasis are common symptoms of migraine. All this indicates a close relationship between the gut and migraines. Considering that we contain more bacterial cells than our own (you may want to read a fascinating book by Ed Yong, I Contain Multitudes: The Microbes Within Us and a Grander View of Life), it is not surprising that certain types of bacteria may help prevent migraines. Bio-Kult is a probiotic that contains 14 different strains of bacteria. It was tested for the prevention of migraine headaches in a double-blind placebo-controlled trial. I mentioned the preliminary results of this study presented in 2017 at the International Headache Congress, but the final results were only recently published in Cephalalgia. The researchers enrolled 100 patients and placed 50 of them into the placebo group and 50 into the probiotic group. 43 patients on the active therapy and 36 on placebo completed the trial. Patients with both chronic and episodic migraines (15 or more headache days a month makes it chronic) were included. After 2 month of treatment, the mean frequency of migraine attacks and their severity were significantly reduced in the probiotic group compared to the placebo group. There was also a significant reduction of the number of abortive migraine medications taken by those in the probiotic group. This was a small study with a high dropout rate, which... --- ### 100 Migraine Drugs, A to Z: ketoprofen - Published: 2019-07-28 - Modified: 2019-07-28 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketoprofen/ - Categories: Headache medications, Migraine Ketoprofen (Orudis, the branded version, is no longer available) is a prescription nonsteroidal antiinflammatory drug (NSAID) without any outstanding features. Just like all other NSAIDs, it is effective for the acute treatment of migraine headaches. A double-blind placebo-controlled randomized trial compared ketoprofen, 75 mg, 150 mg and 2. 5 mg of zolmitriptan (Zomig). All three active therapies were equally effective in relieving migraines and were much more effective than placebo. This does not mean that ketoprofen and zolmitriptan are equally effective in any particular migraine sufferer because some people will respond better to an NSAID and other to a triptan. Also, the usual dose of zolmitriptan is 5 mg, so it is possible that even on average, a 5 mg dose might be superior to ketoprofen. We often combine a triptan with an NSAID such as ibuprofen (Advil) or naproxen (Aleve, Naprosyn) and ketoprofen can also be combined with a triptan. Another double-blind study compared 100 mg ketoprofen suppository (a compounding pharmacy can prepare such a suppository) with 2 mg ergotamine suppository and ketoprofen was found to be superior to ergotamine. Since the introduction of triptans ergotamine has not been widely used because it causes more side effects, particularly nausea. Just like with other NSAIDs, the most common side effects are gastrointestinal - heartburn, stomach pain, bleeding ulcers, etc. NSAIDs can also cause tinnitus (ringing in the ears), rashes, and with long-term use, kidney and heart problems. --- ### Another promising acute therapy for migraines - Published: 2019-07-24 - Modified: 2019-07-24 - URL: https://www.nyheadache.com/blog/another-promising-acute-therapy-for-migraines/ - Categories: Headache medications, Migraine, New treatments Dihydroergotamine (DHE-45) is a very old migraine drug in the family of ergot alkaloids. It is one of the most effective migraine drugs when it is given intravenously and it is often used when patients are admitted to the hospital for migraines that do not respond to other therapies. Dihydroergotamine (DHE) is also available as a nasal spray (Migranal), but it works well only in a limited number of patients and is very expensive. This poor consistency of effect is partly due to the amount of liquid that needs to be sprayed for one dose, most of which is either swallowed or leaks out. A form of DHE to be inhaled into the lungs had been in development for many years, but is not likely to become available due to manufacturing difficulties. A promising new way to deliver DHE as a nasal powder is being developed by Satsuma Pharmaceuticals. The company presented their preliminary data at the recently concluded scientific meeting of the American Headache Society in Philadelphia. Their study showed that powdered form of DHE delivered into the nose gets into the blood faster and better than the existing nasal liquid form, although not as well as when it is given as an intramuscular injection. The device to administer DHE is small and easy to use, unlike another device that is also being developed for intranasal delivery of DHE powder. The company is initiating a large clinical trial, which will hopefully lead to the approval of their product. --- ### Erenumab for trigeminal neuralgia and other news from the American Headache Society meeting - Published: 2019-07-18 - Modified: 2019-07-19 - URL: https://www.nyheadache.com/blog/erenumab-for-trigeminal-neuralgia-and-other-news-from-the-american-headache-society-meeting/ - Categories: Chronic migraine, New treatments, Trigeminal and other neuralgias The annual scientific meeting was held last weekend in Philadelphia. The largest number of presentations was about the CGRP drugs, both monoclonal antibodies (mAbs) for the prevention and soon to be approved oral medications for the abortive treatment of migraine attacks. In addition to the three currently available mAbs, erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality), which are self-injected subcutaneously every month (Ajovy can be given every 3 months), a fourth intravenous mAb, eptinezumab, which is given every 3 month, is likely to come out early next year. Two oral CGRP drugs that are in development are taken as needed for an individual attack of migraine. These drugs are rimegepant and ubrogepant and they are expected to be approved by the FDA in about 6 months. One interesting presentation by N. George and Z. Ahmed from the Cleveland Clinic and other Cleveland hospitals described 8 patients with trigeminal neuralgia (TN) who also suffered from migraines and were given injections of erenumab (Aimovig). Six out of 8 reported good relief of their neuralgia along with migraines. It is possible that the neuralgia pain was part of their migraine, but it may still be worth trying erenumab in patients with TN who do not respond to standard therapies or Botox. --- ### 100 Migraine Drugs, A to Z: ketamine - Published: 2019-07-04 - Modified: 2019-07-05 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ketamine/ - Categories: Headache medications, Migraine, New treatments Ketamine (Ketalar) was officially approved for human use by Food and Drug Administration (FDA) in 1970 and, because of its wide margin of safety, was even administered as a field anaesthetic to soldiers during the Vietnam war. Concerns over the psychedelic effects of ketamine and the arrival of new intravenous hypnotics such as propofol led to a marked decrease in the use of ketamine for anesthesia, but in the recent years its use has been increasing. Its unique properties have led many researchers to do clinical trials for the treatment of pain and depression. Intranasal ketamine was just approved by the FDA for treatment-resistant depression. True efficacy of ketamine for the treatment of pain and migraine headaches is less clear. There have been no double-blind studies of ketamine for the treatment of migraine headaches. A major obstacle to doing such studies is that it is very difficult to blind patients to the effect of ketamine. We do have anecdotal evidence, that is a description of series of patients who were given intravenous ketamine. A report entitled, Ketamine Infusions for Treatment Refractory Headache describes 77 chronic migraine patients who "failed aggressive outpatient and inpatient treatments". These patients were hospitalized and were receiving ketamine infusions for an average of 5 days. Over 70% of these patients improved, although only 27% had sustained improvement. In a report published in The Journal of Headache and Pain authors describe 6 patients admitted to the hospital whose refractory migraines improved with intravenous ketamine, albeit the improvement... --- ### 100 Migraine Drugs, A to Z: indomethacin - Published: 2019-06-17 - Modified: 2019-06-17 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-indomethacin/ - Categories: Headache medications, Migraine Indomethacin (Indocin) is one of the strongest non-steroidal anti-inflammatory drugs (NSAIDs), but unfortunately it is rarely used for the treatment of migraines. It has a higher chance of causing gastro-intestinal (GI) side effects than other NSAIDs, but some patients tolerate it very well, especially if it is used sporadically. The drug can be compounded into a rectal suppository, which reduces (but does not eliminate) GI side effects and provides faster onset of effect than an oral capsule. Even if nausea is not obviously present, migraine is often accompanied by gastric stasis, which means that absorption of oral drugs is slowed down. This is why pharmaceutical companies often try to formulate migraine drugs into nasal sprays, injections, patches and inhalers. Rectal route also bypasses the stomach, but suppositories are less popular in the US than they are in Europe. The dose of oral indomethacin is 25, 50 or 75 mg taken up to three times a day, while suppositories usually contain 50 mg. Indomethacin has some unique properties that differentiate it from other NSAIDs and it is often the only NSAID that is highly effective for episodic and chronic paroxysmal hemicrania and hemicrania continua, rare conditions that are often mistaken for migraines. They are even described as indomethacin-sensitive headaches because no other drug provides such dramatic relief. Paroxysmal hemicrania also resembles cluster headache in that it is always one-sided and is often accompanied by nasal congestion and tearing on the side of the headache. Unlike cluster headaches, which last 30 minutes... --- ### 100 Migraine Drugs, A to Z: ibuprofen - Published: 2019-06-12 - Modified: 2019-06-12 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-ibuprofen/ - Categories: Headache medications Ibuprofen (Advil, Motrin, Nuprin, Nurofen, etc) is a very effective migraine drug. Of course, patients with severe migraines tell me that for them taking ibuprofen is like eating candy, but even those patients can get better relief if they add ibuprofen (or naproxen) to a triptan such as sumatriptan (Imitrex). Over-the-counter ibuprofen (Advil Migraine, Motrin Migraine) is officially approved by the FDA for the treatment of migraines, which means that it has been studied in large placebo-controlled trials to prove that it is safe and effective. Ibuprofen was shown to be more effective than acetaminophen in children. The adult dose is 400 mg, while in children it is 10 mg per kilogram of weight. Liquified form of ibuprofen (Advil Liquigels, Advil Migraine)) and liquid ibuprofen for children tend to work faster than a solid tablet. Frequent intake of ibuprofen (and other NSAIDs and triptans) is thought to lead to medication overuse headache (MOH), but if this does occur, it is rare and the entire concept of MOH remains controversial. Only caffeine and opioid (narcotic) pain killers have been proven to worsen headaches if taken often. It is not to say that frequent or daily intake of ibuprofen is the best way to manage frequent migraines. Many preventive therapies such as Botox, magnesium, propranolol, and other may be more effective and safer. Frequent use of ibuprofen can cause kidney problems and stomach ulcers, which can bleed and even be fatal. --- ### First drug approved for the prevention of cluster headaches - Published: 2019-06-05 - Modified: 2019-06-05 - URL: https://www.nyheadache.com/blog/first-drug-approved-for-the-prevention-of-cluster-headaches/ - Categories: Cluster headaches, Headache medications, New treatments Galcanezumab (Emgality) was just approved by the FDA for the prevention of episodic cluster headaches. Galcanezumab is one of the three new drugs recently approved for the prevention of migraines (the other two are erenumab, or Aimovig and fremanezumab, or Ajovy). These are monoclonal antibodies (mAbs) that block CGRP, a chemical released during attacks of migraine and cluster headaches. The manufacturer of fremanezumab also conducted trials for the prevention of cluster headaches, but could not prove that the drug was more effective than placebo. Galcanezumab was also tested for chronic cluster headaches and it did not seem to help. Only 10-15% of cluster headache sufferers have the chronic form. About 250,000 Americans suffer from cluster headaches. Compared to migraines, which affect over 35 million Americans, this is a rare disease. This makes it difficult to conduct clinical trials of new treatments. The only abortive drug approved for the treatment of an acute cluster attack is sumatriptan (Imitrex) injection. The dose of galcanezumab for the prevention of migraines is 240 mg injection at the start and then, 120 mg every month. The dose for cluster headaches is 300 mg. Of the 106 patients in the cluster headache study only 2 stopped the drug because of side effects. Just like in migraine trials, which involved thousand of patients, the only side effect which occur in more than 2% of patients was injection site reactions, but serious allergic reaction can also occur. Since erenumab was approved for migraines before the other two mAbs... --- ### A case against migraine headache diary - Published: 2019-06-02 - Modified: 2019-06-02 - URL: https://www.nyheadache.com/blog/a-case-against-migraine-headache-diary/ - Categories: Headaches, Migraine, Psychology of headaches Keeping a diary of symptoms has long been considered a part of a successful approach to managing migraine headaches. The diary can help identify potential migraine triggers and contributing factors and a description of specific symptoms can help tailor individual therapy. An article just published in Wired magazine Why tracking your symptoms can make you feel worse, challenges this assumption. In my early years of practicing headache medicine (yes, "headache medicine" is a formal subspecialty of neurology) I would urge my patients to keep a diary, but they would have all kinds of excuses why they did not. I even developed a phone app, which was easy to use and was loaded with features and educational materials. Everyone always has their phone nearby, so unlike with a paper diary, they would not forget it at home or need a pen, or have it eaten by their dog. Nothing doing. Maybe, one in 10 of my patients attempted to keep a diary. Then, since I also have migraines, I tried using the app and I also failed miserably. My excuses? Forgot, too busy, I know all about my migraines, so what's the point? The article in Wired quotes research that suggests that keeping a diary of symptoms can make you feel worse. This seems to be true across different conditions - insomnia, back pain, and also migraine. One possible explanation is that constantly paying attention to sensations in the body we can magnify them. These sensations may send an alarm to... --- ### 100 Migraine Drugs, A to Z: hydroxyzine - Published: 2019-05-27 - Modified: 2019-05-27 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-hydroxyzine/ - Categories: Headache medications, Migraine Hydroxyzine (Vistaril) is an underutilized old anti-histamine drug with some unique properties. Just like diphenhydramine (Benadryl) and other older anti-histamine drugs, hydroxyzine causes some sedation. However, it is the only anti-histamine that is officially approved for "anxiety and tension". It is also approved for itching due to allergic conditions. Off-label (i. e. without FDA-approval) it is used to treat motion sickness, nausea, vomiting, and dizziness. Hydroxyzine is often used as and adjuvant analgesic, that is as an add-on drug that makes pain medications work better. A study comparing injections of hydroxyzine, 50 mg with a pain medication nalbuphine 10 mg, with a combination of hydroxyzine and nalbuphine, and with placebo found no benefit from adding hydroxyzine when treating migraines. A study comparing an injection of hydroxyzine 50 mg plus meperidine (Demerol, a narcotic pain killer), 100 mg was similar to an injection of ketorolac (Toradol) 60 mg in its relief of an acute migraine. Nausea and drowsiness were similar in two groups. Another study compared hydroxyzine 75 mg intravenously plus meperidine 75 mg intramuscularly to DHE 1 mg IV plus metoclopramide (Reglan) 10 mg IV. Pain reduction was greater with DHE/metoclopramide. There have been no studies examining the efficacy of hydroxyzine alone, whether as an intravenous or intramuscular injection or as a tablet. It is likely that it will remain an adjuvant or add-on medication for the treatment of migraine headaches. I sometimes prescribe it to be taken daily to patients whose allergies worsen their migraine headaches or even when... --- ### Exercise speeds recovery from a concussion - Published: 2019-05-20 - Modified: 2019-05-20 - URL: https://www.nyheadache.com/blog/exercise-speeds-recovery-from-a-concussion/ - Categories: Brain disorders, Headaches, Migraine, post-traumatic headache Researchers at SUNY Buffalo and University of Manitoba studied the effect of exercise on recovery from a sports-related concussion in 103 adolescents. The results were published in JAMA Pediatrics. The participants were enrolled within 10 days of a concussion. Half of the kids were given a stretching program and the other half, aerobic exercise on a treadmill. The intensity of aerobic exercise was subthreshold, or just below the level where it caused any post-concussion symptoms and was determined individually for each participant. Both stretching and aerobic exercise were performed for 20 minutes every day for a month. Those who did aerobic exercise recovered in 13 days, while those who did stretching exercise, in 17 days. There were no complications in either group. This was the first randomized controlled trial of exercise, although prior observational studies also showed that early return to physical activity is beneficial for recovery from a concussion. Cognitive rest is also not necessary after a concussion, but the activities should be also subthreshold and not too strenuous, which can worsen symptoms and delay recovery. Other useful strategies include intravenous magnesium, cognitive-behavioral therapy, and Botox injections. --- ### All 3 NYHC docs are SuperDoctors! - Published: 2019-05-13 - Modified: 2019-05-13 - URL: https://www.nyheadache.com/blog/all-3-nyhc-docs-are-superdoctors/ - Categories: Uncategorized 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. --- ### 100 Migraine Drugs, A to Z: hydrocodone - Published: 2019-05-10 - Modified: 2019-05-10 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-hydrocodone/ - Categories: Headache medications, Migraine Hydrocodone (Vicodin, Lortab, Norco) is an opioid or narcotic pain killer, which should not have much of a role to play in the treatment of migraine headaches. Opioids are much less effective for the treatment of migraines than any other pain syndrome. They often make nausea worse, make patients sedated, and do not provide good pain relief. Unfortunately, according to a study published in Headache, half of the patients presenting to an emergency room with a migraine headache are prescribed an opioid drug such as hydrocodone. Patients with migraines who are given an opioid injection stay in an ER longer than if they don't get an opioid. Opioids are not only ineffective, but if used more than once a week can also worsen headaches by causing medication overuse headache and cause addiction. Regular intake of opioids can also worsen other pain conditions, such as neck and back pain, by causing hyperalgesia, an increased sensitivity to pain. Patients presenting to an ER with a migraine should be given and injection of sumatriptan (Imitrex) or a non-steroidal anti-inflammatory drug (NSAID), ketorolac (Toradol). Neither triptans nor NSAIDs are likely to cause rebound or medication overuse headache. There are exceptions when occasional use of opioids is appropriate. Perhaps a fraction of one percent or one out of several hundred patients may respond only to an opioid analgesic and nothing else or some patients have to take an opioid if they have contraindications for the use of NSAIDs and triptans. Some patients do well on... --- ### Vitamin B12 deficiency, "A Problem That's Easy to Miss" - Published: 2019-05-04 - Modified: 2019-05-06 - URL: https://www.nyheadache.com/blog/vitamin-b12-deficiency-a-problem-thats-easy-to-miss/ - Categories: Alternative Therapies, Migraine The role of vitamin B12 is underappreciated by many doctors. This week, The Wall Street Journal published a full-page article on vitamin B12 deficiency, which can be of great help to many of the two million readers of this newspaper. The survey quoted in the article shows that only one third of patients with this deficiency are diagnosed within a year, 22% within 1-2 years, 20% within 2-5 years 10% within 5-10 years and 14% after more than 10 years. It took several years for the author of the WSJ article to be diagnosed. A confounding problem is that even if the doctor orders a vitamin B12 level, the widely used blood test is inaccurate. While the normal range is from 200 to 1,200 (depending on the laboratory), cases of severe deficiency have been described with levels of up to 700. You may have a good amount of vitamin B12 circulating in the blood, but it may not be getting into the cells where it is needed for the normal functioning of the nervous system, blood formation, and other functions. Many patients with a level above 200 are told by their doctors that their level is normal, but it should be at least over 400 and even better if it is above 500. We do have two additional blood tests that can confirm if the body needs additional vitamin B12 - homocysteine and methylmalonic acid levels but they are rarely utilized. It is well worth your time to read the... --- ### Men have migraines too. - Published: 2019-04-30 - Modified: 2019-04-30 - URL: https://www.nyheadache.com/blog/men-have-migraines-too/ - Categories: Migraine Migraine is rightfully considered a women's health issue since of the more than 39 million Americans with migraines, 28 million are women. But 11 million is still a lot of men. Unfortunately, men do not seek help as often as women do and we see this in our office and in clinical trials of new drugs for migraines, where the ratio is closer to 1 to 10. Today's Wall Street Journal has an article, Why Men Won’t Go to the Doctor, and How to Change That, which addresses some of the reasons. The article notes that men are notoriously bad patients. In our office, it is usually a mother, a wife, or a girlfriend who brings the man to the office. Men consider complaining of a headache or any other symptom a sign of weakness. They just grin and bear until they are totally incapacitated. This is probably one of the reasons why women live longer. Fortunately, migraines are not life-threatening but they can certainly ruin relationships, affect job performance, cause depression and other problems. Men are often reluctant to share their feelings and see a therapist and have higher suicide rates than women. Men tend to be not very compliant with treatment and are more likely to come in for Botox injections every 3 months rather than take a pill every day. In this case they are acting rationally since any oral medication has more potential side effects than Botox. Regular exercise, which is at the top of my... --- ### 100 Migraine drugs, A to Z: haloperidol - Published: 2019-04-27 - Modified: 2019-04-27 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-haloperidol/ - Categories: Headache medications, Migraine Haloperidol (Haldol) is a psychiatric drug prescribed  for the treatment of schizophrenia, tics in Tourette syndrome, mania in bipolar disorder, nausea and vomiting, delirium, agitation, and acute psychosis. A cases series published in The Journal of Emergency Medicine in 1995 described six patients who presented with a severe migraine to an emergency room in Toronto and were given haloperidol intravenously. Within an hour all six were either pain-free or significantly improved and none returned to the emergency room within 48 hours. A double blind placebo controlled study published by Finnish researchers in the journal Headache in 2006 examined the efficacy of 5 mg of haloperidol given intravenously in the treatment of severe migraines. Forty patients were enrolled in the study and 80% (16 patients out of 20) of those who received haloperidol had significant pain relief, compared with 15% (3 patients) in the placebo group. Because the majority of patients had taken regular NSAIDs analgesics and triptans without response, the authors concluded that haloperidol appears to be effective in treatment resistant migraine attacks. However, almost all patients who receive haloperidol complained of side effects, mostly sedation and unpleasant restlessness (akathisia). The side effects were mild to moderate in severity and reversible. The restlessness can be relieved by diphenhydramine (Benadryl). Haloperidol is one of the neuroleptic drugs, a category that includes droperidol and phenothiazine drugs such as chlorpromazine mentioned in an earlier post. All these drugs have the potential to cause serious and in rare cases permanent neurological side effect of involuntary movements. This is why they are mostly... --- ### 100 MIgraine Drugs, A to Z: granisetron - Published: 2019-04-21 - Modified: 2019-04-21 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-granisetron/ - Categories: Headache medications, Migraine Granisetron (Kytril, Sancuso) is one of the anti-nausea medications in the family of setrons. Ondansetron (Zofran) and palonosetron (Aloxi) are the other two drugs in this family available in the US. These drugs are approved for the prevention and treatment of chemotherapy-induced and post-surgical nausea and vomiting, but are also used to treat nausea of migraine attacks. Granisetron was found to relieve nausea as well as pain in one anecdotal observation of 7 patients and two controlled trials. The first study was conducted in Canada and it involved 28 patients who presented to the emergency department with an acute migraine. This was a randomized, double-blind, placebo-controlled study of intravenous granisetron (40 micrograms/kg or 80 micrograms/kg). Significant improvement in headache pain was observed in the 80-micrograms/kg group. Except for more nausea at 30 min in the placebo group, no significant differences were noted between treatments. The authors concluded that "granisetron may be effective for acute migraine headache; however, further studies with increased patient numbers are required. " The second Iranian study was also conducted in an emergency room and included 148 patients. The doctors compared intravenous granisetron, 2 mg with intravenous metoclopramide, 10 mg. They found that the drugs were equally effective in the treatment of nausea, but granisetron was somewhat better at relieving pain. The general consensus is that setrons are not very effective for the treatment of migraine pain, while metoclopramide (Reglan) and phenothiazine drugs, such as prochlorperazine (Compazine), promethazine (Phenergan) and chlorpromazine (Thorazine) relieve both nausea and pain.... --- ### The NY Headache Center is featured in this great new video - Published: 2019-04-17 - Modified: 2019-04-17 - URL: https://www.nyheadache.com/blog/the-ny-headache-center-is-featured-in-this-great-new-video/ - Categories: Migraine by Molly Rubin, a video journalist at Quartz.  Quartz is a digital news site founded by the Atlantic. This is a very well done video news piece on migraines. --- ### Migraine raises the risk of stroke if it begins after 50 - Published: 2019-04-15 - Modified: 2019-04-15 - URL: https://www.nyheadache.com/blog/migraine-raises-the-risk-of-stroke-if-it-begins-after-50/ - Categories: Brain disorders, Migraine Patients suffering from migraine with aura (MA) are at a higher risk of strokes. It is not clear what leads to this problem. Elevated homocysteine level increases the risk of strokes and heart attacks and patients with MA are more likely to have this abnormality. Another possible explanation is reported in a recent study mentioned on this blog in December, This study convincingly argues that the risk of stroke is increased because of the higher incidence of a certain type of cardiac arrhythmia, atrial fibrillation in patients with MA. Researchers at the University of South Carolina recently discovered that the risk of strokes is higher only in migraine sufferers who started having migraines after the age of 50. The findings were a part of the Atherosclerosis Risk in Communities (ARIC) study. Among 11,592 black and white participants, 447 had MA and 1,128 MO. The risk of stroke in those whose MA began after the age of 50 was double that of those with no headaches. MA that started before 50 was not associated with stroke. MO was not associated with increased stroke regardless of the age of onset. The absolute risk for stroke in migraine with aura is 8% and migraine without aura is 4%. To reduce the risk of strokes (whether you have migraine with aura or not) you need to keep your cholesterol under control, not smoke, exercise regularly, maintain good blood pressure and weight. --- ### This is a cluster season, again - Published: 2019-04-12 - Modified: 2019-04-12 - URL: https://www.nyheadache.com/blog/this-is-a-cluster-season-again/ - Categories: Cluster headaches Cluster headaches derive their name from the fact that they occur daily for a period of one to several months. It is rarely noted that these cluster periods occur in many patients at the same time. We do not see any cluster patients for several months and then, we see them daily for a couple of months and now is such a period. It is not clear what environmental factors may be playing a role. These periods when cluster patients start having their attacks do not appear to be related to barometric pressure changes, high allergy seasons, pollution, or any other factors. In some patients attacks occur always in the same season and even the same month, but in many a cluster period can start at any time. Cluster headaches often cause extremely severe pain, which is always on one side and rarely switch sides from one cluster period to the next. The pain is accompanied by nasal congestion, runny nose and tearing on the side of the headache. Unlike migraine patients who prefer to lie down in a dark and quiet place and not move, patients with cluster headaches become agitated and cannot sit still. The attacks occur once or several times a day, often at the same time of day or night and last anywhere from 15 minutes to a couple of hours. Cluster headaches occur at least twice as often in men than in women and this is probably why cluster headaches are often misdiagnosed in women. A... --- ### 100 Migraine Drugs, A to Z: galcanezumab - Published: 2019-04-08 - Modified: 2019-04-08 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-galcanezumab/ - Categories: Headache medications, Migraine, New treatments Galcanezumab (Emgality) was the third drug in the family of CGRP monoclonal antibodies (mAbs) to become approved by the FDA for the prevention of migraines. It is more similar to fremanezumab (Ajovy) in its mechanism of action than to erenumab (Aimovig). Erenumab is an antibody that blocks the CGRP receptor, while galcanezumab and fremanezumab are antibodies that block the CGRP molecule. This may explain the fact that some patients who do not respond to one of these drugs may respond to another. Actually, even patients who do not respond or respond only partially to fremanezumab may respond to galcanezumab and the other way around. This should not be surprising since many drugs with the same mechanism of action may have different efficacy and side effects in different patients. In migraine treatment this applies to triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax), and other, as well as beta blockers, such as propranolol (Inderal), atenolol (Tenormin), nebivolol (Bystolic). Just like the other two CGRP mAbs, galcanezumab is injected monthly (although fremanezumab can be also given at a triple dose every three months). The initial dose is 240 mg, or two auto-injector pens, followed by a monthly dose of 120 mg. The main side effects are similar to the other two drugs, namely injection site reactions such as swelling, redness, and an allergic rash. Erenumab can be constipating, while the other two drugs are much less so. The cost of all 3 drugs is the same - between $550 and $600... --- ### Your brain needs vitamin D - keep your level up - Published: 2019-04-04 - Modified: 2019-04-04 - URL: https://www.nyheadache.com/blog/your-brain-needs-vitamin-d-keep-your-level-up/ - Categories: Alternative Therapies, Migraine Yet another study shows that low vitamin D level predisposes to neurological problems. A report just published in a leading neurology journal, Neurology by British and American researchers shows that low levels of vitamin D are associated with a higher risk of delirium in hospitalized patients. This study looked at 313,121 participants, 544 of whom were hospitalized with delirium. The researchers proved that there is genetic evidence supporting connection between vitamin D levels and delirium. They called for trials of correction of low vitamin D levels for the prevention of delirium. It is a strange call to action because we already know from other large studies that vitamin D deficiency predisposes to several neurological problems. These include not only migraines, but also multiple sclerosis, stroke, and other major diseases  Why not just make sure that nobody has a deficiency? Well, one reason is that insurance companies do not want to pay for the test because we do not have proof that correcting this deficiency will prevent these neurological problems. As we know, correlation does not mean causation. However, conducting large scale studies is very expensive and it takes many years to obtain the results. And why was a normal range for vitamin D was established if not to make sure that people are not deficient. As I mentioned in my last post on vitamin D in 2015 everyone should have their vitamin D level checked and if you are deficient, get your level up to the middle of normal range. The... --- ### Ginger improves emergency room treatment of migraine - Published: 2019-03-28 - Modified: 2019-03-28 - URL: https://www.nyheadache.com/blog/ginger-improves-emergency-room-treatment-of-migraine/ - Categories: Alternative Therapies, Migraine Ginger is not only a popular spice, but a truly remarkable medicinal plant. Ginger's proven anti-inflammatory properties may be responsible for its beneficial effects in migraine patients. Ginger may be effective for the treatment of seasickness, morning sickness of pregnancy and I recommend it for nausea of migraine as well. A study published in the journal of the International Headache Society, Cephalalgia examined the effect of ginger, when added to an intravenous pain medication. This was a double-blind placebo-controlled randomized clinical trial performed in the emergency room of a general hospital in Brazil. Adults who suffered from migraines with or without aura one to six times per month were included. Half of the sixty participants were given 400 mg of ginger extract (5% active ingredient) or placebo, in addition to an intravenous drug (100 mg of ketoprofen, a drug not available in the US in an injection, but it is similar to ketorolac, or Toradol) to treat an attack of migraine. Pain severity, functional status, migraine symptoms and treatment satisfaction were recorded. Patients treated with ginger showed significantly better pain relief after 1, 1. 5 and 2 hours. Ginger also significantly improved functional status and overall satisfaction. Another double-blind study involving 100 patients compared the efficacy of ginger with sumatriptan in the treatment of an acute migraine attack.  Patient satisfaction and their willingness to continue treatment was also evaluated after 1 month following intervention. Two hours after using either drug, mean headaches severity decreased significantly. Efficacy of ginger powder and sumatriptan was... --- ### 100 Migraine Drugs, A to Z: gabapentin - Published: 2019-03-25 - Modified: 2019-03-25 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-gabapentin/ - Categories: Headache medications, Migraine Gabapentin (Neurontin) is a drug that was originally developed for the treatment of epilepsy but now it is used for a wide variety of conditions except for epilepsy. It is just not strong enough to control epileptic seizures. Gabapentin can be effective for various pain syndromes, including the treatment of sciatic pain and it has an official FDA approval for the treatment of a very painful condition, postherpetic neuralgia, or shingles pain. Several positive studies of gabapentin have been also reported for the treatment of episodic as well as chronic migraines. However, a review of all rigorous clinical trials of gabapentin for the treatment of migraine found no evidence that it really works. The authors of the review concluded that, "Since adverse events were common among the gabapentin-treated patients, it is advocated that gabapentin should not be used in routine clinical practice". The adverse events were mostly dizziness and somnolence. My personal experience also suggests that gabapentin is not highly effective and I do not use it "in routine clinical practice". However, because gabapentin is proven to relieve other painful conditions and because it has a relatively benign side effect profile, I do use it in some patients with migraine, especially those with associated neck pain. It can also help patients with insomnia, although this indication is also not proven in large trials. Gabapentin is used in doses of up to 3,600 mg a day and higher, although there have been reports of gabapentin abuse and dependence at doses above 3,000... --- ### More about our new study of tDCS for the prevention of migraines - Published: 2019-03-18 - Modified: 2019-03-18 - URL: https://www.nyheadache.com/blog/more-about-our-new-study-of-tdcs-for-the-prevention-of-migraines/ - Categories: Alternative Therapies, Migraine, neurostimulation, New treatments To be eligible for this study you have to live in NYC or its suburbs and cannot be currently receiving Botox or a CGRP monoclonal antibody, such as Aimovig, Ajovy or Emgality. PARTICIPATE IN MIGRAINE RESEARCH A RANDOMIZED SHAM-CONTROLLED STUDY OF HOME-DELIVERED NON-INVASIVE NEUROSTIMULATION FOR MIGRAINE • If you have frequent headaches (on 4 days or more/month) you may be eligible to enroll in a study of non-invasive neurostimulation aiming to reduce migraines. • Neurostimulation provides stimulation of the nerves in the human body. Frequently used neurostimulation methods are for example, acupressure, acupuncture or TENS. • This study uses a new neurostimulation method, tDCS. tDCS is a battery-powered device that delivers stimulation via two sponge pockets placed to a simple headband. Study participants will be assigned either to a group receiving active tDCS or to a control group receiving placebo tDCS. If you are interested in more information about the study, please call the study personnel at 212-794-3550 or 212-440-1954 or email DrMauskop@nyheadache. com --- ### A new study of Cefaly to treat acute migraines - Published: 2019-03-16 - Modified: 2019-03-16 - URL: https://www.nyheadache.com/blog/a-new-study-of-cefaly-to-treat-acute-migraines/ - Categories: Alternative Therapies, Migraine Cefaly is a transcutaneous electrical nerve stimulation (TENS) device designed to treat migraine headaches by stimulating supraorbital nerves. The device was cleared by the FDA in 2014 for both acute and preventive treatment of migraine headaches. The preventive indication was based on a double-blind trial involving only 67 patients, while the use of Cefaly for acute migraines was based only on an open-label trial. A study recently published in Cephalalgia examined the efficacy of this device for acute treatment of migraines in a double-blind trial of 106 patients. The trial confirmed that Cefaly is indeed effective for abortive therapy of migraine attacks. For prevention, it is recommended to use the device for 20 minutes every day, while to treat an acute attack the device should be used for an hour. The primary outcome measure was the mean change in pain intensity at 1 hour compared to baseline. This primary outcome measure was significantly more reduced in the stimulation group compared to the sham group: 60% versus 30% reduction. No serious adverse events were reported and five minor adverse events occurred in the stimulation group. I've had one or two patients report that the device actually triggered a migraine, but this can also happen with any oral migraine drug. The main reason I offer Cefaly before any other device (eNeura TMS or gammaCore) is that it is the most affordable. The price has gone up since it's introduction and ranges from $350 to $500, however the manufacturer offers a 60-day return... --- ### Sign up for our trial of tDCS for the prevention of migraines! - Published: 2019-03-11 - Modified: 2019-03-11 - URL: https://www.nyheadache.com/blog/sign-up-for-our-trial-of-tdcs-for-the-prevention-of-migraines/ - Categories: Uncategorized Advertising flyer --- ### Migraines and dry eyes - Published: 2019-03-09 - Modified: 2019-03-09 - URL: https://www.nyheadache.com/blog/migraines-and-dry-eyes/ - Categories: Alternative Therapies, Migraine Several older reports have suggested an association between dry eye disease (DED) and migraine headaches. Researchers at the Univercity of North Carolina at Chapel Hill just published a large and convincing study confirming this comorbidity. This was a retrospective study which included 72,969 patients older than 18 years seen over a period of 10 years. The study included 41,764 men and 31,205 women. Of these, 5,352 patients (7. 3%) were diagnosed to have migraine headaches and 9,638 (13. 2%) had the diagnosis of DED. The odds of having DED and migraine headaches was 1. 4 times higher than that of patients without migraine headaches. This association was true for men and women older than 65 and women of all ages. Older age and female sex are both risk factors for the development of DED, probably due to hormonal and age-related changes. The incidence of migraines and DED in the general population are reversed - about 12% suffer from migraines and 7% from DED, which is probably due to the fact that the study included only patients see at ophthalmology clinics. The authors conclude that patients with migraine headaches are more likely to have comorbid DED compared with the general population, but this association may not reflect cause and effect. Both conditions do share inflammation as one of the underlying processes. It is very likely that the eye discomfort from DED can be making migraines more frequent and severe. The diagnosis of DED should be considered in all migraine sufferers, especially... --- ### 100 Migraine Drugs from A to Z: frovatriptan - Published: 2019-03-05 - Modified: 2019-03-05 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-from-a-to-z-frovatriptan/ - Categories: Headache medications, Migraine Frovatriptan (Frova) is one of seven drugs in the family of triptans, drugs used to abort a migraine attack. The first drug to receive approval in 1992 was sumatriptan (Imitrex) in an injection form, followed by tablets and nasal spray. Other drugs in this category are rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), almotriptan (Axert), and eletriptan (Relpax). Frovatriptan is probably the least effective triptan and this is in part because it is the longest-lasting triptan and takes the longest to start working. Its half-life is 26 hours, which means that the body clears out half of it in that period of time. The half-life of sumatriptan, rizatriptan and zolmitriptan is 2 to 3 hours, almotriptan - 3 to 4 hours, eletriptan - 4 hours, and naratriptan - 6 hours. When speed of onset is not crucial, which is when migraine develops slowly over a few hours, frovatriptan has the advantage of longer effect. However, if it does not provide good relief to begin with, the amount of time it stays in the body is irrelevant. Short-acting triptans work quickly and stop the migraine attack. Frovatriptan is sometimes used for "mini-prophylaxis" of menstrual migraines - it is taken the day before the expected menstrual migraine and throughout the period. However, other triptans, including sumatriptan and naratriptan can be also effective in preventing predictable migraines, such as those occurring with periods, physical exertion or sexual activity. Another disadvantage of frovatriptan is that it is expensive even in a generic form - $20... --- ### Must read! A very important new study of magnesium. - Published: 2019-02-27 - Modified: 2019-02-27 - URL: https://www.nyheadache.com/blog/must-read-a-very-important-new-study-of-magnesium/ - Categories: Alternative Therapies, Brain disorders, Migraine A study just published in Neurology by the MEGASTROKE project of the International Stroke Genetics Consortium found that "genetically higher serum magnesium concentrations are associated with a reduced risk of cardioembolic stroke... " It is an open access article, so you can download the full text. The study looked at 34,217 cases of strokes and 404,630 noncases, which makes the data highly reliable. Here are some quotes (some modified) from the paper. Several observational prospective studies have reported that low circulating magnesium concentrations and low magnesium intake are associated with increased risk of stroke. In the Nurses’ Health Study, low plasma magnesium concentrations were associated with an approximately 70% to 80% increased risk of embolic and thrombotic stroke. Magnesium may in part reduce the risk of cardioembolic stroke through its antiarrhythmic effects and via atrial fibrillation.  Low serum magnesium concentrations are associated with increased risk of atrial fibrillation, which is a strong risk factor for cardioembolic stroke. (My recent post mentioned that the increased risk of strokes in patients with migraines with aura is possibly related to the higher incidence of atrial fibrillation) Two of the magnesium-associated SNPs (genetic variants) were significantly associated with atrial fibrillation, with higher serum magnesium concentrations being associated with lower risk of atrial fibrillation. Magnesium also has anticoagulant and antiplatelet properties (platelet aggregation is also implicated in migraine). Magnesium is considered to be nature’s calcium blocker as it suppresses many of the physiologic actions of calcium. For example, calcium promotes blood coagulation, whereas magnesium suppresses blood clotting and... --- ### 100 Migraine Drugs, A to Z: fremanezumab - Published: 2019-02-21 - Modified: 2019-02-21 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fremanezumab/ - Categories: Headache medications, Migraine Fremanezumab (Ajovy) is one of the three drugs in the family of CGRP monoclonal antibodies that have been approved for the prevention of migraine headaches. Fremanezumab was approved by the FDA last September. After trying erenumab (Aimovig), which was approved first, I also injected myself with Ajovy monthly for two months. My migraine headaches do not cause any disability, so I did it to see if I can reduce my attacks from triggers such as red wine, which it did, and to reassure my patients about the relative safety of these drugs. Over the years I've tried Botox a couple of times and a few other treatments, but not drugs such as topiramate (Topamax) or divalproex sodium (Depakote), which I rarely prescribe to my patients because of their potential to cause serious side effects. Fortunately, my occasional migraines have always been easily controlled with sumatriptan (Imitrex), so I do not need any preventive therapies. --- ### More magnesium, fewer migraines - Published: 2019-02-11 - Modified: 2019-02-11 - URL: https://www.nyheadache.com/blog/more-magnesium-fewer-migraines/ - Categories: Alternative Therapies, Migraine Having conducted and published research on magnesium and seeing dramatic improvement from magnesium in many of my patients, I try to write about magnesium at least once a year. Up to half of migraine sufferers are deficient in magnesium and could greatly benefit from it. Magnesium supplements are considered "probably effective" for the prevention of migraine headaches, according to the American Headache Society and American Academy of Neurology guidelines. The reason magnesium is listed as only probably effective is poor design of most clinical trials. There was no selection of patients - magnesium was given to all without any regard to their magnesium status. Obviously, those who did not have a deficiency did not benefit from taking magnesium and they diluted positive results seen in those who were deficient. A study conducted by researchers at George Mason University looked at the dietary and supplement data of 2,820 American adults between 20 and 50 years old. They found that higher dietary intake of magnesium led to lower risk of migraines in both men and women. This relationship was even stronger in women, but not men who took magnesium supplements. They also found that the average consumption of magnesium in these 2,820 Americans was only 70%-75% of the Recommended Dietary Allowance. Obviously, it is better to get your magnesium from food, such as whole grains, dark leafy vegetables, avocados, legumes, and other. However, changing your diet is not easy, so the second best choice is to take a supplement. I recommend 400... --- ### 100 Migraine Drugs, A to Z: flurbiprofen - Published: 2019-02-02 - Modified: 2019-02-02 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-flurbiprofen/ - Categories: Headache medications Flurbiprofen is just another nonsteroidal antiinflammatory drug (NSAID), which is reflected in the name of its branded version - Ansaid. All NSAIDs can relieve acute pain of migraine and some have been proven to prevent attacks if taken on a daily basis. Aspirin, ibuprofen, ketoprofen and naproxen are some of the NSAIDs that have been shown to prevent migraines. Flurbiprofen is not one of the more popular NSAID drugs, however it was tested for the prevention of migraines in a double-blind placebo-controlled crossover trial. The trial involved 23 patients who were given first placebo or 100 mg of flurbiprofen twice a day for 8 weeks and after a 2-week "washout" period switched (crossed over) from placebo to flurbiprofen and from flurbiprofen to placebo. Flurbiprofen significantly reduced migraine intensity, total hours with migraine, and the dosing frequency of relief (abortive) medications. Total hours with migraine decreased by 41%, and the use of abortive medications decreased by 31%. Even though this trial involved a small number of patients, very similar mechanism of action to other NSAIDs suggests that flurbiprofen, like other NSAIDs, is an effective preventive agent. However, the reason they are not widely used for this purpose is their safety. They all can cause stomach upset and peptic ulcers, which can bleed and even cause death. They can also cause kidney damage and in those predisposed to heart disease, increase the risk of heart attacks (except for aspirin). On the other hand, millions of arthritis sufferers take these drugs for years... --- ### TOSYMRA, a new migraine product was just approved by the FDA - Published: 2019-01-30 - Modified: 2019-01-30 - URL: https://www.nyheadache.com/blog/tosymra-a-new-migraine-product-was-just-approved-by-the-fda/ - Categories: Headache medications, Migraine Tosymra is a product that uses a novel way to deliver sumatriptan through the nasal passages. Unlike other nasal formulations of sumatriptan, Tosymra uses proprietary technology, Intravail, which enhances the absorption of sumatriptan through the nasal mucosa. This allows a dose of 10 mg to achieve similar blood level to that of a 4 mg injection of sumatriptan. Clinical trials have confirmed high efficacy of Tosymra in migraine patients. Many migraine sufferers experience nausea, which makes oral medications ineffective they take too long to work. Sumatriptan injections can be very effective, but many patients are reluctant to use them and they tend to cause more side effects. Nasal delivery offers a good middle road - better and faster delivery than by mouth without the pain and side effects of an injection. The regular liquid sumatriptan nasal spray (Imitrex NS) has been on the market for a couple of decades, but it has never become a popular product. This is partly due to the fact that it is not consistently or well absorbed. The spray contains 20 mg of sumatriptan delivered through a relatively large droplets of fluid. Some of it is drips out from the nose, while some is swallowed and gives an already nauseated migraine patient a bad taste in the mouth. Another formulation of nasal sumatriptan was Onzetra, which delivered powdered sumatriptan through an ingenious device. It required the patient to blow the powder into the nose and it appeared to have good efficacy.   However, it was... --- ### 100 Migraine Drugs, A to Z: fluvoxamine - Published: 2019-01-27 - Modified: 2019-01-27 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fluvoxamine/ - Categories: Headache medications, Migraine Fluvoxamine (Luvox) is one of the drugs in the selective serotonin reuptake inhibitor (SSRI) class. Unlike other SSRIs, which are approved for the treatment of anxiety and depression, it is approved for the treatment of obsessive-compulsive disorder (OCD), although OCD is often accompanied by anxiety and depression. Fluvoxamine does relieve anxiety and depression as well, but it has been mostly promoted and used for the treatment of OCD. The SSRIs are not very effective for the prevention of migraines, but a single double-blind study involving 64 patients showed that fluvoxamine is as good as amitriptyline for the prevention of migraines with fewer side effects. It may be best suited for migraine patients who also suffer from OCD, but I would not prescribe it for migraines without OCD. Fluvoxamine may have more side effects than other SSRIs, such as fluoxetine (Prozac). Potential side effects of fluvoxamine is similar to those of other SSRIs and include nausea, insomnia, somnolence, headache (most drugs have headache as a potential side effect), decreased libido, nervousness, and dizziness. All antidepressants can also increase the risk of suicide. --- ### 100 Migraine drugs, A to Z: flunarizine - Published: 2019-01-20 - Modified: 2019-01-20 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-flunarizine/ - Categories: Headache medications, Migraine Flunarizine (Sibelium) is a calcium channel blocker approved for the preventive treatment of migraines in most countries, except for the US and Japan. In many countries, flunarizine is considered to be a first-line drug for the prevention of migraines. It is as effective as propranolol (Inderal), a beta blocker which is approved world-wide for migraine prophylaxis (and hypertension). Flunarizine, 10 mg was found to be more effective than 50 mg of topiramate (Topamax), although the average dose of topiramate for migraines is 100 mg. It can take 6 to 8 weeks before flunarizine becomes effective. Vestibular migraine is characterized by vertigo which can occur with or without headache and is often difficult to treat. One observational study suggested that flunarizine may improve the attacks of vertigo. The two most common side effects of flunarizine are drowsiness and weight gain, but can also cause nausea, anxiety, depression, insomnia, and dry mouth. I've recommended purchasing flunarizine abroad to a few of my patients who exhausted other options. None have remained on it, either because of side effects or lack of efficacy. Clearly, giving it to the most severely affected patients is not a fair way to evaluate a drug, but I've stopped recommending it. This is also because of legal and logistical problems in getting flunarizine from outside the US. In the US, we do have a different calcium channel blocker, verapamil (Calan). It is not FDA-approved for migraines (only for high blood pressure) and it is not as effective as flunarizine... --- ### I decided to stop Ajovy too - Published: 2019-01-14 - Modified: 2019-01-14 - URL: https://www.nyheadache.com/blog/i-decided-to-stop-ajovy-too/ - Categories: Headaches, Migraine, neurostimulation, New treatments I've given myself an injection of Ajovy in November and December with some improvement and without constipation which I had from Aimovig. However, Ajovy did not prevent all of my migraines, especially those caused by red wine, (I received some nice red wine over the holidays) and I still had to take sumatriptan (Imitrex). This is not at all surprising; I always tell my patients that even the most effective treatment is not 100% effective - with enough triggers migraine will still occur. It is possible that with continued use of Ajovy my migraines would progressively get better, but my headaches are quickly and completely relieved by sumatriptan. Sumatriptan has a 25 year safety record and for over 10 years has been available without a prescription in most European countries (you may want to read my post on the daily use of triptans - it is by far the most popular with over 250 comments). My next self-experiment is to try to prevent migraines with transcranial direct current stimulation (tDCS). We are about to begin a double-blind sham-controlled study and I will describe it in in an upcoming post. --- ### 100 Migraine Drugs, A to Z: fluoxetine - Published: 2019-01-09 - Modified: 2019-01-09 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-fluoxetine/ - Categories: Headache medications, Migraine Antidepressants are widely used for the preventive treatment of migraine headaches. However, some types of antidepressants are better for this purpose than other. Fluoxetine (Prozac, Sarafem) was the first drug in the family of selective serotonin reuptake inhibitors (SSRIs) to be introduced in 1986. This category of antidepressants became very popular not because these drugs were more effective than the older antidepressants, but because they had fewer side effects. Because tricyclic antidepressants were known to relieve pain and prevent migraine headaches, when the SSRIs became available, they were also studied for various painful conditions. Small studies suggested that fluoxetine and similar drugs may be effective for the prevention of migraines. Here is another such small study. However, larger and scientifically more rigorous trials showed no effect of fluoxetine on migraines. Despite this lack of scientific evidence, SSRIs (escitalopram, or Lexapro, paroxetine, or Paxil, sertraline, or Zoloft) are often prescribed for migraines and some migraine sufferers report feeling better on these drugs. One possible explanation is the placebo effect, but it is more likely to be due to the relief of anxiety and depression with some secondary improvement of migraine headaches. In case of tricyclic and some other antidepressants, their pain relieving properties are independent of their effect on depression. While SSRIs have fewer side effects than many other antidepressants, they also can cause nausea, dizziness, insomnia, loss of libido, inability to reach an orgasm, and other unpleasant symptoms. --- ### Red wine and headaches in the WSJ - Published: 2019-01-03 - Modified: 2019-01-03 - URL: https://www.nyheadache.com/blog/red-wine-and-headaches-in-the-wsj/ - Categories: Headaches, Migraine, Science of Migraine 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. --- ### 100 Migraine Drugs, A to Z: estrogen - Published: 2019-01-01 - Modified: 2019-01-01 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-estrogen/ - Categories: Headache medications, Headaches, Migraine Estrogen can be an effective agent for the treatment of menstrual migraines. Many women report that their migraines tend to occur before or during their period and sometimes with ovulation. For some women menstruation is the only time they get a migraine. The attacks appear to be triggered by a drop in estrogen levels. A steady estrogen level is why 2 out of 3 women stop having migraines during pregnancy and menopause. Most women with menstrual migraines respond well to sumatriptan (Imitrex) and other triptans. If triptan alone does not provide sufficient relief, adding a nonsteroidal anti-inflammatory drug (NSAID) such as naproxen (Aleve) or ibuprofen (Advil) to a triptan can be very effective. When this strategy does not work and the periods are very regular, mini prophylaxis is another approach. This means taking a preventive drug for a week, starting a day or two before the expected migraine attack. Mini prophylaxis can be tried with the usual preventive drugs such as beta blockers and also with a triptan, such as naratriptan (Amerge), which is somewhat longer acting than other triptans. Sumatriptan and other short-acting triptans also prevents migraine attacks and not only menstrual ones. Some of my patients who wake up every morning with a migraine take a triptan in the evening and avert the attack. This is somewhat surprising because the half-life of sumatriptan is only 2. 5 hours. If all these treatments fail, continuous intake (skipping the week of placebo pills) of an estrogen-containing contraceptive such as Lo... --- ### 100 Migraine Drugs, A to Z: erenumab - Published: 2018-12-26 - Modified: 2018-12-26 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-erenumab/ - Categories: Headache medications, Migraine Erenumab (Aimovig) was the first drug in the family of monoclonal antibodies (mAbs) against calcitonin gene-related peptide (CGRP) approved for the prevention of migraine headaches. CGRP is a substance released during a migraine attack. Erenumab was approved in May of this year, followed by approvals of fremanezumab (Ajovy) and galcanezumab (Emgality) in September. Erenumab is an antibody against the CGRP receptor located on a cell, while the other two drugs are antibodies against the molecule of CGRP. They have very similar efficacy and are surprisingly safe with very few side effects. Erenumab has no contraindications or drug interactions. All these drugs are delivered by an injection and can cause a local injection site reaction or a rash, but erenumab can also cause constipation. It is possible that with the wider use of these drugs other side effects may become apparent. We have seen a handful of patients whose headaches worsened, a couple who developed fatigue and muscle aches, stomach pains and thinning of hair. The number of such patients is small and it is premature to attribute these effects to the drug. Just like our colleagues across the country, we at the New York Headache Center encourage our patients to report all potential side effects to the manufacturer or the FDA. Erenumab dose is either a single 70 mg injection or two injections for a total of 140 mg. It comes in a prefilled pen-like device which is very easy to self-administer. It provides dramatic relief to about one in... --- ### Migraine aura increases the risk of atrial fibrillation, which may lead to a stroke - Published: 2018-12-21 - Modified: 2018-12-21 - URL: https://www.nyheadache.com/blog/migraine-aura-increases-the-risk-of-atrial-fibrillation-which-may-lead-to-a-stroke/ - Categories: Migraine, Science of Migraine 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... --- ### Now I've tried Ajovy too - Published: 2018-12-15 - Modified: 2018-12-15 - URL: https://www.nyheadache.com/blog/now-ive-tried-ajovy-too/ - Categories: Headache medications, Migraine, New treatments Fremanezumab (Ajovy) is the second CGRP monoclonal antibody to become after the introduction of erenumab (Aimovig) and it has some differentiating features. I injected myself with Aimovig twice and was able to drink more wine with relative impunity. The relief from my migraines was not complete, but very significant. However, I did experience constipation, which was quite unpleasant. Constipation is the only side effect of Aimovig reported with any frequency besides injection site reactions (an allergic rash can also occur). As one gets older (and I am 62), constipation becomes more prevalent. Although I could manage the constipation, it took an effort and I did not continue with Aimovig. My migraines are not at all disabling and I just cut back on wine. Besides wine, sleep deprivation and certain foods trigger my migraines, but they are easily managed with sumatriptan tablets or when I want fast onset of action, with sumatriptan injections. After a couple of months, I decided to try Ajovy and took a shot on November 6. It worked at least as well as Aimovig and did not cause constipation. The effect lasted exactly a month and then migraines returned, so I took a second shot on December 13. Both Ajovy injections started to work within a day, although in some of my patients it takes a week. I continue to prescribe Aimovig as well as Ajovy and sometimes, the third drug in this family, galcanezumab (Emgality). If someone is prone to constipation, my first choice is definitely... --- ### 100 Migraine Drugs, A to Z: eletriptan - Published: 2018-12-10 - Modified: 2018-12-17 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-eletriptan/ - Categories: Headache medications, Migraine Eletriptan (Relpax) is one of seven triptans approved for the treatment of an acute migraine. While all triptans are similar (but not identical) to each other in their indications, contraindications, side effects and drug interactions, some are more effective than other. Sumatriptan (Imitrex) is the oldest triptan (approved in 1992) and with many companies making generic copies, it is the cheapest. Sumatriptan, rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan, and almotriptan (Axert) are similar in their efficacy, but many patients prefer one over another. It is not clear why this may be the case because they all work on the same two very specific serotonin receptor subtypes (5HT-1b and 5HT-1d). I do have a fair number of patients who find eletriptan to be significantly better than other triptans. Generic copies of eletriptan came on the market relatively recently and their price is still relatively high - $10 a pill, compared to $1 for sumatriptan. Brand versions of triptans cost anywhere from $40 for a pill of Maxalt (rizatriptan) to $120 for each pill of Zomig (zolmitriptan). A very rare patient of mine finds that the generic copies are significantly less effective than the brand. It is even more rare for an insurance plan to pay for it. Eletriptan is available in 20 and 40 mg tablets with the maximum FDA-approved daily dose of 80 mg. However, in some European countries eletriptan is sold in 80 mg tablets and the maximum approved daily dose is 160 mg. I see many patients who are... --- ### 100 Migraine Drugs, A to Z: duloxetine - Published: 2018-11-27 - Modified: 2018-11-27 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-duloxetine/ - Categories: Headache medications, Migraine Duloxetine (Cymbalta) is an antidepressant in the family of serotonin-norepinephrine reuptake inhibitors (SNRIs). Unlike the selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), escitalopram (Lexapro) and other, SNRIs not only treat depression and anxiety, but also relieve pain and prevent migraine headaches. Duloxetine is specifically approved by the FDA for the treatment of major depression, generalized anxiety, musculoskeletal pain, such as low back pain and pain due to osteoarthritis, as well as pain of fibromyalgia and diabetic peripheral neuropathy. Duloxetine is not officially approved for the treatment of migraine headaches, but it is been widely for this indication. There are no large controlled trials, but several small studies show that it may be effective even for chronic migraines with medication overuse. Most studies employed a dose of 60 mg, but one study suggested that high doses of the drug (120 mg) may be more effective for the prevention of episodic migraine headaches. Considering that duloxetine is proven to relieve pain of different types, it is very likely that it is effective for the prevention of migraines as well. It is particularly a good choice in patients with comorbid anxiety and depression and these conditions are 2-3 times more likely to occur in migraine sufferers. Potential side effects include insomnia, drowsiness, fatigue, nausea, dizziness, suicidal thoughts in depressed children and young adults, and other Sudden discontinuation of duloxetine can cause withdrawal symptoms, which may consist of one or more of the following symptoms: dizziness, headache, nausea, diarrhea, paresthesia (pins-and-needles), irritability,... --- ### 100 Migraine Drugs, A to Z: droperidol - Published: 2018-11-19 - Modified: 2018-11-19 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-droperidol/ - Categories: Headache medications, Migraine Droperidol (Inapsine) is not a phenothiazine, but is structurally very similar to this class of anti-nausea and anti-psychotic drugs. It also has similar properties of relieving nausea and being a major tranquilizer. And just like phenothiazines (prochlorperazine or Compazine, chlorpromazine or Thorazine, and other) it helps relieve migraines. An intravenous infusion of droperidol stopped a very severe and prolonged migraine that failed to respond to other treatments in 30 out of 35 patients. Most of them became drowsy from the drug and 5 developed severe restlessness and involuntary movements (akathisia). Intravenous and intramuscular droperidol has been shown to be more effective than prochlorperazine in an emergency room setting, but it had more side effects. Akathisia and sedation were present in 15% of patients. A randomized, double-blind, placebo-controlled trial of droperidol injected intramuscularly involving over 300 patients showed its efficacy in treating migraines. However, droperidol produced the same problematic side effects as all phenothiazines can. In this trial 30% of patients had anxiety, akathisia (restlessness and inability to stay still), and somnolence that was rated as severe. Intravenous diphenhydramine (Benadryl) can help reduce these side effects. Another potentially serious side effect is irregular heart beat, or cardiac arrhythmia, which can be life-threatening. Over the years I've given droperidol on a rare occasion in the office without few side effects and with good relief. However, because of the potential for serious side effects I no longer administer it. Fortunately, we have many other intravenous drugs to stop a severe persistent migraine -... --- ### 100 Migraine Drugs, A to Z: Doxepine - Published: 2018-11-15 - Modified: 2018-11-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-doxepine/ - Categories: Headache medications, Migraine Doxepin (Sinequan) is a tricyclic antidepressant and all drugs in this category (amitriptyline, nortriptyline, desipramine, protriptyline) appear to be effective for the prevention of migraine headaches. Only a single small trial of doxepin was conducted in patients with chronic migraines. However, it is very likely that it is as effective as other antidepressants. Doxepin is one of the more sedating tricyclics and is more often used for insomnia than depression or migraines. A typical starting dose of doxepin is 10 mg. The dose is increased to 25-75 mg for migraines and up to 150 mg for depression. For sleep, even 3 or 6 mg dose can be sufficient and such doses in a branded product, Silenor are approved by the FDA for insomnia. Branded products are usually very expensive and Silenor is no exception - $15 a pill, while 10 mg of doxepin is $. 50. Side effects of doxepin are similar to those with other tricyclics - daytime drowsiness, even if taken only at night, dizziness, dry mouth, constipation, weight gain, and other. These side effects is what limits the usefulness of this category of effective migraine drugs. --- ### 100 Migraine Drugs, A to Z: domperidone - Published: 2018-11-07 - Modified: 2018-11-07 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-domperidone/ - Categories: Headache medications, Migraine Domperidone (Motilium) is not a champagne (that would be Dom Perignon and it can give you a headache) but an excellent nausea medication which is often used for the treatment of nausea associated with migraines. It is available in 58 countries but unfortunately not in the US. In desperate cases I've had some patients get it from Canada or Europe. Domperidone works in a different way from other nausea medications and can be effective when other drugs are not. Besides being good at relieving nausea, one study suggested that it can prevent migraine attacks if taken in the prodrome period, 6 to 12 hours before the attack. Prodrome is a prelude to a migraine attack and it can consist of one or more of the following symptoms: fatigue, elation, irritability, depression, yawning, increased urination, food cravings, and other. Not every person has a prodrome, although some people are just not aware of the warning symptoms which can occur a day or two before the attack. Domperidone was also shown to shorten migraine attacks when taken with paracetamol (acetaminophen, or Tylenol in the US). This combination of domperidone with paracetamol (Domperamol) is as effective as 50 mg of sumatriptan (Imitrex, Imigran). A study comparing domperidone with metoclopramide (Reglan), a drug very popular in the US showed that they are equally effective for nausea in diabetics with gastric motility problems, but domperidone had fewer neurological side effects. These neurological side effects included drowsiness, reduced mental acuity, restlessness, fatigue, and depression. Very rarely,... --- ### 100 Migraine Drugs, A to Z: divalproex sodium - Published: 2018-11-03 - Modified: 2018-11-03 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-divalproex-sodium/ - Categories: Headache medications, Migraine Divalproex sodium (Depakote) is one of two epilepsy drugs that are also approved by the FDA for the preventive treatment of migraine headaches (the other one is topiramate, or Topamax). It was approved by the FDA in 1983 to treat epilepsy, in 1985 it was also approved to treat bipolar disorder, and in 1986, to treat migraines. Divalproex is very effective in about 50% of migraine sufferers. The starting dose is 500 mg of the extended release form (Depakote ER). Some patients require 1,000 mg and in epilepsy patients, up to 2,000 and even more, depending on the blood level of the drug. Potential side effects include nausea, drowsiness, dizziness, hand tremor, and in about 10% of patients, weight gain and hair loss. These side effects can be quite unpleasant, but unfortunately, much more serious side effects can occur as well. These are rare, but when they occur, they can be devastating. The drug carries a so called black box warning. It in includes hepatotoxicity, or liver damage, which can be fatal. It usually occurs during the first 6 months of treatment and the FDA label calls for monitoring patients closely and regularly performing blood tests. Fatal cases of pancreatitis have been also reported. Another major problem with this drug is birth defects if taken by the mother during pregnancy. Considering that the majority of migraine sufferers are women of child-bearing age and because of all other potential side effects I rarely prescribe divalproex. It is appropriate to try divalproex... --- ### 100 Migraine Drugs, A to Z: dihydroergotamine - Published: 2018-10-29 - Modified: 2018-10-29 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dihydroergotamine/ - Categories: Headache medications, Migraine Dihydroergotamine (DHE-45) when given intravenously (IV) is considered to be the most effective migraine medication. It was introduced in 1943 and has been the go-to drug for migraines that do not respond to other medications. We usually consider using dihydroergotamine (DHE) after the failure of oral triptans, nonsteroidal antiinflammatory and steroid drugs, as well as injections of ketorolac (Toradol), sumatriptan (Imitrex), and metoclopramide (Reglan), and in some patients, nerve blocks. Raskin protocol, named after Neil Raskin who still practices headache medicine in San Francisco, calls for IV DHE with metoclopramide to be given every 8 hours to break a persistent migraine attack that does not respond to other measures. The Raskin protocol is typically administered in a hospital. However, if the patient is able to, we sometimes have her come in for an infusion in the morning and a second time in the late afternoon. DHE often worsens nausea and we usually pretreat patients with ondansetron (Zofran) or metoclopramide. A minority of patients do not experience nausea with their migraines and they usually do not develop it with dihydroergotamine. A few of our patients self-administer this drug subcutaneously at home. Subcutaneous injection is not as effective as when the drug is given intravenously, but for some patients it works very well. Some take an oral nausea medication or even self-inject a nausea drug prior to giving themselves an injection of DHE. DHE is available only in glass vials and it is prescribed with a syringe. Dihydroergotamine nasal spray (Migranal) has... --- ### 100 Migraine Drugs, A to Z: diclofenac - Published: 2018-10-24 - Modified: 2018-10-24 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-diclofenac/ - Categories: Headache medications, Migraine Diclofenac (Cambia, Voltaren) is one of the nonsteroidal anti-inflammatory drugs (NSAIDs) used for the treatment of migraine headaches. Cambia, which contains 50 mg of powdered diclofenac, is specifically approved by the FDA for the treatment of migraine headaches. It works faster because the powder gets dissolved in a glass of water and the solution of diclofenac (or any other drug) gets absorbed faster than a solid pill. Cambia has a licorice taste, so if you are born disliking licorice (yes, it is an inherited trait), this drug is not for you. It is also not for you if your insurance refuses to pay for it - the out-of-pocket cost is $70 to $80 for a single a dose, or $630 to $740 for a box of 9 packets. The insurers rightfully want you to first try generic diclofenac in a tablet form, which costs $0. 30 a pill. Drinking a full glass of water will speed up the dissolution of the tablet and in some patients could potentially match the efficacy of Cambia. Taking diclofenac in any formulation on an empty stomach makes it work faster, but may increase the risk of heartburn and peptic ulcers. All NSAIDs taken very frequently can increase the risk of heart attacks and strokes in people with cardiovascular risk factors. However, some NSAIDs are worse than other and diclofenac is one of the worst ones while naproxen is one of the safest ones. I mention this on every suitable occasion - NSAIDs have not... --- ### 100 Migraine Drugs, A to Z: dichloralphenazone - Published: 2018-10-15 - Modified: 2018-10-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dichloralphenazone/ - Categories: Headache medications, Migraine Dichloralphenazone is one of three ingredients in the headache drug, Midrin. The other two ingredients are isometheptene, a drug that constricts blood vessels and acetaminophen. Midrin actually is a combination of four drugs because dichloralphenazone is broken down in the body into chloral hydrate, which is an old sedative hypnotic drug used for insomnia and antipyrine, a non-steroidal anti-inflammatory pain medicine. Midrin is a very old drug which was introduced before the 1962 Congressional act that required rigorous clinical trials for the FDA approval. It has been marketed for both migraine and tension-type headaches. The directions, which are not based on any research studies, recommend: "For relief of migraine headaches: The usual adult dosage is two capsules at once, followed by one capsule every hour until relieved, up to 5 capsules within a twelve hour period. For relief of tension headache: The usual adult dosage is one or two capsules every four hours up to 8 capsules a day. " Several small studies of Midrin have been published. One double-blind study, published in 1976 involved 43 patients who were rotated from Midrin to acetaminophen and then, placebo. Midrin was found to be more effective. Another double-blind study, published in 2001 compared Midrin with sumatriptan (Imitrex), 100 mg and found them to be equally effective. I do come across an occasional patient for whom Midrin is more effective than the triptans or any other drug without causing any side effects. Or, sometimes the side effect of sedation is preferable to having... --- ### 100 Migraine Drugs, A to Z: desvenlafaxine - Published: 2018-10-12 - Modified: 2018-10-12 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-desvenlafaxine/ - Categories: Headache medications, Migraine Desvenlafaxine (Pristiq) is an antidepressant in the family of serotonin and norepinephrine reuptake inhibitors (SNRIs). Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac) and escitalopram (Lexapro) are more popular for the treatment of depression and anxiety, but they are less effective than SNRIs for the prevention of migraines and the treatment of pain. Venlafaxine (Effexor) was the first drug in the class of SNRIs, but at the doses below 150 mg works as an SSRI, inhibiting only the reuptake of serotonin. At 150 mg it begins to inhibit the reuptake of norepinephrine, which is responsible for pain relief. Venlafaxine is broken down in the body into an active metabolite, desvenlafaxine. So desvenlafaxine can be considered a purified form of venlafaxine. The FDA approved recommended starting and maintenance dose for desvenlafaxine is 50 mg daily and this dose produces the dual effect, while venlafaxine requires titration from 37. 5 mg daily to the maintenance dose of 150 - 300 mg daily. Potential side effects of desvenlafaxine include increased or excessive sweating, dizziness, drowsiness, dry mouth, constipation, insomnia, and loss of appetite. While venlafaxine has been shown to prevent migraine headaches, such research is lacking for desvenlafaxine. However, considering that two other SNRI drugs, duloxetine (Cymbalta) and milnacipran (Savella) are FDA-approved for pain, it is very likely that desvenlafaxine can also help prevent migraines and relieve other types of pain. --- ### 100 Migraine Drugs, A to Z: desipramine - Published: 2018-10-08 - Modified: 2018-10-08 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-desipramine/ - Categories: Headache medications, Migraine Desipramine (Norpramin) belongs to the family of tricyclic antidepressants which have been proven to be effective for the treatment of various pain syndromes and for the prevention of migraine headaches. Desipramine is used much less frequently for migraines than amitriptyline (Elavil) or nortriptyline (Pamelor) and there are no controlled trials of this drug for the prevention of migraines. However, it has been proven to be as effective in relieving pain of diabetic neuropathy as amitriptyline. It was also shown to be effective for the treatment of postherpetic neuralgia (shingles pain) and chronic low back pain. Desipramine has the advantage of being less sedating than the more popular tricyclic antidepressants and causing fewer other side effects, such as dry mouth and constipation. In one study desipramine caused less weight gain than amitriptyline (but as much as nortriptyline). It is dosed similarly - it is started with 10 or 25 mg and the dose is gradually increased as needed and as tolerated. The average dose for the treatment of pain is between 25 and 75 mg, while for depression it can go up to 150 mg. All tricyclic antidepressants can cause cardiac arrhythmias, especially at high doses and an electrocardiogram is indicated in those with heart disease or multiple risk factors for heart disease. We tend to avoid it in the elderly also because of the increase in the risk of falls due to sedation, as well as constipation. Tricyclics can lower seizure threshold and should be avoided in people with epilepsy. --- ### 100 Migraine Drugs, A to Z: celecoxib - Published: 2018-10-05 - Modified: 2018-10-05 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-celecoxib/ - Categories: Headache medications, Migraine Celecoxib (Celebrex) is a non-steroidal anti-inflammatory drug (NSAID) that belongs to a subclass of selective COX-2 inhibitors. This subclass of drugs tends to be safer on the stomach compared to aspirin, naproxen (Aleve), ibuprofen (Advil) and other non-selective NSAIDs. 400 mg of Celecoxib was shown to be as effective as 550 mg of naproxen for the acute treatment of migraine headaches. A course of celecoxib was also shown to be better than a course of prednisone for the treatment of medication overuse headaches. Celecoxib is a prescription drug and even though it is available as a generic, it costs $3-$4 a pill, but many insurers do pay for it. Another selective COX-2 inhibitor, rofecoxib (Vioxx) was possibly even more effective than celecoxib for the acute treatment of migraines. However, its long-term use for arthritis in those with heart disease or risk factors for heart disease was found to contribute to heart disease and heart attacks and it was taken off the market. This was very unfortunate because migraine patients tend to be young without risk factors for heart disease and they tended to use rofecoxib only occasionally. Such use was perfectly safe and certainly safer than the use of naproxen, ibuprofen, diclofenac, and other NSAIDs. Valdecoxib (Bextra) was another COX-2 inhibitor taken off the market. --- ### More science to support the use of cannabis for pain - Published: 2018-10-01 - Modified: 2018-10-01 - URL: https://www.nyheadache.com/blog/more-science-to-support-the-use-of-cannabis-for-pain/ - Categories: Alternative Therapies, Chronic migraine, Pain, Pain Research We've been prescribing medical marijuana for migraines and other painful conditions since it was legalized in the state of New York four years ago. While it does not seem to help most of our patients, it does benefit a significant minority. The benefits may include relief of pain, nausea, anxiety, and improved sleep. Various ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD) produce different effects and often neither one alone is as effective as a combination of the two (so called entourage effect). Although marijuana is a very effective medicine for some patients, there is no good science to explain how it works, in what combination of ingredients and for what types of pain. A very interesting study that sheds some light on the possible mechanism of action of THC was just published in a leading neurology journal, Neurology by Israeli researchers. They enrolled fifteen patients with chronic neuropathic pain in the leg (like sciatica) in a double-blind placebo-controlled crossover study. Nine patients were given THC in the first part of the study and placebo in the second and six were given placebo first and then THC. In addition to measuring the effect of THC on pain the researchers performed functional MRI (fMRI) scans before and after administering THC or placebo. THC was significantly better than placebo at relieving pain and the fMRI scans showed THC-induced changes in the way pain may be processed in our brains. They found that THC produced a reduction in functional connectivity between the anterior cingulate... --- ### Galcanezumab, the third CGRP monoclonal antibody for migraine is approved - Published: 2018-09-28 - Modified: 2018-09-28 - URL: https://www.nyheadache.com/blog/galcanezumab-the-third-cgrp-monoclonal-antibody-for-migraine-is-approved/ - Categories: Headache medications, Migraine, New treatments The FDA has just approved galcanezumab (Emgality), the third CGRP monoclonal antibody for the prophylactic treatment of migraines. It follows erenumab (Aimovig) and fremanezumab (Ajovy) and just like these two drugs it appears to be very safe and very effective for over 50% of patients. Galcanezumab is also administered by a monthly subcutaneous injection. The initial dose is two 120 mg injections, followed by a single 120 mg injection every month. Similarly to erenumab, it comes in an autoinjector pen which is easy to self-administer. Fremanezumab is not available in an autoinjector pen but only in a small prefilled syringe, which may make some patients hesitant to use it, however injecting with a prefilled syringe is often less painful. Galcanezumab and fremanezumab list as their only side effect injection site reaction, while erenumab also has the side effect of constipation. Erenumab was approved four months ago and at our Center we have already injected about 300 patients. Constipation is a problem for a small number of patients and in a couple of them it was severe enough that they stopped the injections. Fremanezumab was approved only a couple of weeks ago and we've treated only about a dozen patients so far, so it is too early to tell if it will also cause constipation. After all, these three drugs are similar to each other in that they block the effect of calcitonin gene-related peptide (CGRP), a chemical released during a migraine attack. The only difference in the way they work... --- ### 100 Migraine Drugs, A to Z: bisoprolol - Published: 2018-09-24 - Modified: 2018-09-24 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-bisoprolol/ - Categories: Headache medications, Migraine Bisoprolol (Zebeta) is one of about a dozen drugs in the beta-blocker family, medications that were developed for the treatment of high blood pressure, or hypertension. The oldest beta blocker, propranolol (Inderal) was approved by the FDA for the treatment of hypertension about 60 years ago and a decade later it was also approved for the prevention of migraine headaches. Timolol (Blocadren) is the only other beta blocker that is officially approved for migraines, but most likely they all work. Even though they are very similar, beta blockers may have different efficacy and especially, different side effects from patient to patient. A drug that works well and without side effects in one person may cause side effects in the next. Also, not all beta blockers have been subjected to rigorous double-blind trials for the prevention of migraines, so we tend to prescribe the ones that do have some evidence supporting their efficacy in migraines. Bisoprolol is one of the beta blockers that has scientific evidence suporting its use in migraines. A blinded study comparing bisoprolol, 5 mg with metoprolol (Lopressor, Toprol), 100 mg, another beta blocker showed them to be equally effective in the treatment of migraines. The European Federation of Neurological Societies recommends bisoprolol as a second-line beta blocker for the prophylactic treatment of migraine headaches, after propranolol and metoprolol. THe US guidelines list bisoprolol further down the list. --- ### Botox relieves hemiplegic migraine and migraine with aura - Published: 2018-09-22 - Modified: 2018-09-22 - URL: https://www.nyheadache.com/blog/botox-relieves-hemiplegic-migraine-and-migraine-with-aura/ - Categories: Botox, Chronic migraine, injections, Migraine A recent report by neurologists from the Mayo Clinic suggests that onabotulinumtoxinA (Botox) injections can relieve not only headache pain, but associated neurological symptoms, such as visual aura, numbness and weakness, which can precede or accompany a migraine attack. This article describes 11 patients with hemiplegic migraine, which means that these patients developed weakness on one side of their body prior and during an attack. From the description of these cases, it appears that at least a couple of patients had migraine with sensory-motor aura rather than true hemiplegic migraine. But regardless of the precise nature of their symptoms, Botox was effective in reducing these symptoms, along with headaches in 9 out of 11 patients. Ten of the 11 patients had chronic migraine and on average they failed five preventive drugs before starting Botox. Two of the physicians who wrote the report have already presented some of these cases in 2013. As mentioned in the blog post describing this older report, I have also successfully treated many patients with visual, sensory and motor aura with Botox injections. Just like with patients in the current article, many of my patient responded to Botox after failing several preventive drugs. We seem to understand how Botox relieves pain, but it is less clear how it helps neurological symptoms such as weakness, numbness and visual impairment. One possible explanation is that Botox reduces painful messages from the surface of the skull to the brain, which reduces excitability of the brain and this in turn... --- ### Fremanezumab (Ajovy), a second CGRP monoclonal antibody for migraines is approved - Published: 2018-09-17 - Modified: 2018-09-17 - URL: https://www.nyheadache.com/blog/fremanezumab-ajovy-a-second-cgrp-monoclonal-antibody-for-migraines-is-approved/ - Categories: Headache medications, Migraine Fremanezumab (Ajovy) was just approved by the FDA for the preventive treatment of migraine headaches. It is the second drug, following erenumab (Aimovig), with a similar mechanism of action. While erenumab blocks calcitonin gene-related peptide (CGRP) receptor, fremanezumab binds to the CGRP molecule and blocks its attachment to the CGRP receptor. Both are very effective in preventing migraine attacks and both, so far, appear to be very safe. Just like erenumab, it is approved for the prevention of migraines without regard to the frequency of attacks, unlike onabotulinumtoxinA (Botox), which is only approved for chronic migraines, which are defined as occurring on 15 or more days each month. Here are some differences between the two drugs that we know of so far. Fremanezumab can be injected monthly or with a triple dose, every three months. Considering that one of my patients developed a rash from erenumab (no surprise there - any drug can cause an allergic reaction), I probably will start with a single shot once a month and then may give a triple dose every three months. The second difference is that constipation is not listed as a side effect of fremanezumab in the FDA-approved prescribing information, while it is listed as occurring in 3% of patients on erenumab. Since these drugs have a similar mode of action, I will not be surprised if fremanezumab also causes constipation in some patients. So far, only two of my patients (out of about 300) declined to continue erenumab because of constipation.... --- ### 100 Migraine Drugs, A to Z: bupivacaine - Published: 2018-09-15 - Modified: 2018-09-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-bupivacaine/ - Categories: Headache medications, Migraine Bupivacaine (Marcaine, Sensorcaine) is a numbing agent (local anesthetic) similar to lidocaine (Xylocaine), but with a longer duration of effect. Bupivacaine effect lasts 4 to 8 hours, while lidocaine, only 2 hours. However, lidocaine begins to work in 2 to 5 minutes, while bupivacaine takes 5 to 10 minutes. We use bupivacaine to treat migraines in two ways. One is in combination with lidocaine to perform nerve blocks. Nerve blocks can be very effective in stopping a stubborn migraine that does not respond to medications such as triptans, NSAIDs, intravenous magnesium, ketorolac, and other. We also give nerve blocks to pregnant women who fail to respond to intravenous magnesium and before using systemic drugs, that is drugs taken by mouth or by injection and that are distributed throughout the body, including the fetus. The nerve blocks are done with small needles, although during a migraine attack even a small needle can be painful. However, relief from the numbing effect of lidocaine comes within minutes, while bupivacaine in the mixture provides longer lasting relief. Some headache specialists give regular nerve blocks every 3 months in place of onabotulinumtoxinA (Botox) injections. Nerve blocks are not as effective as Botox, but we do give nerve blocks when the effect of Botox wears off sooner than 3 months. Ideally, we try to give Botox earlier, but many insurance companies will not allow Botox injections more often than every 3 months. We also use bupivacaine by itself for sphenopalatine ganglion (SPG) blocks . These blocks... --- ### 100 Migraine Drugs, A to Z: dexamethasone - Published: 2018-09-10 - Modified: 2018-09-10 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-dexamethasone/ - Categories: Headache medications, Migraine Dexamethasone (Decadron) is a strong corticosteroid (steroid) anti-inflammatory medication similar to prednisone and methylprednisolone (Medrol). Considering that inflammation occurs during a migraine attack and that non-steroidal anti-inflammatory drugs (NSAIDs) work well for migraines, you'd expect that a steroid medication would also be effective. And they do help, but mostly in combination with migraine drugs such as sumatriptan (Imitrex), rizatriptan (Maxalt) and other. In a blinded study, 4 mg of dexamethasone given along with 10 mg of rizatriptan was more effective than rizatriptan alone and it reduced the rate of migraine recurrence. Dexamethasone given intravenously in an emergency room setting also reduced the rate of migraine recurrence. The usual oral and intravenous dose of dexamethasone is between 4 mg and 12 mg. Potential side effects include anxiety, or feeling "hyper", depression, insomnia, dizziness, upset stomach, increased blood sugar, and other. The multitude of potential side effects is why we first try triptans (tablets and injections), NSAIDs, and nausea medications, before adding steroids. When these drugs not help and intravenous treatment is called for (and the patient is able to come to our office), before giving steroids we try magnesium sulfate, ketorolac (Toradol), ondansetron (Zofran) or metoclopramide (Reglan), and dihydroergotamine (DHE-45). We may also give nerve blocks or a sphenopalatine ganglion block to avoid giving a steroid medication. --- ### 100 Migraine Drugs, A to Z: codeine - Published: 2018-09-05 - Modified: 2018-09-05 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-codeine/ - Categories: Headache medications, Migraine Codeine is a mild opioid (narcotic) pain killer, which has less of an addiction potential of butorphanol, described in the previous post, or most other opioid drugs. However, it definitely can cause addiction and can be a "gateway drug" leading to the abuse of stronger prescription and illicit drugs. Some countries allow codeine to be sold without a doctor's prescription, but it is always in a combination with other drugs. In Canada, codeine has to be mixed with two other drugs, usually with acetaminophen and caffeine and it is sold without a prescription, but from behind the counter rather than from open shelves. A combination of codeine with caffeine, butalbital and either acetaminophen or aspirin (Fioricet with codeine and Fiorinal with codeine) is particularly problematic because caffeine can also cause medication overuse headache and butalbital is also addictive. The main problem with codeine is that just like other opioid drugs it is not very effective and can cause or worsen nausea. If taken regularly (more than once a week) opioids can also cause medication overuse (or rebound) headache even in the absence of addiction. Codeine with acetaminophen is worth considering if triptans (sumatriptan or Imitrex and similar drugs) and NSAIDs (Advil or ibuprofen, Aleve or naproxen, and other) are ineffective or contraindicated. I do have patients taking Fioricet or Fiorinal with codeine or codeine with acetaminophen with good relief and few side effects, but I can count those patients on the fingers of one hand. --- ### 100 Migraine Drugs, A to Z: butorphanol - Published: 2018-09-03 - Modified: 2018-09-03 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butorphanol/ - Categories: Headache medications, Migraine Butorphanol nasal spray (Stadol NS) is approved by the FDA for the treatment of acute migraine attacks. It belongs to the agonist-antagonist type of opioid (narcotic) drugs, while morphine, methadone, oxycodone, and most other opioids are pure agonist drugs. The agonist-antagonist drugs were originally thought to be less addictive, but unfortunately this is not the case. Also, opioid analgesics despite being very strong pain killers, are not very effective for the treatment of migraines. This is in part due to the fact that migraine pain is accompanied by nausea (and other symptoms), while opioids tend to cause nausea or make it worse. Other side effects of butorphanol include constipation, upset stomach, dizziness, drowsiness, feeling strange or even having frank hallucinations. The bottom line, despite the fact that it is FDA-approved for migraines, stay away from butorphanol - it is only modestly effective and has many potential side effects, including addiction. --- ### Botox for migraines in children - Published: 2018-08-27 - Modified: 2018-08-27 - URL: https://www.nyheadache.com/blog/botox-for-migraines-in-children/ - Categories: Botox, Headaches in children, Migraine Injections of onabotulinumtoxinA (Botox) are approved for the treatment of chronic migraine headaches in adults. Botox is also widely used off-label (not an FDA-approved use) for the treatment of migraines in children. We know that botulinum toxin is safe in children because another very similar form of botulinum toxin, abobotulinumtoxinA (Dysport) is approved for the treatment of cerebral palsy in children as young as 2. The youngest child with chronic migraines whom I treated with Botox was 8 years old. Two groups of physicians presented results of their treatment of migraines in children with Botox at the recent annual scientific meeting of the American Headache Society held in San Francisco. The first report, whose lead author was Ilya Bragin of St. Luke's University Health Network describes positive results of Botox injections in 30 adolescents with chronic migraines. All 30 had to fail amitriptyline (Elavil) and topiramate (Topamax) to be eligible to receive Botox. Seven of of them had a history of a head trauma. The adult injection protocol of 155 units injected into 31 sites was followed. Both migraine frequency and severity improved with no reported side effects. The second report from doctors in Delaware describes 44 children aged 11 to 20, who were treated with Botox for their chronic migraines. The dose ranged from 35 to 155 units, depending on pain location and child's tolerance of injections. About 70% of children had at least a 50% improvement in their migraine frequency and severity. No child developed any side effects.... --- ### 100 Migraine Drugs, A to Z: cyproheptadine - Published: 2018-08-22 - Modified: 2018-08-22 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-cyproheptadine/ - Categories: Headache medications, Migraine Cyproheptadine (Periactin) is one of the most popular drugs for the prevention of migraine headaches in children. Unfortunately, there is only one scientific study suggesting that cyproheptadine (4 mg per day) is as effective as propranolol (80 mg per day) for the prevention of migraines in patients aged from 16 to 53. There are no double-blind placebo-controlled trials of this drug in children and it is not likely that any will be conducted. It may not be such a big loss since most headache specialists do not consider it to be very effective. Cyproheptadine is an anti-histamine, which means that if allergies contribute to migraines, it could help. It is available in 2 mg and 4 mg tablets and the dose ranges from 2 to 12 mg taken at bedtime. Some kids can tolerate as much as 8 mg taken three times a day. The drug is popular with pediatricians because it is fairly safe, even if it is not very effective. Common side effects are sleepiness, dizziness, dry mouth, and weight gain. Parents of very skinny kids and of kids who are finicky eaters may like the weight gain. --- ### 100 Migraine Drugs, A to Z: clonidine - Published: 2018-08-19 - Modified: 2018-08-19 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clonidine/ - Categories: Headache medications, Migraine Blood pressure medication propranolol was the first preventive drug approved for the treatment of migraine headaches over 50 years ago. It belongs to the family of beta blockers, but other types of blood pressure drugs can be effective for migraines as well. Clonidine (Catapres) works not on beta but alpha receptors and has very limited scientific evidence for its efficacy in the prevention of migraines. It is used only if other blood pressure medications are ineffective, cause side effects, or are contraindicated. It is in category C of evidence (possibly effective) of the migraine treatment guidelines issued by the American Academy of Neurology. Clonidine is also used to treat pain, but the evidence that it really helps is also slim. Anecdotally, it seems to help reduce withdrawal symptoms when stopping opioid (narcotic) drugs. Besides beta blockers, ACE inhibitors (lisinopril), ACE receptor blockers (candesartan, olmesartan) and calcium channel blockers (flunarizine, verapamil) are probably more effective for the prevention of migraine headaches than clonidine, but most are also in the same category C - possibly effective. --- ### 100 Migraine Drugs, A to Z: clonazepam - Published: 2018-08-15 - Modified: 2018-08-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-clonazepam/ - Categories: Headache medications, Migraine Clonazepam (Klonopin) is a drug approved for the treatment of panic attacks and certain types of seizures. It is also used "off label" to treat anxiety, insomnia, and muscle spasm. Clonazepam belongs to the family of benzodiazepines, which includes diazepam (Valium), alprazolam (Xanax), and lorazepam (Ativan). Clonazepam tends to have a longer lasting effect and it is thought to be less likely to cause physical and psychological dependence and tolerance, i. e. the need to keep increasing the dose to achieve the same effect. Clonazepam is not the first or even the tenth choice when treating migraine headaches. However, adding clonazepam to other medications can provide significant relief. This could be in part due to the fact that patients with migraines are 2-3 times more likely to have anxiety and panic attacks. They are also often anxious about getting their next migraine and this anxiety and tension becomes a self-fulfilling prophesy. Anecdotal reports, including one from a fellow headache expert and friend, Dr. Morris Meizels, suggest that in some patients who do not respond to a variety of other treatments, clonazepam can be very effective. I use it in a very small number of patients whose anxiety, neck pain, and/or insomnia are major contributors to their migraine headaches and whose migraines do not respond to several standard preventive therapies. Before prescribing clonazepam, among the medications we try first are antidepressants, such as nortriptyline or duloxetine. These have no risk of addiction, but sometimes can be difficult to stop due to... --- ### 100 Migraine Drugs, A to Z: chlorpromazine - Published: 2018-08-08 - Modified: 2018-08-08 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-chlorpromazine/ - Categories: Headache medications, Migraine Chlorpromazine (Thorazine) belongs to the phenothiazine family, which includes prochlorperazine (Compazine) and promethazine (Phenergan), drugs used to treat nausea and vomiting. These drugs can relieve not only the accompanying nausea, but the migraine headache as well. The Australian & New Zealand Association of Neurologists recommends chlorpromazine as one of the drugs for the treatment of moderate to severe migraine in an emergency setting. Chlorpromazine is approved for the treatment of schizophrenia, severe mania and also for nausea, vomiting, severe hiccups, and other conditions. Chlorpromazine is considered to be a stronger antiemetic (anti-nausea) drug than prochlorperazine and promethazine, but it can have more side effects. Side effects include dizziness, drowsiness, but the most unpleasant side effect is severe restlessness and involuntary movements. Some patients describe it as wanting to crawl out of their skin. This side effect usually can be relieved by diphenhydramine (Benadryl). Prolonged use of phenothiazines can lead to persistent involuntary movements, which are extremely unpleasant and do not go away after the medicine is stopped. Higher incidence of side effects is why chlorpromazine should be used for nausea only if milder drugs such as ondansetron (Zofran), metoclopramide (Reglan) and prochlorperazine (Compazine) do not help. --- ### 100 Migraine Drugs, A to Z: cannabidiol - Published: 2018-08-06 - Modified: 2018-08-06 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-cannabidiol/ - Categories: Alternative Therapies, Headache medications, Migraine Medical marijuana (MM) is now legal in 30 states. Most states approve its use for specific medical conditions and severe pain and nausea, which are symptoms of migraine, are usually on the list. I've been prescribing MM since it was legalized in the State of NY four years ago. My estimate is that one out of three patients find it useful. Some take it daily for the prevention of migraine attacks, but the majority use it as needed, whenever an attack occurs. MM sometimes relieves all of the symptoms of migraine, but sometimes only pain or only nausea. Some patients find that it helps them to go to sleep and when they wake up, the headache is gone. A few patients have told me that they take it regularly for insomnia and that it often works better than prescription drugs, such as zolpidem (Ambien) and does not cause side effects. The calming effect of MM is also useful when dealing with a very upsetting and debilitating condition such as migraine. Most states require an analysis of the amount of active ingredients in every MM product by an independent laboratory. The two main ingredients are tetrahydrocannabinol (THC) and cannabidiol (CBD). This is one of the advantages of going the legal route - you know that the product will be the same each time you buy it. However, my patients have told me that they prever products from one or another dispensary even when using products with the same concentration of THC... --- ### How to quickly relieve painful knots in the shoulders - Published: 2018-08-04 - Modified: 2018-08-05 - URL: https://www.nyheadache.com/blog/how-to-quickly-relieve-painful-knots-in-the-shoulders/ - Categories: Alternative Therapies, Pain Almost everyone has an occasional pain in the upper back and shoulders, often caused by prolonged sitting in front of a computer or just by stress. The pain is due to muscle spasm and keeping those muscles in good shape helps prevent this problem. It also helps to be aware of your body through regular meditation practice or Awareness Through Movement method developed by an Israeli physicist Moshe Feldenkrais. I’ve posted Feldenkrais exercise videos for neck pain here and here. Most people are shocked at the immediate improvement in the range of movements they notice even after the first set of exercises. I recently had a tight knot in one of my shoulders which did not go away after 90 minutes of hot yoga. Lying on the floor at the end of the yoga session I did a 5-minute Feldenkrais exercise which made the knot melt away. In this video I demonstrate this exercise that relaxes tight muscles and stops shoulder and upper back pain. Instead of watching the video you can follow these written instructions: Lie down on your back with a thin pillow or a soft pad under your head. Spend a minute paying attention to spots where your head, shoulders, back, arms and legs touch the ground. Then, bend your knees and keep your feet flat on the floor. Stretch your arms in front of you and put your palms together with your arms forming a tall triangle. Keep your eyes on the thumbs and slowly lift... --- ### 100 Migraine Drugs, A to Z: candesartan - Published: 2018-07-23 - Modified: 2018-07-23 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-candesartan/ - Categories: Headache medications, Migraine Candesartan (Atacand) is a blood pressure medication in the class of ACE receptor blockers (ARBs), none of which are approved for the treatment of migraines. Because they are available in a cheap generic form no pharmaceutical company will spend hundreds of millions of dollars on large trials required for the official FDA approval. This does not mean that unapproved drugs are ineffective, it's just the evidence is weaker because it is based on small trials. Unfortunately, only four oral drugs are FDA-approved for the prevention of migraines - two beta blockers and two epilepsy drugs (Botox and Aimovig or erenumab are injectable). So most of the preventive drugs we prescribe are "off label", that is they lack FDA approval. Candesartan was first shown to work for the prevention of migraine headaches in a 60-patients Norwegian trial published in JAMA in 2003. This was a double-blind crossover trial, which means that half of the patients were first placed on a placebo and then switched to candesartan and the second group started on candesartan and then were switched to placebo. This trial showed that when compared to placebo, 16 mg of candesartan resulted in a very significant reduction in mean number of days with headache, hours with headache, days with migraine, hours with migraine, headache severity index, level of disability, and days of sick leave. Candesartan was very well tolerated - there was no difference in side effects in patients taking the drug and those taking the placebo. In another trial, the... --- ### 100 Migraine Drugs, A to Z: butterbur - Published: 2018-07-22 - Modified: 2018-07-22 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butterbur/ - Categories: Alternative Therapies, Migraine The New York Headache Center participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in Neurology and the American Academy of Neurology endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex), where it had to pass strict safety studies. However, Germany does not allow butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur is still made in Germany and is sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany. The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their manufacturing plant in Germany. However, my concerns about butterbur have not been addressed. Here is my email response to the manufacturer: “Thank you for this additional information. It is good to see that the FDA conducted a “comprehensive inspection” of the manufacturing facility in Germany. However, my concerns about the safety of Petadolex are not due to possible deficiencies in manufacturing, but are related to the extraction process. As far as I know, this is why German... --- ### 100 Migraine Drugs, A to Z: caffeine - Published: 2018-07-16 - Modified: 2018-07-16 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-caffeine/ - Categories: Headache medications, Headaches, Migraine Caffeine can be considered a drug since it is available in a pure form in tablets and injections. It is also included in medications, such as Excedrin, Fioricet, and Fiorinal. It is considered to be an analgesic adjuvant, meaning that it enhances the effect of other pain medicines, such as aspirin and acetaminophen, but it has been shown to relieve tension-type headaches by itself as well. However, there are no studies showing that caffeine alone taken by mouth relieves migraine headaches. It does enhance the effect of acetaminophen and aspirin in Excedrin and this combination has been proven to relieve mild and moderately severe migraines. In a pilot open-label study of intravenous infusion of 60 mg of caffeine citrate for an acute migraine showed significant relief within an hour of infusion. The study was published in 2015 in the Journal of Caffeine Research (who knew such a journal existed). Besides caffeine, Fioricet, Fiorinal, and Esgic contain either acetaminophen or aspirin and butalbital, which is a barbiturate. Barbiturates are used for epilepsy, anesthesia, and in the past had been used for insomnia. However, they are addictive and they are no longer widely used. However, butalbital's use in headache products stubbornly persists despite its addictive nature and lack of proof that it relieves migraines. These products can cause not only addiction, but also medication overuse headaches, most likely due to their caffeine content. Caffeine can cause headaches directly, but much more often the headache is due to caffeine withdrawal when it is... --- ### 100 Migraine Drugs, A to Z: Boswellia - Published: 2018-07-15 - Modified: 2018-07-15 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-boswellia/ - Categories: Alternative Therapies, Headache medications Boswellia serrata is not a drug, but a plant, but I am including herbal products as well if a serious scientific journal has published articles on it. Most of the available information on Boswellia is in mentioned in my previous post. I would only add that of all herbal products, Boswellia is the first one I recommend because it is very safe and I continue to see many patients who respond well to it. My preferred brands of Boswellia are Nature's Way and Pure Encapsulations, although Nature's Way is cheaper. --- ### A new book on headaches that is worth reading - Published: 2018-06-25 - Modified: 2018-06-25 - URL: https://www.nyheadache.com/blog/a-new-book-on-headaches-that-is-worth-reading/ - Categories: Alternative Therapies, Headaches Jan Mundo, who is a Somatic and Headache Coach, and Bodyworker just wrote a book, The Headache Healer’s Handbook, which was published by the New World Library. I've known Jan and her wonderful work with headache patients for many years and was happy to write a foreword to her very readable and useful book. Here is the foreword: Headaches afflict close to half of the US population with 40 million suffering from migraines, which can be very disabling. Many books have been written for the general public, including two of my own, but Jan Mundo’s Headache Healer’s Handbook brings a unique perspective to this problem. When I treat patients in the office, they are usually reassured by the fact that I am also a migraine sufferer and so it is with Jan’s book – she knows first-hand what it feels like to have a migraine. More importantly, she has discovered ways to relieve her own attacks and those of other countless migraineurs. Like Jan, I am a big proponent of non-drug treatments and this is what she details in her book. I also like her hands-on approach, both literally and figuratively. Psychologists have proven that active treatments, where people are doing things to improve their condition, are much more effective than passive treatments, such as massage, chiropractic, and acupuncture, where things are done to them. This leads to the transfer of external locus of control to internal locus of control or in other words, a shift from a passive and... --- ### 100 Migraine Drugs, A to Z: baclofen - Published: 2018-06-23 - Modified: 2018-06-23 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-baclofen/ - Categories: Headache medications, Migraine Baclofen (Lioresal) is one of several muscle relaxants that have been tested for the treatment of migraine headaches. The testing was not very rigorous - baclofen was subjected only to one open label trial. The trial done by an Israeli neurologist, Dr. Rachel Hering-Hanit involved 54 patients. After a 4-week baseline assessment period, patients were given baclofen for 12 weeks. The drug was given three times a day with the dose ranging from 15 to 40 mg. What was impressive about this study is that not only 86% of patients improved by at least 50%, but also that 51 out of 54 patients completed the study. It is very likely that many would have dropped out if the treatment was ineffective or had a high rate of side effects. Only 3 patients dropped out because of side effects. Dr. Hering-Hanit also tested baclofen in 9 cluster headache sufferers with six improving within a week on doses ranging from of 15 to 30 mg. The main side effect of this drug is drowsiness. Some patients may not need to take it three times a day - one nightly dose may suffice. I start with 10 mg nightly and gradually increase the dose. However, another muscle relaxant, tizanidine has been shown to relieve chronic migraine in double-blind studies and I tend to use it much more frequently than baclofen. Tizanidine has the same main side effect - sedation. --- ### 100 Migraine drugs, A to Z: butalbital - Published: 2018-06-20 - Modified: 2018-06-20 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-butalbital/ - Categories: Headache medications, Migraine Butalbital, a short-acting barbiturate, is one of the three ingredients in headache drugs such as Fioricet, Fiorinal, Esgic and their generic equivalents. Fiorinal and Fioricet derive their name from the Montefiore Headache Clinic, where they were developed over 60 years ago. In those days extensive clinical trials were not required by the FDA and they were approved without much testing. The approval was and still is only for the treatment of tension-type headaches. They have never been shown to be effective for migraines, although this is what they are mostly used for. Fioricet and Esgic contain butalbital, caffeine, and acetaminophen, while in Fiorinal acetaminophen is replaced with aspirin. Neurologists have a strong dislike of this drug, although general practitioners tend to like it because they are very familiar with it. The dislike comes from the fact that butalbital is addictive and caffeine can make headaches worse. I've seen patients who openly admitted that they often take Fiorinal to relieve anxiety and many become physically dependent and addicted to it. My most memorable patient was one who took 20 to 30 tablets every day. I had to hospitalize her for detoxification. In patients who take more than 5-6 tablets a day sudden discontinuation can lead to an epileptic seizure. We usual switch patients to a long-acting barbiturate, phenobarbital, which is easier to stop. Withdrawal from caffeine worsens headaches, for which sumatriptan tablets or injections can help. Botox injections and other preventive migraine drugs can also make the withdrawal process less painful.... --- ### Orgasmic headaches - Published: 2018-06-16 - Modified: 2018-06-16 - URL: https://www.nyheadache.com/blog/orgasmic-headaches/ - Categories: Headaches Headaches that occur during sexual activity tend to elicit fear and embarrassment. Embarrassment is why most people are not aware that this is a fairly common condition - you would not share your experience at a party. The fear is justified - a rupture of an aneurysm in the brain is a deadly condition with 40% of patients dying before they reach the hospital. Fortunately, even though the pain is excruciating, in the vast majority of cases, the pain of an orgasmic headache is brief and the cause is benign. Sex-induced headaches are three times more common in men. In 80% of people the pain is sudden, occurs at the time of the orgasm, and lasts 30 minutes to a couple of hours. In the remaining 20%, the pain builds up gradually during sex before the orgasm and often does not reach a crescendo if the sexual activity is aborted. These headaches tend to be common during sex with the usual partner or less often with masturbation. Anecdotally, aneurysm rupture is more likely to occur during an extramarital affair - due to the divine punishment, or more likely, greater excitement and higher elevation of blood pressure than what would occur with the spouse. This post was prompted by a recent patient who developed an orgasmic headache during masturbation for the first time at the age of 60. The headache had occurred the day before and had completely resolved by the following day. However, with the first orgasmic headache we usually... --- ### 100 Drugs for Migraine, A to Z: buspirone - Published: 2018-06-13 - Modified: 2018-06-13 - URL: https://www.nyheadache.com/blog/100-drugs-for-migraine-a-to-z-buspirone/ - Categories: Headache medications, Migraine Anxiety is one of the conditions comorbid with migraines - if you have migraines you are 2-3 times more likely to suffer from anxiety as well. The relationship is bidirectional, meaning that if you have anxiety, you are more likely to develop migraines. Antidepressants are proven to relieve anxiety even in the absence of depression and they are a better long-term solution than anxiety drugs such as diazepam (Valium) or alprazolam (Xanax) because they are not addictive and do not lose their efficacy over time. A unique drug that is used only for anxiety and not depression and does not cause addiction, is buspirone (Buspar). Several studies suggest that buspirone is effective for the treatment of migraines. In a 74-patient randomized, prospective, parallel group, double-blind, placebo-controlled study (the most rigorous type of study) headache frequency showed a 43% reduction in the buspirone-treated group, but only a 10% reduction in the placebo group. This effect was independent of the presence or absence of anxiety. Similarly, antidepressants prevent migraines even if the patient is not depressed. Buspirone has a favorable side effect profile and it does not cause withdrawal symptoms, which is often a problem with other anxiety drugs and to a lesser extent, antidepressants. --- ### Update: I injected myself with Aimovig (erenumab) and here's what happened so far - Published: 2018-06-10 - Modified: 2018-06-10 - URL: https://www.nyheadache.com/blog/update-i-injected-myself-with-aimovig-erenumab-and-heres-what-happened-so-far/ - Categories: Headache medications, Migraine On June 1, I injected myself with erenumab (Aimovig). I still had to take sumatriptan for an incipient migraine on June 2 and June 5. On Thursday, June 7, I had a glass of red wine (pinot noir) with dinner and had no headache. Last night, June 9, I decided to stress-test my response to erenumab and had a beer before dinner and a big glass of sparkling wine with dinner. In the past, this combination had always resulted in a migraine a few hours later. This time, nothing happened! And here is an excerpt from an email from a patient who was one of the first to receive Aimovig: "Hello Doctor, It has been a week now and I wanted to share with you the outcome. It’s a very important improvement as I was able to stop taking Relpax compared to 40mg a day! 3-4 times I felt the migraine coming but it was like « stopped » and I was feeling ok. It happened during the day and at night twice. Overall it’s a fantastic improvement. " Certainly, this all could be due to the placebo effect, but I doubt it, especially because my migraines did not stop right after the injection. I should stress that erenumab is not going to help everyone. Clinical trials suggest that about 60% of migraine sufferers will benefit, but this is a very high success rate, especially considering the lack of any significant side effects. Cheers! --- ### 100 Migraine Drugs, A to Z: botulinum toxin - Published: 2018-06-07 - Modified: 2018-06-07 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-botulinum-toxin/ - Categories: Botox, Headache medications, Migraine The FDA has approved 4 different types of botulinum toxin for various therapeutic indications. The oldest, the most popular and the only one approved for the prevention of chronic migraines is onabotulinumtoxinA, or Botox. I've been injecting Botox for headaches for over 25 years and have written many blog posts and long articles about it. You can read about Botox for kids with chronic migraines in this post. A new development in the botulinum toxin field is a long-acting form of botulinum toxin, daxibotulinumtoxinA , which may become available in a couple of years. Its effect on muscles and nerve endings appears to last 6, instead of the 3 months seen with Botox. --- ### 100 Migraine drugs, A to Z: Atenolol - Published: 2018-06-04 - Modified: 2018-06-04 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-atenolol/ - Categories: Headache medications Atenolol (Tenormin) is a blood pressure medicine in the beta blocker family. Atenolol is considered to be equally effective in preventing migraines to propranolol (Inderal), which was the first drug to be approved for the prevention of migraines over 50 years ago. The effect of atenolol lasts all day and it can be taken once a day. It has the same side effect profile as propranolol. The most common side effects are caused by excessive lowering of blood pressure or slowing of the pulse rate and include fatigue, lightheadedness, exercise intolerance, cold extremities, and occasionally impotence, depression and insomnia. Some but not all beta blockers can worsen asthma. You do not have to have high blood pressure to take atenolol or another beta blocker - they prevent migraines even if blood pressure is normal. We still do not know how these drugs prevent migraines. We do not prescribe beta blockers if the blood pressure is low (below 110/70) because the risk of side effects is high. However, if the blood pressure is in the middle of normal range or higher, this is a good choice. Beta blockers also help with anxiety and many performers take them only before giving a speech, a presentation, or a musical performance. Under these circumstances, a short-acting beta blocker, such as propranolol is a better choice than atenolol. Beta blockers are also very effective for the benign essential or familial tremor. --- ### I just injected myself with erenumab (Aimovig) - Published: 2018-06-02 - Modified: 2018-06-02 - URL: https://www.nyheadache.com/blog/i-just-injected-myself-with-erenumab-aimovig/ - Categories: Headache medications, Migraine, New treatments As expected, we've been overwhelmed by the demand for the new preventive therapy for migrianes, erenumab (Aimovig). It offers a unique and highly effective therapy with virtually no known side effects, at least so far. My patients are usually glad to hear that I have migraines (without an aura, but I also have auras without a headache) because I can better relate to their experience. They often ask if I had tried this or another treatment and indeed, I've tried many, sometimes less out of necessity but more for the experience. I have never tried drugs such as topiramate (Topamax) or divalproex (Depakote) because they have many potentially serious side effects and I prescribe them very reluctantly after trying many other treatments. I have injected myself with Botox on two occasions, have given myself a nerve block and an intravenous infusion of magnesium. Luckily, even when I have periods of very frequent attacks, my migraines are easily controlled with sumatriptan tablets or injections. I prefer injections when I want quick relief, such as before going to bed, in the middle of the night, or during a busy work day. Although over 3,000 patients have been exposed to erenumab in clinical trials and some of them have been on it for 5 years, the true safety of the drug may not be known for at least another 3-5 years. Even though my migraines do not cause any disability or interfere with my life (except for the need to avoid wine), in... --- ### Cannabis relieves pain in the elderly - Published: 2018-05-23 - Modified: 2018-05-23 - URL: https://www.nyheadache.com/blog/cannabis-relieves-pain-in-the-elderly/ - Categories: Alternative Therapies, Headache medications, Pain, Pain Research Medical marijuana appears to be very effective for the treatment of pain, according to a new study just published in the European Journal of Internal Medicine. The study was conducted by researchers at the Soroka University Medical Center, Ben-Gurion University of the Negev, in Be'er-Sheva, Israel. Israeli scientists have been at the forefront of the research of medical applications of cannabis, starting with the discovery of THC in 1964 by a Hebrew University professor Raphael Meshulam. In the current study, the researchers evaluated 2736 patients above 65 years of age who received medical cannabis from January 2015 to October 2017 in a specialized medical cannabis clinic. The mean age was 74 years. The most common indications for cannabis treatment were pain (67%) and cancer (61%). After six months of treatment, 94% of the respondents reported improvement in their condition and the reported pain level was reduced from a median of 8 on a scale of 0-10 to a median of 4. Most common adverse events were dizziness (9. 7%) and dry mouth (7. 1%). After six months, 18. 1% stopped using opioid (narcotic) analgesics or reduced their dose. The authors concluded that "the therapeutic use of cannabis is safe and efficacious in the elderly population. Cannabis use may decrease the use of other prescription medicines, including opioids. " Even though it was a very large study, it was an observational study with its obvious limitations. They also stressed the need for double-blind prospective trials to confirm the safety and efficacy... --- ### A very promising new treatment for cluster headaches - Published: 2018-05-21 - Modified: 2018-05-21 - URL: https://www.nyheadache.com/blog/a-very-promising-new-treatment-for-cluster-headaches/ - Categories: Cluster headaches, Headache medications A new and very promising preventive treatment for cluster headaches being developed by Eli Lilly may become available in the near future. We hope that the FDA recognizes that this is a relatively rare condition with few available treatments and will not require extensive clinical trials, especially because the safety of this drug has been demonstrated in a large number of migraine patients. CGRP monoclonal antibodies are very effective for the prevention of migraines and four companies are developing such drug. Thankfully, one of these companies, Eli Lilly decided to study this type of treatment for cluster headaches. The company just announced the results of a phase 3 trial in 106 patients that showed their product, galcanezumab to be effective in preventing episodic cluster headaches. The drug did not help prevent attacks in patients with chronic cluster headaches, which constitute 10-15% of cluster patients. Last week, the first CGRP monoclonal antibody, erenumab (Aimovig) was approved for the preventive treatment of migraine headaches. Considering that all four CGRP drugs are similar, it is possible that erenumab is also effective for cluster headaches. However, because it was not studied for this indication and has no FDA-approval, insurance companies are not likely to pay for it. On the other hand, cluster attacks last one to three months, so the cost is less prohibitive than it is for the long-term treatment of migraines and patients are more desperate to find relief at any cost. Cluster headaches affect less than 0. 5% of the population... --- ### Migraine drugs, A to Z: timolol eye drops - Published: 2018-05-19 - Modified: 2018-05-19 - URL: https://www.nyheadache.com/blog/migraine-drugs-a-to-z-timolol-eye-drops/ - Categories: Headache medications, Migraine Propranolol (Inderal) and other blood pressure medications in the beta blocker family are effective for the prevention of migraines. In a previous post 4 years ago I mentioned a report of 7 patients whose migraines were aborted with beta blocker, timolol, eye drops that are used to treat glaucoma. The same group of doctors at the University of Missouri, Kansas City conducted a double-blind crossover study of timolol eye drops for the treatment of acute migraines. The results of the trial were published this month in JAMA Neurology. The treatment consisted of 4 drops of 0. 5% timolol (this compares with 10 to 30 mg dose taken orally. Ten patients treated almost 200 migraine attacks. Four participants found timolol highly effective compared with placebo and one patients rated placebo as highly effective compared with timolol. No side effects were observed. Instilling timolol eye drops is not likely to become widely used for the treatment of acute migraines. However, this treatment maybe worth trying in patients who do not respond or do not tolerate triptans and NSAIDs. --- ### Aimovig (CGRP monoclonal antibody) is approved by the FDA! - Published: 2018-05-18 - Modified: 2018-05-18 - URL: https://www.nyheadache.com/blog/aimovig-cgrp-monoclonal-antibody-is-approved-by-the-fda/ - Categories: Uncategorized 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. --- ### 100 Migraine drugs, A to Z: Amlodipine - Published: 2018-05-16 - Modified: 2018-05-16 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amlodipine/ - Categories: Headache medications Calcium channel blockers, a family of drugs used to treat hypertension, are sometimes used for the prevention of migraine headaches. Anecdotal reports suggest that verapamil (Calan) can treat migraine with aura and other neurological symptoms. Double-blind trials of verapamil for the prevention of migraines have been unconvincing. Verapamil seems to be more effective for the prevention of cluster headaches, but even there the evidence is anecdotal. Amlodipine (Norvasc) is another calcium channel blocker that has been reported to prevent migraine headaches, although reports include a very small number of patients. Since verapamil has been studied more extensively, it is usually used first. However, if verapamil works well but causes constipation, which can be severe, we usually switch to amlodipine. Amlodipine is less likely to cause constipation, but both drugs can cause swelling of the ankles, dizziness and other side effects. --- ### 100 Migraine drugs, A to Z: Amitriptyline - Published: 2018-05-14 - Modified: 2018-05-14 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amitriptyline/ - Categories: Headache medications Amitriptyline (Elavil) and other drugs in the family of tricyclic antidepressants have been proven to be very effective in the preventive treatment of migraine headaches and many other painful conditions. Several double-blind, placebo-controlled trials have proven the utility of amitriptyline for the prevention of migraines. Amitriptyline is also an effective antidepressant, so it is perfect for patients with anxiety or depression. However, its effect on migraines and pain is proven to be independent of its effect on depression. That is, even in the absence of depression or anxiety, the drug prevents migraines and relieves pain. Amitriptyline has an additional benefit for people with insomnia - it helps sleep. On the other hand, in some people this effect lasts too long and they feel sleepy or tired the next day. In such cases we try a different and less sedating tricyclic antidepressant, such as nortriptyline (Pamelor), desipramine (Norpramine), or protriptyline (Vivactil). This potential side effect is why we always start this and most other preventive drugs at a small dose, 10 or 25 mg nightly. Some people need only 25 mg, while other require 100 mg. This is often due to the variable absorption of the drugs. Fortunately, in case of amitriptyline a simple blood test can tell us how much of the drug is being absorbed. Some patients will achieve a good therapeutic level with 25 mg, while others need 100 or 150 mg. So, in the absence of side effects and lack of relief, the dose is slowly increased.... --- ### 100 Migraine drugs, A to Z: amiloride - Published: 2018-05-12 - Modified: 2018-05-12 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amiloride/ - Categories: Headache medications, Migraine Only about 20% of migraine sufferers experience an aura. The most common type of aura is visual and it typically consists of partial obscuration of vision with colorful zigzags and blind spots spreading over half of the visual field of both eyes. Sometimes, the aura consists of gradual narrowing of the visual fields which ends in tunnel vision or complete loss of vision. The typical duration is 20 to 60 minutes and usually the aura itself is not disabling, but the headache that follows can be more severe than during attacks without aura. Migraine aura can occur without a subsequent headache. In some people aura does interfere with normal functioning and can be more disabling than the headache. In rare instances, the visual disturbance persists for days, weeks, and months. In such cases I do a battery of blood tests, including for RBC magnesium, vitamin B12, homocysteine, CoQ10 levels, and other. If RBC magnesium level is low or at the bottom of normal range, a gram of magnesium sulfate given intravenously can abort the aura. We sometimes give an infusion of magnesium without first doing a blood test. Amiloride (Midamore) is a potassium-sparing diuretic (water pill), which means that unlike most diuretics, it does not deplete potassium. It is used to treat high blood pressure, heart failure and to remove excess fluid in the body. It has been reported to reduce aura and headache symptoms in 4 of 7 patients with otherwise intractable aura. Potential side effects of amiloride include... --- ### 100 Migraine drugs, A to Z: Alpha-lipoic acid - Published: 2018-05-09 - Modified: 2018-05-09 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-alpha-lipoic-acid/ - Categories: Headache medications, Migraine Alpha-lipoic acid is one of the natural supplements included in this list of 100 migraine drugs. According to a study by Magis and colleagues, a daily dose of 600 mg of alpha- lipoic acid (known as thioctic acid in some countries) was significantly better than placebo in reducing the frequency of migraine attacks, headache days and pain severity. No side effects were reported in this 44-patient study. However, some of my patients have complained of upset stomach, which is not surprising since it is an acid. This was a small study and it does not conclusively prove that alpha-lipoic acid relieves migraines. The use of this supplement is most proven in the treatment of peripheral neuropathies, which suggests that it may work for other neurological conditions such as migraine. Alpha-lipoic is being investigated as a treatment for multiple sclerosis, Alzheimer’s, diabetes, strokes and other conditions. --- ### Brain is damaged by repeated head trauma, even without a concussion - Published: 2018-05-01 - Modified: 2018-05-01 - URL: https://www.nyheadache.com/blog/brain-is-damaged-by-repeated-head-trauma-even-without-a-concussion/ - Categories: Brain disorders, Head trauma A group of American and Israeli researchers published a study in the journal Brain, suggesting that hits to the head, even those that do not cause an overt concussion, contribute to the chronic traumatic encephalopathy (CTE). CTE has been found in many football players, combat veterans, and other athletes who suffer from repeated head injuries. The current study examined brains of four teenage athletes who had sustained repetitive hits to the head in the days and weeks before their death. They did not have typical symptoms of concussion - headaches, dizziness, confusion, memory difficulties, or vision problems. One of them had an early-stage CE and two had accumulation of tau protein that is implicated in CTE and Alzheimer's disease. These researchers proceeded to create a mouse model of repetitive and subconcussive head trauma, which also showed that relatively mild repetitive head injuries lead to degenerative changes in the brain. These findings are not very surprising - repeatedly hitting your head cannot be good for your brain, regardless of the severity of each injury. However, many questions remain unanswered - what is the role of certain genetic traits that are known to predispose to CTE, could magnesium, which is depleted by trauma, or other supplements help reduce the damage, and what other interventions could possibly protect the brain. --- ### 100 Migraine drugs, A to Z: Acetylsalicylic acid - Published: 2018-04-30 - Modified: 2018-04-30 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-acetylsalicylic-acid/ - Categories: Headache medications Acetylsalicylic acid, also known as aspirin, is a truly miracle drug. It is an excellent pain and fever-reducing medicine and prevents several types of cancer and cardiovascular disease. Aspirin has been proven to be a very effective migraine medicine, especially if you take 3 regular strength (975 mg) or two extra strength tablets (1,000 mg). Aspirin works fast, but it can relieve a migraine even faster if it is taken in an effervescent form. These are more common in Europe, but in the US you can buy Alka-Seltzer, which contains aspirin and sodium bicarbonate. Sodium bicarbonate (baking soda)is an excellent antacid and reduces the risk of stomach irritation by aspirin. Stomach irritation and peptic ulcers, along with bruising and bleeding are the main potential side effects of aspirin. These can be dangerous and even life-threatening, but are not likely to occur if aspirin is taken for an occasional migraine. The risk of side effects goes up with taking aspirin daily, which has been proven to prevent migraines and to reduce the risk of episodic migraines becoming chronic. It definitely does not cause medication overuse headaches. Some studies suggest that as little as 81 mg a day is sufficient to prevent migraines, but 325 mg appears to be a more effective dose. Anecdotally, aspirin has been also reported to prevent migraine auras. So, how does one decide whether to take aspirin daily. The decision is easier if you have another reason to take it, such as risk factors for coronary or... --- ### 100 Migraine drugs, A to Z: Amantadine - Published: 2018-04-28 - Modified: 2018-04-28 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-amantadine/ - Categories: Headache medications Amantadine (Symmetrel) is a medication that has U. S. Food and Drug Administration (FDA) approval for use both as an antiviral and an antiparkinsonian medication. However, it is not an effective antiviral drug and is no longer used for this indication. However, it is used for several "off label", that is not FDA-approved indications, including fatigue of multiple sclerosis and migraines. Amantadine has a blocking effect on the NMDA receptor, which is involved in pain messaging in the brain. Other NMDA receptor blockers are an Alzheimer's drug memantine (Namenda) and magnesium. There are only two case reports - one of 14 patients (10 responded to amantadine) and another report of 3 patients with migraines responding to amantadine. So, this is one of the drugs we try after the failure of many other drugs. Amantadine does have the advantage of having few side effects, but its efficacy in migraines is purely anecdotal. --- ### 100 Migraine drugs, A to Z: Abobotulinumtoxin A - Published: 2018-04-24 - Modified: 2018-04-24 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-abobotulinumtoxin-a/ - Categories: Botox, Headache medications, Migraine AbobotulinumtoxinA (Dysport) is a product that is very similar to OnabotulinumtoxinA (Botox), but only Botox is approved by the FDA for the treatment of chronic migraines. Botox is the oldest of the four neurotoxins that are being used for various medical and cosmetic indications. While AbobotulinumtoxinA (Dysport) is very similar to Botox and small clinical trials suggest that it is also effective for the treatment of migraine headaches, it is not exactly the same and should not be substituted for Botox. They differ because these are not synthetic molecules, but rather complex proteins that are produced by a slightly different strain of the Clostridium botulinum bacteria. They are also processed in a different manner. Allergan, manufacturer of onabotulinumtoxinA, or Botox holds the patent for the use of a neurotoxin to treat migraines, so other companies cannot promote their products for this indication. Other toxins are approved for cosmetic and certain other medical indications. Other toxins are a little cheaper than Botox, but I almost exclusively inject Botox because I've been using it for over 25 years with excellent results and very few side effects, because it has been extensively tested in thousands of migraine patients, and because it is the toxin that is usually covered by insurance companies. --- ### 100 Migraine drugs, A to Z: Acetaminophen - Published: 2018-04-23 - Modified: 2018-04-23 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-acetaminophen/ - Categories: Headache medications Many migraine sufferers do not find acetaminophen (Tylenol) to be strong enough to treat migraine headaches and it does not have an official FDA approval for migraines (ibuprofen does). However, it is one of the most popular drugs for all kinds of pain, including migraines. And, in fact, double-blind placebo controlled trials have proven that acetaminophen does relieve pain and associated symptoms of migraine headaches. One such study published in 2000 in the Archives of Internal Medicine by Dr. R. Lipton and his colleagues compared 1,000 mg of acetaminophen with placebo in 351 migraine sufferers. After 2 hours, 58% in the acetaminophen group and 39% in the placebo group reported relief. Twice as many had no pain at all after 2 hours in the acetaminophen group compared to placebo - 22% vs 11%. No side effects were reported in either group. This study does not prove that acetaminophen is as strong as prescription drugs, such as sumatriptan (Imitrex), because the authors excluded patients with very severe attacks - those who needed to lie down and those who had vomiting more than 20% of the time. So, while acetaminophen can help some patients with milder migraines, it can be a useful adjunct to a prescription drug, such as sumatriptan, especially if ibuprofen, naproxen, and other NSAIDs are contraindicated or cause upset stomach or other side effects. Acetaminophen is better tolerated than NSAIDs, but it should not be used at a high dose for long periods of time because it can cause... --- ### 100 Migraine drugs, A to Z: Almotriptan - Published: 2018-04-20 - Modified: 2018-04-25 - URL: https://www.nyheadache.com/blog/100-migraine-drugs-a-to-z-almotriptan/ - Categories: Headache medications Almotriptan (Axert) belongs to the family of triptans, which are, by far, the most effective drugs for the acute treatment of migraine headaches. The first drug in this category, sumatriptan (Imitrex) was introduced in 1992 as an injection. Sumatriptan injection remains the most effective treatment - it works for 80% of migraine sufferers. The tablets of sumatriptan and other triptans are a bit less effective, but still provide good relief for over 60% of patients. For some, combining a triptan with 400 mg of ibuprofen (Advil, Motrin) or 500 mg of naproxen (Aleve, Naprosyn, Anaprox) makes it much more effective. Almotriptan is one of the five relatively fast-acting triptans. The other four are sumatriptan, rizatriptan (Maxalt), zolmitriptan (Zomig), and eletriptan (Relpax). Naratriptan (Amerge) and especially frovatriptan (Frova) take longer to begin helping, but their effect tends to last longer. In Europe, many triptans are sold without a prescription, which indicates that these are very safe drugs. There is no evidence that triptans cause medication overuse headaches (unlike caffeine and opioid/narcotoc drugs). See my post on daily use of triptans and a recent article debunking the myth of medication overuse headaches. --- ### 100 Migraine drugs, A to Z: acetazolamide - Published: 2018-04-18 - Modified: 2019-04-26 - URL: https://www.nyheadache.com/blog/migraine-drugs-a-to-z-acetazolamide/ - Categories: Headache medications This is the first in a 100-part series of blogs on various migraine drugs. Yes, we do use that many drugs to treat migraines, although only a handful are FDA-approved for migraines. Many of these drugs are in the same family, but they are all somewhat different from each other. Acetazolamide (Diamox) is a diuretic (water pill), which is used to treat mountain sickness. Unlike other diuretics, it is somewhat selective in removing extra fluid from the brain and the lungs, rather than equally from all parts of the body. Migraine sufferers whose migraines are triggered by traveling to high altitudes can sometimes prevent these migraines by taking acetazolamide the day before their ascent and then throughout their stay at high altitude. A handful of my patients continued to take acetazolamide even after they returned to the sea level because they found it to be effective in preventing all of their migraines. These patients tended to have barometric pressure changes as their main migraine trigger. For people who get only occasional weather-related headaches, taking acetazolamide daily is not necessary. However, they can often prevent an attack by taking the drug the day barometric pressure drops and for as long as the pressure fluctuates. To avoid having to constantly watch the weather forecast, a couple of apps can send you a warning whenever barometric pressure drops (it usually takes a drop of 20 millibars of pressure to trigger a migraine). One such free app is MigraineX. Interestingly, people who live at... --- ### Certain drugs do not help concussion recovery, but other can - Published: 2018-03-28 - Modified: 2018-03-28 - URL: https://www.nyheadache.com/blog/certain-drugs-do-not-help-concussion-recovery-but-other-can/ - Categories: Brain disorders, Head trauma, Headache medications Several drugs are often used to treat symptoms of concussion, including an epilepsy drug, gabapentin (Neurontin), amitriptyline (Elavil) and other antidepressants. A recent study by doctors at the University of Utah in Salt Lake City examined the role of medications in the treatment of concussions. They studied 277 patients who suffered a concussion and were seen at the local sports medicine clinic. Patients were evaluated for 22 symptoms including headaches. The patients were divided into three groups: those prescribed amitriptyline or nortriptyline, those who were prescribed gabapentin, and those who were not prescribed any medication at all. Patients who were prescribed medications tended to have more severe headaches and other symptoms. However, headaches and other symptoms decreased significantly within days after the initial visit equally in all three groups. This study does not prove that all treatments for postconcussion syndrome are ineffective. A recent presentation by Dr. Bert Vargas of the Sports Neurology and Concussion Program at the University of Texas Southwestern Medical Center in Dallas stressed that many migraine treatments can be very effective for postconcussion headaches and other symptoms. The features of postconcussion headaches often resemble migraines and migraine medications, such as triptans (sumatriptan, or Imitrex, and other) can be very effective. Unfortunately, only 2% - 5% of patients with posttraumatic headaches receive migraine drugs. The vast majority are treated with acetaminophen or NSAIDs, such as ibuprofen or naproxen. Botox injections have also been reported to be very effective for postconcussion headaches, which has been my experience as... --- ### Biohaven Follows Allergan in Announcing Positive Results for Rimegepant - an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine - Published: 2018-03-26 - Modified: 2018-03-26 - URL: https://www.nyheadache.com/blog/biohaven-follows-allergan-in-announcing-positive-results-for-rimegepant-an-oral-cgrp-receptor-antagonist-for-the-acute-treatment-of-migraine/ - Categories: Headache medications, Migraine Last month Allergan reported that their oral CGRP receptor antagonist, ubrogepant was safe and effective in the acute treatment of migraine attacks (see my post). Today, results of a phase 3 trial of a similar drug, rimegepant were reported. Biohaven is the company developing rimegepant, which it licensed from Bristol-Myers Squibb. Rimegepant was shown to be about as effective as ubrogepant with very few side effects, confirming that one of more of these "gepants" will make it to the market. These drugs are expected to be approved some time in 2020. One piece of information that was not initially released by Allergan is that 5 patients on ubrogepant developed liver function abnormalities on blood tests, compared to only 1 on placebo. None of the patients taking rimogepant had liver function abnormalities. This could spell trouble for the Allergan drug, as it did for the original Merck drug, telcagepant. Both Allergan and Biohaven have additional oral CGRP antagonists in development for the preventive treatment of migraines. --- ### Allergan Announces Positive Results for Ubrogepant - an Oral CGRP Receptor Antagonist for the Acute Treatment of Migraine - Published: 2018-03-21 - Modified: 2018-03-21 - URL: https://www.nyheadache.com/blog/allergan-announces-positive-results-for-ubrogepant-an-oral-cgrp-receptor-antagonist-for-the-acute-treatment-of-migraine/ - Categories: Chronic migraine, Headache medications, Migraine, New treatments The first of the four CGRP monoclonal antibodies developed for the prevention of migraines is expected to be approved by the FDA in the next 2-3 months. The other three should be approved within a year. All four will be given by an injection (three subcutaneously and one, intravenously). Most people prefer tablets to injections and two companies are developing three drugs with the same mechanism of action as the monoclonal antibodies (blocking CGRP), but in a tablet form. The original CGRP drug in a tablet form was developed by Merck and it was very effective for the prevention and acute treatment of migraines, but a few patients developed liver side effects. The side effects were not serious, just abnormal blood tests, which returned to normal once the drug was stopped, but nevertheless Merck stopped the development of telcagepant in 2009. This led pharma companies to shift to the development of monoclonal antibodies, which bypass the liver, but can be given only by injection. Allergan and Biohaven are two companies that are developing oral CGRP drugs in the hope that they can achieve good efficacy without the side effects. Allergan just released the results of the first phase 3 study of ubrogepant. The study included 1327 U. S. adult patients who were given placebo, ubrogepant 50 mg or 100 mg. They treated a single migraine attack of moderate to severe headache intensity. Both doses were significantly better than placebo in achieving pain freedom at 2 hours after the initial dose.... --- ### FDA approves the first blood test to diagnose concussion - Published: 2018-03-11 - Modified: 2018-03-11 - URL: https://www.nyheadache.com/blog/fda-approves-the-first-blood-test-to-diagnose-concussion/ - Categories: Chronic migraine, Head trauma, post-traumatic headache The news headlines are filled with stories of professional football players suffering from brain damage, but you do not to have to participate in sports to sustain a concussion - it is an everyday occurrence. In the US, in 2013 there were 2. 8 million concussion-related emergency room visits and hospitalizations with 50,000 people dying from brain injuries. Three out of four concussions are mild. However, even mild concussion can cause impaired thinking or memory, poor concentration and emotional problems. The U. S. Food and Drug Administration has recently approved the first blood test to evaluate concussion in adults. The diagnosis of concussion or in medical lingo, mild traumatic brain injury (mTBI), has been based purely on the description of symptoms by the patient, neurological examination, including the 15-point Glasgow Coma Scale, and brain imaging, such as CT scan to detect brain damage or bleeding. The majority of patients with a concussion have normal MRI and CT scans. This new blood test will help health care providers decide if a CT scan is necessary. This will avoid unnecessary scans which expose patients to radiation. It should also save money. The Brain Trauma Indicator developed by Banyan Biomarkers, Inc. works by measuring levels of proteins, known as UCH-L1 and GFAP, that are released from the brain into blood and measured within 12 hours of head injury. Levels of these blood proteins after mTBI can help predict which patients may have brain lesions visible by CT scan and which won’t. Test results... --- ### Intravenous lidocaine for pain (and headaches) - Published: 2018-02-28 - Modified: 2018-02-28 - URL: https://www.nyheadache.com/blog/intravenous-lidocaine-for-pain-and-headaches/ - Categories: Blocks, Migraine, Pain Lidocaine is an effective local anesthetic that is injected for dental procedures, minor surgeries, as well as nerve blocks, including nerve blocks for migraines, cluster, and other types of headaches. Since it is a numbing medicine, lidocaine has been also given intravenously in the hope of relieving widespread pain or pain that does not respond to local injections. Unfortunately, it is not as effective intravenously as it is for local injections and nerve blocks for either headaches or other pain conditions. A controlled study of intravenous lidocaine for pain was just published by Korean researchers in the Regional Anesthesia and Pain Medicine - "Efficacy and Safety of Lidocaine Infusion Treatment for Neuropathic Pain: A Randomized, Double-Blind, and Placebo-Controlled Study". The researchers decided to examine whether pain relief from intravenous lidocaine can be sustained through repeated lidocaine infusions. This was a randomized, double-blind, placebo-controlled study of infusions of lidocaine (3 mg/kg of lidocaine administered over 1 hour) vs infusions of normal saline, given once a week for 4 consecutive weeks in patients with postherpetic neuralgia or complex regional pain syndrome (formerly called RSD, or reflex sympathetic dystrophy). The results were assessed by the change in pain score from baseline to after the fourth infusion and then again, 4 weeks later. Forty-two patients completed this study and the percentage reduction in pain scores after the final infusion was significantly greater in the lidocaine group compared with the saline group. However, this pain reduction was not detectable at the 4-week follow-up. None of... --- ### Botox for TMJ; the effect on clenching and grinding of teeth - Published: 2018-02-24 - Modified: 2018-02-24 - URL: https://www.nyheadache.com/blog/botox-for-tmj-the-effect-on-clenching-and-grinding-of-teeth/ - Categories: Botox, Migraine, TMJ TMJ syndrome is a disorder which often coexists with migraine and tension-type headaches and is characterized by pain in the jaw joint and surrounding muscles. It is very common, but the exact cause remains unclear. In many people TMJ is a sleep disorder, which can occur in the absence of overt stress, but stress definitely plays a role in most people. Headaches in patients with traumatic brain injury can be also worsened by bruxism (clenching and grinding of teeth), while treating bruxism contributes to the relief of headaches. Dentists usually advise patients to sleep with a custom-made bite guard, but it only reduces grinding and may not stop clenching. The standard injection protocol for migraines includes injections into the temples (temporalis muscles), which are involved in clenching, but my 25 years of using Botox suggests that many patients get much better results if lower jaw (masseter) muscles are also injected. A study just published in Neurology tested the safety and efficacy of onabotulinumtoxin-A (Botox) injections into those muscles (masseter and temporalis) in patients with sleep bruxism. This study included adults with sleep bruxism which was confirmed by an overnight sleep study. The study was randomized and placebo-controlled (half received Botox and the other half, placebo), with an open-label extension (when everyone receives Botox). Participants were injected with 200 units of Botox - 60 into each masseter and 40 into each temporalis muscle or placebo (by comparison, a total of 155 units is used to treat chronic migraine headaches). They were... --- ### gammaCore for migraine - Published: 2018-02-12 - Modified: 2018-02-12 - URL: https://www.nyheadache.com/blog/gammacore-for-migraine/ - Categories: Alternative Therapies, Migraine, neurostimulation An electric stimulation device, gammaCore has received clearance from the U. S. Food and Drug Administration (FDA) as an acute treatment of pain associated with migraine in adult patients. gammaCore is a hand-held device that stimulates the vagus nerve in the neck through the skin and was developed following and based on my 2005 publication describing the use of implantable vagus nerve stimulator for refractory chronic cluster and migraine headaches. This adds to the approval gammaCore received for the acute treatment of pain associated with episodic cluster headache in adult patients in April 2017. The clearance is limited to pain of migraine, rather than migraine attacks, meaning that the device relieves pain and may not relieve other migraine symptoms, such as nausea and sensitivity to light and noise. The FDA clearance of gammaCore for the acute treatment of pain associated with migraine was supported by the results of the multicenter, randomized, double-blind, sham-controlled trial that demonstrated that "treatment with gammaCore for the acute treatment of pain associated with migraine was superior to sham, and also enabled patients to reach pain freedom more frequently by 30, 60, and 120 minutes compared with sham treatment". Just like with all other studies with gammaCore, the therapy was found to be well tolerated by patients. gammaCore is also available outside of the U. S. , including in Canada and the European Economic Area. The manufacturer offers a free trial of the device, which cannot be purchased, but only rented. Some insurance plans may pay... --- ### The Feldenkrais method - Published: 2018-02-03 - Modified: 2018-02-03 - URL: https://www.nyheadache.com/blog/the-feldenkrais-method/ - Categories: Alternative Therapies, Brain disorders A recent article in the New York Times by the health columnist, Jane Brody, Trying the Feldenkrais Method for Chronic Pain, described her very positive experience with the Feldenkrais method. Then, at about the same time a patient told me that Feldenkrais lessons made a big difference in her neck and back pain. I started to read about Feldenkrais (download an article from the Smithsonian Magazine), took a lesson with my patient's teacher, and then invited this teacher to work in our office. This method was developed by a Russian-born Israeli engineer Dr. Moshe Feldenkrais (1904-1984). He was a physicist who was educated at Sorbonne and worked with Frédéric Joliot-Curie, then worked in the British survey office and during the war, as a science officer in the Admiralty. In 1936, while in France, he became one of the first Europeans to earn a black belt in judo. A knee injury led Feldenkrais to develop a movement method named after him. He did not call it therapy and always insisted that he did not treat patients, but rather taught lessons on how to move naturally. At the same time, his lessons often led to a dramatic relief of pain, improved movement and functioning in individuals who suffered from cerebral palsy, strokes, multiple sclerosis, back, and neck pains. He felt that the key to healing was to become aware of what one is doing. Dancers, artists, and athletes have been using Feldenkrais lessons to improve their performance and to heal and avoid... --- ### Feverfew for migraines - Published: 2018-01-28 - Modified: 2018-01-28 - URL: https://www.nyheadache.com/blog/feverfew-for-migraines/ - Categories: Alternative Therapies, Migraine Feverfew (tanacetum parthenium) is one of the oldest herbal remedies for the treatment of migraine headaches. It was first mentioned as a treatment for inflammation 2,000 years ago. Feverfew is a member of the daisy family and all above-ground parts of the plants are safe to ingest and it is usually consumed as dried leaves or tea made of dried flowers. Besides migraine, it has been used for the treatment of fevers, rheumatoid arthritis, stomach aches, toothaches, insect bites, psoriasis, allergies, asthma, tinnitus, dizziness, nausea, and vomiting, infertility, problems with menstruation and labor during childbirth. We do have some scientific evidence for the effectiveness of feverfew in the prevention of migraine headaches. Here is a brief description of two of the five published trials of feverfew. A study, Randomized double-blind placebo-controlled trial of feverfew in migraine prevention was published in the Lancet by British researchers led by JJ Murphy. 60 patients completed this study, in which half of the migraine patients received feverfew and the other half, placebo. After four months the treatment was switched (so called crossover study). Patients in the feverfew group had 4. 7 fewer attacks, while placebo resulted in 3. 6 fewer attacks. Global assessment of improvement was 74 vs 60. Feverfew also reduced the severity of nausea and vomiting. Another, more rigorous study by German researchers led by HC Diener was published in Cephalalgia. It was entitled, Efficacy and safety of 6. 25 mg t. i. d. feverfew CO2--extract (MIG-99) in migraine prevention – a... --- ### Terrorism and headaches - Published: 2018-01-22 - Modified: 2018-01-22 - URL: https://www.nyheadache.com/blog/terrorism-and-headaches/ - Categories: Chronic migraine, Headaches, Headaches in children, Psychology of headaches Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer from tension-type headaches, according to a study just published in Neurology. The researchers evaluated 213 of 358 adolescent survivors of the 2011 massacre at a summer camp in Norway that resulted in deaths of 69 people. These survivors were compared to over 1,700 adolescents of the same sex and age who were not exposed to terrorism. The survivors were not only much more likely to suffer from migraines and tension-type headaches, but were also much more likely to have daily or weekly attacks. Many previous studies have shown that physical, sexual, and emotional abuse in childhood and posttraumatic stress disorder (PTSD) are strong risk factors for the development of migraines and chronic pain in many previous studies. Having a family history of migraines further increases this risk, as does head trauma, and having other painful or psychological disorders. Headache is also one of the first symptoms reported by adolescent girls and women who were raped. The authors of the current report cite evidence that "Childhood maltreatment during periods of high developmental plasticity seems to trigger modifications in genetic expression, neural circuits, immunologic functioning, and related physiologic stress responses. It is plausible that exposure to interpersonal violence could induce functional, neuroendoimmunologic alterations, affecting central sensitization and pain modulation and perception. Central sensitization, expressed as hypersensitivity to visual, auditory, olfactory, and somatosensory stimuli, has long been thought to play a key role... --- ### Migraines can be prevented with CoQ10 supplementation - Published: 2018-01-08 - Modified: 2018-01-08 - URL: https://www.nyheadache.com/blog/migraines-can-be-prevented-with-coq10-supplementation/ - Categories: Alternative Therapies, Headaches in children, Migraine Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of migraine sufferers are deficient in CoQ10, according to a study by Dr. Andrew Hershey and his colleagues published in the journal Headache. They tested 1,550 children and adolescents and a study in such a large population tends to be very reliable. Supplementing these children with 1 to 3 mg/kg of CoQ10 produced significant improvement not only in CoQ10 levels but also in the frequency of attacks (from 19 a month to 12) and the disability (the disability score dropped from 47 to 23). This deficiency is present in adults as well, as was shown in another study by a Swiss neurologist, Dr. Peter Sandor and his colleagues. They gave 100 mg of CoQ10 three times a day or placebo to 42 adult migraine sufferers and discovered that a 50% drop in migraine attack frequency occurred in 48% of patients on CoQ10 and only 14% of patients on placebo. The Hershey study was done in a more logical way - determine who is deficient and give them CoQ10. If you give CoQ10 to those who need it and those who don't, the results of the study and in practice will not be as impressive. Although CoQ10 is not expensive ($7 a month for 200 mg a day) and is very safe, why supplement to someone who does not need it? Although the blood test for CoQ10 is fairly expensive ($158 at... --- ### Dementia and magnesium levels - Published: 2018-01-03 - Modified: 2018-01-03 - URL: https://www.nyheadache.com/blog/dementia-and-magnesium-levels/ - Categories: Alternative Therapies Magnesium deficiency is found in up to 50% of migraine sufferers, 40% of those with cluster headaches, 45% of the elderly diabetics, and in a high percentages of people with other chronic diseases. Magnesium has been shown to relieve migraine and cluster headaches, post-concussion syndrome, lower blood pressure, prevent irregular heart beats, and improve breathing in asthmatics. A new study by Dutch researchers published in the leading neurology journal, Neurology reports on an association between magnesium and dementia (Alzheimer's and other types). Brenda Kieboom and her colleagues measured magnesium levels in almost 10,000 people without any evidence of dementia and followed them for an average of 8 years. The average age at the start of the study was 65. Only 2 subjects had magnesium level above normal and 108 below normal. The surprising discovery, which was suggested by previous contradictory studies, is that people with both low normal and high normal levels (lowest and highest quintile of the normal range) were at an increased risk of developing dementia. There are two hypotheses as to why low magnesium levels could predispose to dementia. One is that magnesium blocks NMDA receptor, which is involved in the development of dementia, traumatic brain injury, pain, migraines, and other conditions. The second theory is that magnesium deficiency promotes inflammation, which is found in brains of patients with dementia (and migraines). The authors did not offer any theories as to why high normal magnesium levels were also associated with the development of dementia. The researchers admit... --- ### Botox for kids with chronic migraines - Published: 2017-12-27 - Modified: 2017-12-27 - URL: https://www.nyheadache.com/blog/botox-for-kids-with-chronic-migraines/ - Categories: Botox, Chronic migraine, Headaches in children A new report by doctors at UC Irvine describes successful treatment of 9 children aged 8 to 17 with migraine headaches using Botox injections. It may sound surprising, but unfortunately children also suffer from chronic migraines. Chronic migraine is defined as headaches that occur on 15 or more days each month and on at least 8 of those days headaches have migraine features. In children with episodic and chronic migraines, migraine features, such as throbbing, unilateral location, sensitivity to light and noise are less common than in adults. There are only 5 treatments that are approved by the FDA for the prevention of migraine attacks. Four are drugs - 2 blood pressure medications, propranolol (Inderal) and timolol (Blocadren) and 2 epilepsy drugs, topiramate (Topamax) and divalproex sodium (Depakote). The fifth treatment is Botox injections. While Botox is not approved for kids with migraines, it is approved to treat eye conditions in children 12 years of age and older. Botox is also widely used to treat younger children with cerebral palsy (CP), although there is no official FDA clearance for such use. For a child with CP, Botox injections can make a difference between being wheelchair-bound and walking unassisted. However, very young children with CP are at the highest risk of serious complications and even death because they have small bodies and very stiff muscles, which require relatively large doses of Botox. The dose to treat migraines is much smaller and therefore a lot safer. My youngest child with chronic migraines... --- ### Ignore fearmongering: triptans still do not increase the risk of strokes and heart attacks - Published: 2017-12-18 - Modified: 2017-12-18 - URL: https://www.nyheadache.com/blog/ignore-fearmongering-triptans-still-do-not-increase-the-risk-of-strokes-and-heart-attacks/ - Categories: Migraine A group of highly respected researchers at the Albert Einstein College of Medicine just published their second article in the journal Headache on the cardiovascular disease (CVD) risks in migraine sufferers. Not surprisingly, they have found that there is an increase in the CVD risk factors with increasing age - more people develop diabetes, hypertension, heart attacks, strokes, get stenting and other heart procedures as they get older. This study concludes that, "Among people with episodic migraine in the US population, the number of women and men with relative contraindications to triptans... includes over 900,000 women and men. This includes more than half a million individuals with episodic migraine who have not had a prior cardiovascular events or procedures. " They also extensively refer to the FDA-approved label for triptans, which says that "It is strongly recommended that sumatriptan not be given to patients in whom unrecognized coronary artery disease is predicted by the presence of risk factors... ". This is because triptans can slightly constrict blood vessels, especially diseased ones (but vasoconstriction is not how triptans relieve migraines). This is a strange conclusion considering that in the first article devoted to this large and extensive study they admit that "Serious cardiac events following triptan administration are very rare and in claims analysis, triptan use is indeed not associated with increased risk of CVD". And the triptan label includes this statement (mentioned by the authors): “Considering the extent of use of sumatriptan in patients with migraine, the incidence of these... --- ### Breakthrough in the treatment of migraines - Published: 2017-12-08 - Modified: 2017-12-08 - URL: https://www.nyheadache.com/blog/breakthrough-in-the-treatment-of-migraines/ - Categories: Cluster headaches, injections, Migraine, New treatments Two landmark studies on an entirely new type of treatment for migraines have been just published in the New England Journal of Medicine. One of the reports describes a phase 3 trial (final phase that can lead to the FDA approval), which was conducted by Teva Pharmaceuticals using a monoclonal antibody, fremanezumab to treat patients with chronic migraine (patients with 15 or more headache days each month). The study involved 1,130 patients who were divided into three groups: one group received monthly injections (subcutaneously, i. e. under the skin) of the active medicine, another group was given an injection of the real medicine every 3 months and placebo injections monthly in between, and the third group received placebo injections every month. Patients in both groups that received real shots did much better than those given placebo. They had fewer days with headaches, used less of the abortive migraine medications, and had a lower impact of migraines on their lives. The effect of the drug lasted 3 months, which suggests that one injection every three months will be sufficient. We also hope that patients will be able to inject themselves and not have to come to doctors' offices every month. The side effects were mostly related to the injection itself - pain, swelling, and bruising. The second study conducted by Amgen and Novartis utilized a similar drug, erenumab (it will have the brand name of Aimovig when it becomes available in the middle of next year) to prevent episodic migraines, that... --- ### Vomiting from too much pot is similar to cyclic vomiting syndrome - Published: 2017-12-02 - Modified: 2017-12-02 - URL: https://www.nyheadache.com/blog/vomiting-from-too-much-pot-is-similar-to-cyclic-vomiting-syndrome/ - Categories: Alternative Therapies, Migraine Excessive consumption of marijuana can lead to bouts of severe nausea and vomiting, which in medicalese is called cannabinoid hyperemesis syndrome (CHS). With many states legalizing medical and recreational marijuana, there has been an increase in ER visits and admissions to the hospital for severe vomiting. This is often misdiagnosed as cyclic vomiting syndrome (CVS), a condition which is more common in children than adults and is related to migraines. CVS, which is mentioned in a previous post, is often relieved by sumatriptan (Imitrex). Unfortunately, people who overindulge in pot, do not realize that it is responsible for their symptoms and end up undergoing endoscopies, MRI scans and other procedures. Taking a hot shower is known to relieve pot-related vomiting, but hot shower also works for some patients with CVS, so this does not help in differentiating the two conditions. German researchers tried to find a reliable way to differentiate CHS and CVS and concluded that the only way to tell these apart is to completely stop marijuana. They do note that CHS can develop after years of using marijuana and that after marijuana use is stopped, it may take several days and up to a couple of months for symptoms to subside. So far, we've prescribed medical marijuana to a couple of hundred patients with headaches, migraines, and nerve pain and have not seen such a problem. It is possible that the amount used for medicinal purposes is too small to cause CHS. The cost of medical marijuana is... --- ### Psychological factors in chronic migraine - Published: 2017-11-24 - Modified: 2017-11-24 - URL: https://www.nyheadache.com/blog/psychological-factors-in-chronic-migraine/ - Categories: Alternative Therapies, Chronic migraine, Pain, Pain Research, Psychology of headaches Psychological factors play a major role in migraines. This is not to say that migraine is a psychological disorder - we have good genetic and brain imaging studies confirming its strong biological underpinnings. The divide between biological and psychological is very artificial since we know that physical illness leads to psychological problems and the other way around. Stress is obviously one of the major triggers of migraines and we know that people with migraines are at least twice as likely to develop anxiety, depression, and other mental disorders. These are not cause-and-effect relationships because anxiety and depression can precede the onset of migraines. The connection is probably due to shared underlying problems with serotonin, dopamine, and other neurotransmitters. We have strong evidence that addressing psychological factors involved in migraines through biofeedback, meditation, and cognitive therapy can lead to the reduction of migraine frequency, severity, and disability. Studies in chronic pain patients have shown that people with external locus of control (thinking that uncontrollable outside chance events are major contributors to pain) have more disability than people with internal locus of control (those who feel that their actions are contributing to pain and that active involvement in treatment can relieve pain). Chronic migraine sufferers (defined as those with 15 or more headache days each month) are known to have greater disability than those with episodic migraines. In a recent study by researchers at the Yeshiva University and Albert Einstein College of Medicine, 90 chronic migraine patients were evaluated for psychological symptoms.... --- ### Visual snow is related to migraines, can be disabling - Published: 2017-11-20 - Modified: 2017-11-20 - URL: https://www.nyheadache.com/blog/visual-snow-is-related-to-migraines-can-be-disabling/ - Categories: Brain disorders, Migraine People who have experienced "visual snow" know what it means. Their vision tends to be distorted by white spots that resemble what you see on the television when there is no signal. At the latest meeting of the International Headache Society, the topic of visual snow was addressed in four presentations. The first presentation by British and Swiss researchers attempted to give a definition, so that this phenomenon can be studied scientifically. They collected data on 636 subjects by using an online survey of patients. 636 is a surprisingly high number because this is thought to be a relatively uncommon symptom. I certainly do not see more than a handful of patients each year. They found this phenomenon to be present with equal frequency in men and women and 39% reported to have it all their lives. The majority (56%) saw black and white static, 44% saw colored spots, while 45% experienced flashing, and 52% described it as transparent. The most common non-visual symptom was tinnitus, or ringing in the ears, which was present in 74%. Only 226 patients gave information on headaches and 83% of them suffered at least one attack of migraine. They concluded that visual snow is an unrecognized symptom, which can be very disabling and which deserves further research. The second presentation reported on 90 patients of the original 636 who agreed to keep a diary of their symptoms for 30 days. The results showed that the visual snow was least noticeable outdoors, in bright sun.... --- ### Curcumin helps improve memory, possibly migraines. - Published: 2017-11-13 - Modified: 2017-11-13 - URL: https://www.nyheadache.com/blog/curcumin-helps-improve-memory-possibly-migraines/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Migraine Curcumin, which is one of the ingredients in turmeric, has long been touted for many of its anti-inflammatory and anti-cancer properties. A study presented at the 2017 Alzheimer's Association International Conference showed that curcumin improves memory in healthy adults without Alzheimer's disease. This double-blind study was performerd by Dr. Gary Small and his colleagues at UCLA and it involved 40 men and women with a mean age of 63. Half of these subjects received 90 mg of Theracurmin brand of cucurmin twice a day, while the other half was given placebo for a period of 18 months. Researchers administered both verbal and visual memory tests and also measured brain deposits of amyloid plaques and tau tangles using special imaging methods (PET scans). These deposits are found in the brains of patients with Alzheimer's. The scores for both types of memory improved in the curcumin group, but not in the placebo group. Curcumin also prevented buildup of amyloid plaques and tau tangles in the brains. Daily curcumin also improved attention and mood. Four patients in the curcumin group and two in the placebo group had stomach pains and nausea. These were the only side effects. The authors concluded that "This relatively inexpensive and nontoxic treatment may have a potential for not only improving age-related memory decline, but also as a prevention therapy, possibly staving off progression, and eventually future symptoms of Alzheimer's disease. " There is less clinical evidence for the use of curcumin for the prevention of migraines. A recent... --- ### More on intravenous ketamine for migraines - Published: 2017-11-05 - Modified: 2017-11-05 - URL: https://www.nyheadache.com/blog/more-on-intravenous-ketamine-for-migraines/ - Categories: Alternative Therapies, Headache medications, Migraine, New treatments Ketamine is a medicine that is sometimes given intravenously for anesthesia. It is a controlled drug because it can induce euphoria and is potentially addictive. In a previous post I mentioned several anecdotal reports about the beneifical effect of ketamine for a prolonged migraine aura, hemiplegic migraine and other types of headaches. A presentation at the recent annual meeting of the American Society of Anesthesiologists described the results of ketamine infusion on severe migraines in patients admitted to the Thomas Jefferson University Hospital in Philadelphia from 2014 to 2016. 48 of the 61 patients (77%) responded to this treatment, meaning that their pain levels improved by at least 2 points on a 1 to 10 scale. On average, the infusion had to be given for 5 days. Side effects included sedation (51%), blurry vision (38%), nausea or vomiting (38%), hallucinations (28%), vivid dreams (13%), and low blood pressure (5%). The authors described the adverse effects as mild in nature and only 1 patient discontinued treatment. However, having hallucinations, drop in blood pressure or vomiting does no sound like mild side effects to me. On the other hand, these were patients whose migraine did not respond to other treatments and they needed to be hospitalized, so these side effects could in fact be acceptable if the treatment ultimately provides relief. Review of patient records admitted to the same hospital between 2006 and 2014 showed the mean headache pain rating using a 0-10 pain scale dropped from 7 on admission to 4... --- ### Stem cells help stroke victims, will revolutionize medicine - Published: 2017-10-30 - Modified: 2017-10-30 - URL: https://www.nyheadache.com/blog/stem-cells-help-stroke-victims-will-revolutionize-medicine/ - Categories: Alternative Therapies, Brain disorders, Chronic migraine, Head trauma There is little doubt that stem cells, along with genetics and computer science will revolutionize medicine. There are more than a dozen journals devoted to stem cell research and many general and speciality medical journals also publish research on stem cells, which means that a couple of hundred articles are published every month. At first, the research was stymied by the controversy about the fetal sources of stem cells. For the most part this problem has been circumvented by the discovery of other sources, such as umbilical cord, placenta, fat tissue, and other. In neurology, multiple sclerosis, spinal cord injuries, and strokes have been the main targets of stem cell research. The latest study of stem cells for stroke victims conducted at Stanford by Gary Steinberg and his colleagues produced very encouraging results. This trial included only 18 patients, but they all had their stroke anywhere between 6 months and 3 years before the study - past the usual time where further recovery is expected. Improvement occurred in the majority of patients and the improvement was not affected by the age of the patient or the severity of the stroke. Although stem cells were injected directly into the brain through a small hole that was drilled in the skull, there were no serious complications or side effects. The researchers also noted that stem cells did not replace damaged cells but rather stimulated patients' own repair mechanisms. This is at odds with the original idea that stem cells by their nature... --- ### The effect of post-traumatic headaches on the brain - Published: 2017-10-21 - Modified: 2017-10-21 - URL: https://www.nyheadache.com/blog/the-effect-of-post-traumatic-headaches-on-the-brain/ - Categories: Alternative Therapies, Botox, Chronic migraine, Head trauma, post-traumatic headache Chronic pain is known to alter the structure of the brain. Mayo Clinic researchers used MRI scans to examine brains of 29 patients with post-traumatic headaches and compared their scans to those of 31 age-matched healthy volunteers. The average frequency of headaches was 22 days a month. Patients with post-traumatic headaches were found to have thinning of several areas of their cerebral cortex which are responsible for pain processing in the frontal lobes. Cortex covers the surface of the brain and contains bodies of brain neurons. Drs. Chiang, Schwedt, and Chong, who presented their findings at the annual meeting of the International Headache Society held last month in Vancouver, also discovered that the thinning was correlated with the frequency of headaches. This study did not address possible treatments, but it would make sense that with better control of headaches, this brain atrophy might be reversible. To treat post-traumatic headaches we often use Botox injections, which have been shown to help posttraumatic headaches. Even though Botox is approved only for chronic migraines, many patients with post-traumatic headaches do have symptoms of migraines and can be diagnosed as having post-traumatic chronic migraines (without such a designation insurance companies may not pay for Botox). We also check RBC magnesium, CoQ10 and other vitamin levels, which are often low in chronic headache sufferers and if corrected, can lead to a significant improvement. Epilepsy drugs and anti-depressants can also help. While the above mentioned treatments can help headaches and potentially could reverse brain atrophy, there... --- ### Gut bacteria can cause big holes in the brain - Published: 2017-10-16 - Modified: 2017-10-24 - URL: https://www.nyheadache.com/blog/gut-bacteria-can-cause-big-holes-in-the-brain/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine Biome, or the collection of bacteria living in our bodies has been receiving belated and well deserved attention. The discovery that bacteria living in our intestines can cause cerebral cavernous malformations or CCM (see photo) is quite dramatic. But there is no need to panic since this is a rare condition. However, it does indicate that gut bacteria can have a major impact on our brains. It was a serendipitous discovery by Dr. Mark Kahn, professor of medicine at U. Penn, who studied mice with CCM. He noticed that mutant mice prone to CCM stopped developing holes in their brains after being moved to a new building. The exception was mice who developed an abscess after having their intestines accidentally stuck with a needle during a routine injection. Dr. Kahn and his colleagues identified a specific bacterium, Bacteroides fragilis, which was responsible for the development of brain caverns. This finding may explain why there is such a wide variety of presentations in people who have the familial form of CCM. Some have no lesions even when they are 70, while others have hundreds of them at age 10. Just like mutant mice, humans seem to need an additional trigger to start developing CCMs. This finding provides a clear path to developing an effective treatment and perhaps, just a simple probiotic could keep such patients healthy. In fact, a probiotic containing 14 different strains of bacteria (Bio-Kult, made in UK) is effective in preventing migraine headaches, according to a study presented... --- ### Two different types of exercise prevent migraines - Published: 2017-10-11 - Modified: 2017-10-11 - URL: https://www.nyheadache.com/blog/two-different-types-of-exercise-prevent-migraines/ - Categories: Alternative Therapies, Headaches A new study by Swiss researchers compared the effect of high intensity interval training (HIT) with moderate intensity continuous training (MCT) and with no exercise at all on the number of migraine headache days. The results were presented at the International Headache Congress held in Vancouver last month. Not surprisingly, both types of exercise reduced the number of migraine headache days, but HIT was more effective. In the study, patients in HIT group did 4 periods of intensive exercise (90% of maximum intensity) each lasting 4 minutes, separated by periods of 3 minutes at 70% of maximum. The moderate intensity exercise was done at 70% for 45 minutes. Both groups performed these exercise twice a week. A previous study has established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate however has many potential side effects, including some serious ones. A Swedish study of 46,648 people established a strong inverse correlation between physical activity and the frequency of headaches. HIT has been gaining in popularity since the 1980's because it provides all of the benefits of exercise in a shorter period of time. --- ### What to do when Botox stops working - Published: 2017-10-07 - Modified: 2017-10-07 - URL: https://www.nyheadache.com/blog/what-to-do-when-botox-stops-working/ - Categories: Botox, Chronic migraine, Cluster headaches, Migraine Botox is the most effective and the safest preventive treatment for migraine headaches. However, in a very small number of patients, Botox loses its effectiveness over time. This happens for two main reasons - the person develops antibodies as a defense mechanism to block the effect of Botox or headaches change in character and stop responding to Botox. It is easy to tell these two reasons apart. If Botox fails to stop movement of the forehead muscles and the patient can frown and raise her eyebrows, it is most likely because of antibodies. On a very rare occasion this is due to a defective vial of Botox, so to confirm that antibodies have formed, we give a small test dose amount of Botox into the forehead. If again there is no paralysis, we know that antibodies have developed. This can happen after one or two treatments or after 10, but in my experience over the past 25 years, significantly fewer than 1% of patients develop this problem. Fortunately, some patients who develop antibodies to Botox, known as type A toxin, may respond to a similar product Myobloc, which is a type B toxin. Myobloc is not approved by the FDA to treat chronic migraine headaches, but it has a similar mechanism of action and has been shown to relieve migraines in several studies. Injections of Myobloc can be a little more painful, it begins to work a little faster than Botox, but the effect may last for a slightly shorter... --- ### Color of the ambient light can help or worsen migraines - Published: 2017-09-21 - Modified: 2017-09-21 - URL: https://www.nyheadache.com/blog/color-of-the-ambient-light-can-help-or-worsen-migraines/ - Categories: Alternative Therapies Bright light bothers many migraine sufferers and in some, a flash of bright light, such as sun reflecting off a window glass or water can instantly trigger a severe migraine. Sensitivity to light may be color dependent, according to a presentation by Japanese researchers at the International Headache Congress held in Vancouver earlier this month. Dr. K. Niwa and his colleagues in Tokyo studied 936 patients with chronic headaches aged between 12 and 77. They compared 546 patients with episodic and chronic migraines with 392 patients with episodic and chronic tension-type, cluster, new daily persistent and other types of headaches. They exposed these patients to yellow, white, gray, blue green, and red ambient light. They measured the degree of discomfort on a 6-point scale, ranging from none to unbearable. White, blue, and red lights aggravated discomfort both during a migraine attack and between attacks. Green light reduced discomfort between attacks of migraine and reduced pain intensity during a migraine, regardless of the presence or absence of light sensitivity. This was true for patients with both episodic and chronic migraine headaches. Those with chronic tension-type headaches had only mild discomfort from white light, while patients with all other types of headaches had no positive or negative reaction to various colors of ambient light. This study confirmed previous reports (and our patients' experience) that blue and white light worsens migraine pain. The more important finding is that green light seems to be very beneficial. Considering the low cost of this treatment, migraine... --- ### Medication overuse (rebound) headache is a myth - Published: 2017-09-18 - Modified: 2017-09-18 - URL: https://www.nyheadache.com/blog/medication-overuse-rebound-headache-is-a-myth/ - Categories: Headache medications, Science of Migraine Caffeine and opioid (narcotic) drugs, if taken regularly, are proven to worsen headaches. This will not come as a surprise to anyone drinking large amounts of coffee - skipping your morning cup will leave you with a headache. Taking too much Excedrin, Fioricet, or Percocet will also make you want to take these drugs more and more often and with diminishing relief. However, most neurologists and headache specialists believe that triptans (sumatriptan, rizatriptan, et al. ) and NSAIDs (naproxen, ibuprofen, et al. ) can also cause "medication overuse headaches". This remains a belief, rather than a scientific fact and it leads to thousands of headache sufferers being unfairly accused of causing or worsening their own headaches. They are being denied a safe and effective treatment that could relieve their suffering and reduce disability. My most popular blog post that so far has elicited 247 comments, is one on the daily use of triptans. Drs. Ann Scher of Uniformed Services University, Paul Rizzoli and Elizabeth Loder of Brigham and Women's Hospital have just published an article in a leading neurology journal, Neurology, entitled, Medication overuse headache. An entrenched idea in need of scrutiny. Last year I described a debate on this topic between Dr. Scher and Dr. Richard Lipton of the Montefiore Headache Clinic at the meeting of the American Headache Society. The abstract of this new article can be easily understood by the lay public, so I am including its full text. "It is a widely accepted idea that medications... --- ### Triptans (like Imitrex) mix well with antidepressants - Published: 2017-09-01 - Modified: 2017-09-01 - URL: https://www.nyheadache.com/blog/triptans-like-imitrex-mix-well-with-antidepressants/ - Categories: Headache medications Sumatriptan (Imitrex), rizatriptan (Maxalt) and the other 5 triptans work on serotonin receptors to stop a migraine attack. Many antidepressants, such as fluoxetine (Prozac), escitalopram (Lexapro), that belong to the SSRI family and venlafaxine (Effexor) and duloxetine (Cymbalta), that belong to the SNRI family of drugs also affect serotonin or its receptors. Because both triptans and antidepressants affect serotonin, it is understandable that there has been concern about the potential for serotonin-related side effects when these drugs are used together. In 2006 the FDA released a warning, “Potentially Life-Threatening Serotonin Syndrome With Combined Use of SSRIs or SNRIs and Triptan Medications. ” Fortunately, this is the case of "fake news". My colleague in Houston, Dr. Randy Evans under the Freedom of Information Act, requested all the data that the FDA used to issue this warning. He published an article on his findings and concluded that "The data do not support prohibiting the use of triptans with SSRIs or SNRIs. " A new study presented at the 59th Annual Scientific Meeting of the American Headache Society confirmed Dr. Evans' conclusion. Dr. Yulia Orlova and her colleagues at the John R. Graham Headache Center at Brigham and Women's Faulkner Hospital in Boston conducted a population-based study using information on more than 6. 5 million patients. Over a 14-year period, about 19,000 were prescribed both triptans and SSRI or SNRI antidepressants. Between 4 and 7 patients (0. 02% to 0. 04%) developed serotonin syndrome. In most cases serotonin syndrome is mild and consists... --- ### Magnesium reduces the size of hemorrhagic strokes - Published: 2017-08-28 - Modified: 2017-08-28 - URL: https://www.nyheadache.com/blog/magnesium-reduces-the-size-of-hemorrhagic-strokes/ - Categories: Alternative Therapies, Brain disorders Researchers at Northwestern University in Chicago examined possible correlation between magnesium level on admission to the hospital with the size of a stroke due to bleeding as well as functional outcomes. Their findings were published in Neurology. 290 patients presenting with a non-traumatic intracranial hemorrhage had their demographic, clinical, laboratory, radiographic, and outcome data analyzed and assessed for associations between serum magnesium levels and initial hematoma volume, final hematoma volume, in-hospital hematoma growth, and functional outcome at 3 months. Lower admission magnesium levels were associated with larger initial bleeds and larger final hematoma volumes. Lower admission magnesium level was associated with worse functional outcomes at 3 months after adjustment for age, initial hematoma volume, hematoma growth, and other factors. The evidence indicates that the beneficial effect of magnesium is due to the reduction in hematoma growth. The authors concluded that having higher magnesium level can reduce the size of a bleed in the brain. Unfortunately, magnesium is not a part of the routine blood tests included in the so-called comprehensive metabolic panel. This panel does include potassium, sodium, calcium and other tests, but magnesium needs to be ordered by the doctor separately. Very few doctors do and this can be detrimental to your health. Not only strokes are bigger, but many other much more common health problem can stem from magnesium deficiency. Readers of this blog know well that magnesium deficiency is very common in migraine patients and that taking magnesium (or getting an intravenous infusion) can provide dramatic relief.... --- ### Another study shows benefits of fish oil - Published: 2017-08-21 - Modified: 2017-08-21 - URL: https://www.nyheadache.com/blog/another-study-shows-benefits-of-fish-oil/ - Categories: Alternative Therapies, Trigeminal and other neuralgias Omega-3 polyunsaturated fatty acids (PUFA) which are found in fish oil, have been studied in a wide variety of diseases, ranging from Alzheimer's disease to Herpes Zoster (shingles). Omega-3 PUFA have proven anti-inflammatory and neuroprotective properties and have been used to treat rheumatoid arthritis, Crohn's disease, ulcerative colitis, psoriasis, lupus erythematosus, multiple sclerosis, as well as migraine headaches. A new study just published in Neurology showed a strong beneficial effect of Omega-3 PUFA in the treatment of diabetic nerve damage, or diabetic sensorimotor polyneuropathy in patients with type 1 diabetes. After one year of taking 750 mg of EPA and 560 mg of DHA (two of the main omega-3 fatty acids) there was a significant improvement in the nerve function. Omega-3 PUFA are proven to help patients with coronary artery disease, while in many other conditions, including migraines, the evidence is not as strong. However, considering that we have a very large amount of data showing a benefit in a wide variety of conditions and that Omega-3 PUFA are very safe and inexpensive, it is reasonable to try EPA with DHA for any auto-immune or inflammatory condition, as well as depression. Eating fatty fish, such as salmon and sardines 2-3 times a week can be sufficient for general health, but those with coronary artery disease and other conditions could benefit from a daily supplement. Also, fish often contains mercury, which can cause neurological and other problems. Omax3 and prescription fish oil, Lovaza are my preferred products because they contain no... --- ### Botox injections improve not only migraine symptoms, but also sleep and fatigue - Published: 2017-08-14 - Modified: 2017-08-14 - URL: https://www.nyheadache.com/blog/botox-injections-improve-not-only-migraine-symptoms-but-also-sleep-and-fatigue/ - Categories: Botox, Chronic migraine, Migraine Sleep disturbances and fatigue are more common in patients with chronic migraine headaches than in people without migraines. Sometimes it is not clear what came first, migraines or the sleep problem with secondary fatigue. A multicenter study performed in Australia, South Korea, and the US examined the effect of Botox injections given for chronic migraines on sleep and fatigue. This was a 108-week study of 715 adult patients who received Botox injections every 12 weeks. Their sleep quality was assessed by the Pittsburgh Sleep Quality Index and fatigue was measured by the Fatigue Severity Scale, both standard and proven measures of sleep and fatigue. The authors presented their findings at the American Headache Society meeting held two months ago in Boston. While sleep quality was poor before injections were started, significant improvement was noted 24 weeks later and the improvement persisted for the rest of the study. The same was true for fatigue. These findings suggest that sleep difficulty and fatigue are more often the result of chronic migraine, rather than the other way around. This does not mean that sleep issues should not be addressed while chronic migraine is being treated. Patients are advised to adhere to sleep hygiene, which consists of going to sleep and getting up at the same time, not reading or looking at any screens in bed, sleeping in a cool and quiet environment, exercising and eating at least 2 hours before bedtime, and avoiding caffeine after 1 PM. Regular practice of progressive relaxation and... --- ### Anxiety contributes to disability in kids with headaches - Published: 2017-08-07 - Modified: 2017-08-07 - URL: https://www.nyheadache.com/blog/anxiety-contributes-to-disability-in-kids-with-headaches/ - Categories: Alternative Therapies, Headaches in children, Psychology of headaches Anxiety is at least twice as common in both children and adults with migraine headaches compared to people without migraines. A new study presented at the recent American Headache Society meeting examined the impact of anxiety on functioning in pediatric migraine population. The researchers analyzed records of 530 kids with migraine and 371 with tension-type headache seen in the pediatric neurology clinic of the Boston Children's Hospital. Dr. Lebel and her colleagues discovered that physiological anxiety was associated with more severe functional disability in kids with both migraines and tension-type headaches. Physiological anxiety often manifests itself by sleep difficulties, racing heart, shortness of breath, feeling shaky, fatigue, and other. The other two types of anxiety, worry and social anxiety did not seem to lead to more disability. This study confirms the importance of cognitive and behavioral treatments, such as progressive relaxation, biofeedback, meditation, and cognitive therapy. Kids are very good at these techniques and they are particularly receptive to smartphone-based apps. For meditation, I recommend 10% Happier and Headspace. TaraBrach. com offers free podcasts for meditation and ThisWayUp. org. au provides very inexpensive and scientifically proven cognitive-behavioral therapy. At the NY Headache Center we always try to avoid drugs, especially in children. In addition to cognitive and behavioral techniques, we address sleep, exercise, diet and supplements such as magnesium, CoQ10, and other. If medication is needed, this study suggests that a beta blocker, such as propranolol (Inderal) may be a good choice because in addition to preventing migraines, it reduces... --- ### Occipital (back of the head) headaches in children - Published: 2017-08-05 - Modified: 2017-08-05 - URL: https://www.nyheadache.com/blog/occipital-back-of-the-head-headaches-in-children/ - Categories: Headaches in children Most children who complain of headaches report pain in the forehead and/or temples. Doctors and parents tend to get more alarmed when a child complains of a headache in the back of the head and such children are more likely to have an MRI scan of the brain. According to a new study published in Neurology, there is no reason for concern. The researchers examined records of 308 children under 18 (median age was 12) seen at a pediatric neurology clinic and found that 7% of them had pain only in the occipital area, while another 14% had pain in the occipital and another part of the head. The majority of children had migraine headaches. Not surprisingly, more kids with pain in the back of the head had an MRI scan. However, they did not have any more abnormal MRI findings than children with pain in other parts of the head. In fact none of the 4 children in this group who had a serious problem (2 had tumors and 2 had increased pressure) had occipital pain. Considering that migraine headaches are common in children (4-11% of all kids) there is no need to do MRI scans in all kids with recurrent headaches. The American Academy of Neurology and Child Neurology Society do not recommend a CAT or MRI scan in children with recurrent headaches and a normal neurologic examination. However, 45% of children do get neuroimaging. Imaging is particularly unnecessary if other members of the family suffer from similar... --- ### Sumatriptan injections still underutilized. New lower dose, easy-to-use device could help - Published: 2017-07-30 - Modified: 2017-07-30 - URL: https://www.nyheadache.com/blog/sumatriptan-injections-still-underutilized-new-lower-dose-easy-to-use-device-could-help/ - Categories: Headache medications, injections, Migraine Sumatriptan (Imitrex) injection was introduced 25 years ago, but it remains extremely underutilized. Of course, why would you inject yourself if a pill does the job. Unfortunately, for many migraine sufferers sumatriptan and other triptan tablets do not provide complete or fast enough relief. In many patients tablets do not work well because some wake up with a severe migraine, in some it starts very suddenly, and in others it is accompanied by nausea and vomiting. All these conditions require a quickly acting drug that bypasses the stomach. Zolmitriptan (Zomig) and sumatriptan nasal sprays or sumatriptan nasal powder (Onzetra) sometimes work well and quickly enough, but the gold standard in the abortive treatment of migraines (and cluster headaches) is sumatriptan injection. Sumatriptan injection works within 10-15 minutes and often provides complete relief of the headache and associated symptoms - nausea, sensitivity to light and noise, and other. Because of a sudden surge in the sumatriptan level in the blood, side effects are more common than with tablets. These can include pins-and-needles like sensations, tightness in the neck or chest, or temporary worsening of the headache. These side effects last only 15-20 minutes and do not prevent most patients from using injections. Sumatriptan injections were originally released only in a 6 mg dose. A few years later, 4 mg dose became available. Last year, a simple-to-use autoinjector with 3 mg of sumatriptan (Zembrace) was approved by the FDA. Studies presented at the recent annual meeting of the American Headache Society in... --- ### Migraine increases the risk of stroke during and after surgery - Published: 2017-07-23 - Modified: 2017-07-23 - URL: https://www.nyheadache.com/blog/migraine-increases-the-risk-of-stroke-during-and-after-surgery/ - Categories: Brain disorders, Migraine It is an established fact that migraine, and especially migraine with aura increases the risk of strokes. The increase in the risk is small, but according to a new study published in the British Medical Journal, it is higher during and after surgery. The researchers examined records of 124,558 surgical patients at the Massachusetts General and two other hospitals. Among these, 8. 2% or 10,179 patients had a history of migraines with 1,278 or 12. 6% having migraine with aura. The risk of stroke during or within 30 days after surgery was 1-2 in 1,000 among patients without migraine history, 4 in 1,000 in those who had migraines and 6 in 1,000 in patients who had migraine with aura. So, the absolute risk of a stroke is still very small, but the relative risk is statistically much higher. They also discovered that strokes were more common in patients who during surgery needed medications to increase their blood pressure. Most of the strokes occurred within the first two days after surgery. We do not know why migraine carries an increased risk for strokes, so the only recommendation the authors offer is for migraine diagnosis to be included in the preoperative risk assessment of patients. I would add that according to another study, taking high doses of magnesium and potassium supplements could possibly reduce this risk. Magnesium alone was shown to reduce the risk of strokes in another review of studies involving 6,477 patients. Our own research and that of others have... --- ### Telemedicine is effective to treat headache patients - Published: 2017-07-19 - Modified: 2017-07-19 - URL: https://www.nyheadache.com/blog/telemedicine-is-effective-to-treat-headache-patients/ - Categories: Headaches We often get requests for a telephone consultation from patients who live too far to come in for a visit. Unfortunately, insurance companies do not cover telephone or video-link consultations. An additional obstacle in the US is that doctors cannot treat patients outside the state where they are licensed because each state licenses their own doctors. If patients can afford to pay, we do offer follow-up telephone consultations to patients who live out of state or abroad and who were first seen in our office. A group of Norwegian researchers examined how safe and effective it is to treat patients without seeing them in person by using a video link. The results of their study was published in a recent issue of the journal Neurology. They compared 3 and 12 month outcomes after a single consultation in 200 patients using telemedicine with 202 patients seen in the office. All patients were referred by their primary care doctor. They included only patients with non-acute headaches, that is those whose headaches started gradually more than 4 weeks prior to the visit and showed no clinical or MRI abnormalities. Doctors ordered about the same number of MRI scans in both group (58 and 62). Over the subsequent year a serious underlying cause was found in one patient in each group. Treatment outcomes after 1 year were the same in both group, although in both groups the improvement in headache severity and its impact on the daily life was modest. There was a high... --- ### New information on cluster headaches - Published: 2017-07-17 - Modified: 2017-07-17 - URL: https://www.nyheadache.com/blog/new-information-on-cluster-headaches/ - Categories: Blocks, Botox, Cluster headaches, Headache medications Cluster headache is one of the most painful conditions that has lead some patients call it a suicide headache. A new observational study done by researchers at the Eli Lilly company and Stanford University was presented at the recent annual scientific meeting of the American Headache Society. Considering that cluster headaches are relatively rare, the major strength of this study is its size - 7589 patients. These patients were compared to over 30,000 control subjects without headaches. We've always known that cluster headaches are more common in men with previous studies indicating that male to female ratio is between 5:1 and 3:1. However, only 57% of patients in this new report were males. This does not reflect my experience - I see at least five times as many men as women. It is possible that I underdiagnose cluster headaches in women or the study used unreliable data. In fact, the study data was collected from insurance claims, so I suspect that the truth is closer to my experience and to the older published data. The study did find that thoughts of suicide were 2. 5 times more common in patients with cluster headaches compared to controls, while depression, anxiety and sleep disorders were twice as common. Cluster headache patients also were 3 times more likely to have drug dependence. The most commonly prescribed drugs were opiates (narcotics) in 41%, which partially explains high drug dependence rates, steroids, such as prednisone (34%), triptans, such as sumatriptan (32%), antidepressants (31%), NSAIDs (29%),... --- ### Another report on Botox for trigeminal neuralgia - Published: 2017-07-10 - Modified: 2017-07-10 - URL: https://www.nyheadache.com/blog/another-report-on-botox-for-trigeminal-neuralgia/ - Categories: Botox, Trigeminal and other neuralgias Trigeminal neuralgia is a rare, but an extremely painful conditions. Patients compare the quality and the severity of pain to an electric shock. The underlying cause is usually compression of the trigeminal nerve by a blood vessel inside the skull and underneath the brain. Surgery to place a teflon pad between the nerve and the blood vessel is curative, but many patients can avoid surgery by using drugs such as carbamazepine, oxcarbazepine, baclofen, and other. Botox, which is approved only for one pain condition - chronic migraines, appears to help other painful conditions, including trigeminal neuralgia (TN). A single previous double-blind placebo-controlled study by Chinese doctors confirmed our clinical observation that Botox does indeed help TN. A new report presented at the annual meeting of the American Headache Society, also by Chinese researchers describes another positive study. This study compared a single injection of Botox with two injections separated by two weeks. It is not clear what was the logic in giving a second treatment so soon after the first one since Botox effect lasts 3 months. They followed 81 patients for 6 months and both groups had more than 80% success in the first 3 months and somewhat less of an effect in the last 3 months of the study. This was not a blinded study, but placebo response is relatively low in TN, probably because of the high pain intensity. While this study was not as scientific as the first one, it does offer some additional evidence of... --- ### More support for the use of Botox in posttraumatic headaches - Published: 2017-06-30 - Modified: 2017-06-30 - URL: https://www.nyheadache.com/blog/more-support-for-the-use-of-botox-in-posttraumatic-headaches/ - Categories: Botox, Chronic migraine, Head trauma, post-traumatic headache Concussion, even when it is mild, can result in a post-concussion syndrome. The main symptom is a headache and it is present in 60% of people within the first year after a mild traumatic brain injury. In people with personal or family history of migraines these headaches are often post-traumatic chronic migraines. Post-traumatic headaches and other symptoms such as dizziness and difficulty with vision, concentration and memory are often difficult to treat. However, an effective treatment of headaches often leads to an improvement in other symptoms as well. Treatment with epilepsy drugs (Topamax, Depakote, Neurontin), blood pressure medications (propranolol), or antidepressants (Elavil, Cymbalta) can be effective in some, but not in all and not without side effects. Botox injections have been very effective without any serious side effects in many of my patients and similar results have been published by other doctors (see here and here). Dr. Sylvia Lucas of University of Washington in Seattle presented her experience with the treatment of posttraumatic headaches with Botox at the annual meeting of the American Headache Society held in Boston last month. She described 15 patients who sustained a mild traumatic brain injury and suffered from chronic migraines for an average of 8 months prior to being treated with Botox. After a series of three Botox treatments given every 3 months most patients had a significant improvement in the number of headache days, as well as improved physical and social functioning, emotional well-being, energy level and a reduction in pain. As expected,... --- ### Our report on stem cells for migraines is published - Published: 2017-06-28 - Modified: 2017-06-28 - URL: https://www.nyheadache.com/blog/our-report-on-stem-cells-for-migraines-is-published/ - Categories: Alternative Therapies, Chronic migraine, Migraine Stem cells hold great promise in the treatment of many conditions, possibly including migraines. In a post from 3 years ago I've written about a report from Australia that described 4 patients with refractory chronic headaches who had a very good response from stem cells. They were given stem cells for other conditions and coincidentally their migraines improved. Since many patients come to our practice after seeing several other neurologists and headache specialists, we often have to resort to new, non-traditional, and unproven treatments. This is how I started using Botox 25 years ago (the FDA approved it for migraines only 6 years ago). After reading the Australian report I decided to try stem cell treatment in some of my most refractory patients. Only patients who failed to respond to Botox and at least 3 preventive drugs were offered to participate in this pilot study. The only type of stem cells that the FDA allows to be injected are cells taken from patient's own body without altering them. The richest source of stem cells in our bodies is fat. My colleague, Dr. Kenneth Rothaus who is a plastic surgeon, performed a liposuction to obtained fat tissue, from which we separated active cells. We enrolled 9 patients and 3 did have significant temporary improvement. The results are obviously not dramatic, but it is possible that in less severely affected patients this treatment could work better. More importantly, using stem cells from an umbilical cord or placenta is more likely to be... --- ### Opioid hydromorphone (Dilaudid) does not help migraine - Published: 2017-06-26 - Modified: 2017-06-26 - URL: https://www.nyheadache.com/blog/opioid-hydromorphone-dilaudid-does-not-help-migraine/ - Categories: Headache medications, Migraine Unfortunately, opioid hydromorphone (Dilaudid) is still administered to 25% of patients with an acute migraine visiting an ER. Benjamin Friedman and his colleagues at the Montefiore Medical Center in the Bronx compared the efficacy of 1 mg of intravenous hydromorphone with an intravenous nausea medicine, prochlorperazine (Compazine), 10 mg plus diphenhydramine (Benadryl), 25 mg. They presented their findings last month at the annual meeting of the American Headache Society. The study was blinded, but a safety monitoring committee stopped it early because the results were so lopsided. Prochlorperazine with diphenhydramine was twice as effective (60%) as hydromorphone (31%) in stopping a migraine and in preventing it from coming back within 48 hours. So, if you end up in an ER for your migraine, refuse hydromorphone (Dilaudid), meperidine (Demerol), or any other opioid (narcotic) medication. Here is my old post with drugs other than prochlorperazine that are also effective. --- ### A migraine vaccine should be out next year - Published: 2017-06-24 - Modified: 2017-06-26 - URL: https://www.nyheadache.com/blog/a-migraine-vaccine-should-be-out-next-year/ - Categories: Uncategorized 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. --- ### Living at high altitudes leads to more migraines - Published: 2017-06-21 - Modified: 2017-06-21 - URL: https://www.nyheadache.com/blog/living-at-high-altitudes-leads-to-more-migraines/ - Categories: Alternative Therapies, Migraine Many migraine sufferers complain about worsening of their migraines when they travel to high altitudes. But do people who permanently live at high altitudes are more likely to have migraines? A report published in the European Journal of Neurology describes a population-based study done in Nepal in which researchers compared the incidence of migraines in Nepalese living at low and high altitudes. A previous study done in Peru suggested such an association between migraine and living at a high altitude. 2,100 Nepali-speaking adults were recruited into this study. More than half, or 1,100 (52. 4%) lived above 1000 meters (3,280 feet) and almost one quarter or 470 (22. 4%) lived at 2,000 meters (6,560 feet). The researchers took into account the age and the gender of participants. Migraine prevalence increased from 28% to 46% with altitude between 0 and 2,499 meters and thereafter decreased to 38% at 2,500 meters. The likelihood of having migraines was almost two times greater at all higher altitudes compared with those living below the altitude of 500 meters. In addition, frequency and duration of migraine attacks doubled and pain intensity increased by 50% at higher altitudes. The authors concluded that "dwelling at high altitudes increases not only migraine prevalence but also the severity of its symptoms". Acetazolamide (Diamox) can be an effective drug for the prevention of headaches at high altitudes and with barometric pressure drops. Unfortunately, we do not know if taking this medicine long-term is also effective for the prevention of headaches in... --- ### New research on cannabis for migraines - Published: 2017-06-19 - Modified: 2017-06-19 - URL: https://www.nyheadache.com/blog/new-research-on-cannabis-for-migraines/ - Categories: Alternative Therapies, New treatments, Science of Migraine Medical marijuana has been legalized in NY and more than 20 other states. It is approved in NY for several medical conditions, including pain and some of my patients with headaches (about one out of 3), arthritis, and other pains have found it to be very helpful. Some patients use it acutely (as a vaporizer or tincture) and report relief of pain, and/or nausea and for some it allows them to go to sleep and sleep off their migraines. Tablets of medical marijuana can prevent migraines if taken once or twice a day. Most people need products with a low THC/CBD ratio which does not cause euphoria or other cognitive effect. Despite the requirement by states to have verified amounts of active ingredients, THC and CBD in the medical marijuana products, the efficacy and the side effects vary from manufacturer to manufacturer. This could be in part due to ingredients other than THC and CBD. Fortunately, many researchers are looking into the effect of pure ingredients and their mechanism of action. Such a study was presented at the recent meeting of the American Headache Society by scientists from the Missouri State University led by Paul Durham. They developed a new animal model of migraine in rats and triggered a process in the rats' brains that is similar to a migraine in humans. Administering cannabidiol (CBD) suppressed increased sensitivity in the trigeminal nerve and produced other positive effects, suggesting a possible mechanism by which CBD may relieve migraine and other facial... --- ### A new book for migraine sufferers and their families - Published: 2017-06-14 - Modified: 2017-06-14 - URL: https://www.nyheadache.com/blog/a-new-book-for-migraine-sufferers-and-their-families/ - Categories: Alternative Therapies, Botox, Headache medications, Headaches Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the latest book on migraines, Understanding Your Migraines, the answer is a definite yes. The book is written by two colleagues who for many years co-directed the Dartmouth Headache Clinic. Dr. Morris Levin is now the Director of the Headache Center and a Professor of Neurology at UCSF, while Dr. Thomas Ward is Professor of Neurology Emeritus at the Geiser School of Medicine at Dartmouth and the editor of the journal Headache. They are clearly highly qualified to write such a book, but qualifications are not enough - you need to be a good writer as well. And in fact, excellent writing style and case-based discussion are two of the major strengths of the book. The book consists of 17 chapters, which cover diagnosis and our understanding of the underlying causes of this condition. What the readers will find most useful is the treatment approaches. Drs. Levin and Ward go into great detail about various non-drug options, including nutrition, exercise, meditation, acupressure, herbal products, vitamins and minerals. They also present pros and cons of various medications, nerve blocks and describe in detail the most effective and the safest preventive treatment for chronic migraines, Botox injections. One chapter is devoted to specifics of migraines in pregnancy and another one to children and adolescents. The book also includes individual chapters on tension-type headaches, cluster and other less common headache types, and postconcussion headaches.... --- ### When nothing relieves your migraines, rehabilitation might - Published: 2017-06-05 - Modified: 2017-06-05 - URL: https://www.nyheadache.com/blog/when-nothing-relieves-your-migraines-rehabilitation-might/ - Categories: Alternative Therapies, Chronic migraine, Migraine, Psychology of headaches The most satisfying part of our work is that we can help more than 95% of our patients. However, a small number of headache sufferers defy our best efforts and continue to have severe pain, which ruins their quality of life. I just returned from my second visit to lecture at the Berolina Klinik, a rehabilitation hospital in Germany. It has an outstanding record in rehabilitating chronic headache and other types of patients. I wrote about this clinic after my first visit in 2014. A report just published in Headache describes a successful rehabilitation program of chronic headache patients in an outpatient setting at the Cleveland Clinic. Drs. Krause, Stillman and their colleagues report on 379 patients who were admitted to the IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) program. The program lasts 3 weeks, during which patients come to the clinic for 8 hours 5 days a week. Patients are informed that "the primary purpose of treatment is not to reduce pain, but rather to improve their ability to function during pain". Despite this warning the average pain on admission was 6. 1, while on discharge 3. 5 and a year later, 3. 3. Functional impairment, anxiety, and depression also improved and stayed improved a year after the treatment. The program is clearly very effective and has an additional advantage of not requiring expensive hospitalization. Most patients stay at a hotel across the street from the clinic. Here is an outline of the 3-week program:... --- ### A new drug is approved for temporal arteritis, cause of headaches in those over 50 - Published: 2017-05-31 - Modified: 2017-05-31 - URL: https://www.nyheadache.com/blog/a-new-drug-is-approved-for-temporal-arteritis-cause-of-headaches-in-those-over-50/ - Categories: Headache medications, Headaches, New treatments Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected. It is not common below the age of 60 and becomes more prevalent with the advancing age. Temporal arteritis is also known as giant cell arteritis because it causes inflammation of arteries with giant cells seen under the microscope. Headache is often the first symptom and it is typically localized to one temple, but it can involve other parts of the head and occur on both sides. If left undiagnosed and untreated temporal arteritis can cause a stroke and blindness, which can affect both eyes. Besides headaches, temporal arteritis can cause neck and jaw pain, weakness, muscle aches, and a mild fever. The preliminary diagnosis is made by blood tests (ESR and CRP) and it is confirmed by a biopsy of the temporal artery. Polymyalgia rheumatica is a related rheumatological condition, which can occur alone or with temporal arteritis and it causes severe muscle pains. Temporal arteritis (and polymyalgia rheumatica) are treated with steroid medications, such as prednisone. Although the initial dose is high, relatively small doses are usually effective for maintenance. Since the condition can last for years and long-term intake of prednisone can cause many potentially serious side effects it is very important to perform a temporal artery biopsy in most cases, rather than rely just on blood tests and clinical diagnosis. Subcutaneous injection of Actemra (tocilizumab) was just approved by the FDA for the treatment of temporal... --- ### Preeclampsia can have lasting effects on the brain - Published: 2017-05-27 - Modified: 2017-05-27 - URL: https://www.nyheadache.com/blog/preeclampsia-can-have-lasting-effects-on-the-brain/ - Categories: Alternative Therapies, Brain disorders, Headaches Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated, they can cause strokes and kidney failure. Fortunately, these conditions are very responsive to intravenous infusions of high doses of magnesium (5-6 grams at a time, while we give 1 gram to our migraine patients). A study recently published in Neurology suggests that even if preeclampsia is treated effectively, it can lead to persistent brain lesions. The researchers found these small white matter lesions (WMLs) in the healthy controls as well, but not as many as in women who suffered from preeclampsia 5 to 15 years prior to the study. We also see these lesions, which appear as small spots, on MRI scans of patients with migraines. The exact nature of these spots remains unclear, but the leading theory is that they are due to impaired blood flow. The authors looked at a wide variety of factors that might have predisposed women to preeclampsia and subsequent WMLs, but did not find any. They did confirm previous findings indicating that age and high blood pressure increases the number of WMLs, but those with preeclampsia had more WMLs in the temporal lobes of the brain. They also found a decrease of the cortical volume, which means loss of brain cells on the surface of the brain. Surprisingly, one of the factors they did not measure was magnesium levels. If preeclampsia responds so well to magnesium, it is possible that these women have... --- ### Hyperbaric oxygen for traumatic brain injury and postconcussion syndrome - Published: 2017-05-12 - Modified: 2017-05-12 - URL: https://www.nyheadache.com/blog/hyperbaric-oxygen-for-traumatic-brain-injury/ - Categories: Alternative Therapies, Brain disorders, Head trauma Inhalation of pure oxygen under high flow is an effective treatment for an acute cluster headache, although not migraines. Headache is one of the most common symptoms of traumatic brain injury and postconcussion syndrome and there is evidence that oxygen under pressure can help those conditions. A review article on the use of oxygen to treat mild and moderate traumatic brain injury and postconcussion syndrome was recently published in Neurology. THe authors reviewed 5 previously published studies and concluded that hyperbaric oxygen in fact does help patients with brain trauma and postconcussion syndrome. While cluster headache patients can breathe in oxygen through a mask from a tank of oxygen delivered to their home, hyperbaric oxygen requires a special room or a chamber. Hyperbaric means that oxygen is under increased pressure, although the authors report that moderate pressure (between 1 and 2 ATA) may be better than high pressure. Even hyperbaric air, that is normal air under pressure, may have beneficial effects. The authors conclude that, there is sufficient evidence for the safety and preliminary efficacy from clinical data to support the use of hyperbaric oxygen in mild to moderate traumatic brain injury and postconcussion syndrome. They also state that “It would be a great loss to clinical medicine to ignore the large body of evidence collected so far that consistently concludes that hyperbaric oxygen is effective in treatment of brain injuries. ” Fortunately, there are many hospitals and private clinics all around the country that offer hyperbaric oxygen. They often... --- ### Update on medical marijuana from the founder of the field - Published: 2017-05-05 - Modified: 2017-05-05 - URL: https://www.nyheadache.com/blog/update-on-medical-marijuana-from-the-founder-of-the-field/ - Categories: Alternative Therapies, Migraine, Pain The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other night I attended a lecture in NYC by the "father of cannabis", Raphael Mechoulam. According to Wikipedia, "Dr. Mechoulam is an Israeli organic chemist and professor of Medicinal Chemistry at the Hebrew University of Jerusalem in Israel. Mechoulam is best known for his work (together with Y. Gaoni) in the isolation, structure elucidation and total synthesis of THC (? 9-tetrahydrocannabinol), the main active ingredient of cannabis and for the isolation and the identification of the endogenous cannabinoids anandamide from the brain and 2-arachidonoyl glycerol (2-AG) from peripheral organs together with his students, postdocs and collaborators. " Dr. Mechoulam identified THC in 1964 and in his lecture he lamented the paucity of research into the many potential healing properties of cannabis in the past 50 years. He strongly feels that the two main active ingredients in marijuana, THC and CBD should be tested rigorously in large double-blind studies just like any other prescription drug. This will allow doctors to prescribe a proven medicine, rather than rely on anecdotal reports and go through trial and error, as we are doing now. His research suggests that cannabis ingredients could possibly help a wide variety of conditions, from diabetes and cancer to pain and nausea. Prescribing medical marijuana is at least possible in New York and 20 other states, so that we do not have to wait, possibly up to 10 years, for a... --- ### Non-drug treatment of insomnia helps headaches - Published: 2017-05-01 - Modified: 2017-05-01 - URL: https://www.nyheadache.com/blog/non-drug-treatment-of-insomnia-helps-headaches/ - Categories: Alternative Therapies, Chronic migraine, Headaches, Migraine, Psychology of headaches Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days. Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine. The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to... --- ### Learn from The Migraine World Summit - Published: 2017-04-26 - Modified: 2017-04-26 - URL: https://www.nyheadache.com/blog/learn-from-the-migraine-world-summit/ - Categories: Alternative Therapies, Migraine I am certain that you will learn a lot of useful information from listening to the top headache experts in the world. The event is free during the week when it is held (April 23 - 29), but afterwards you will have to pay for full access to all interviews. The Migraine World Summit is in its second year and it again assembled excellent speakers to address a wide variety of headache-related topics. Last year I spoke on non-drug therapies and this year the speakers are again addressing not only medications, but many alternative treatments and self-care. In addition to many leading neurologists, the event features Ping Ho, MA, MPH, a UCLA expert on alternative therapies, meteorologist, Michael Steinberg of Accuweather, Vidyamala Burch, a mindfulness expert, an Australian psychologist, Paul Martin, a geneticist, Professor Lyn Griffiths of Queensland UT (the event is organized by an Australian migraine sufferer Carl Cincinnato, so there are many Australians represented), and over 30 other experts. Here is a blurb from the organizers: In it's first year, The Migraine World Summit became the largest ever conference for migraine patients. In 2017, we're back with 36 brand NEW interviews where you'll discover even more about... What are the best treatments for migraine? What can I do when I've already tried everything? What are the secrets to finding effective natural alternatives? How can I cope with the anxiety, judgment and social stigma of chronic migraine? What new treatments are coming that I should be aware of? What... --- ### Blood vessels, stroke and migraine - Published: 2017-04-24 - Modified: 2017-04-24 - URL: https://www.nyheadache.com/blog/blood-vessels-stroke-and-migraine/ - Categories: Brain disorders, Migraine Stroke is slightly more common in migraine sufferers. There are two main types of stroke: hemorrhagic, which results from a burst blood vessel in the brain and ischemic, which is due to a blood clot closing off blood supply to a part of the brain. Closure of a blood vessel by a clot can be due to a blood clotting disorder, cholesterol plaque, or dissection of a blood vessel. Dissection is a lengthwise tear in the blood vessel wall. A study just published by Italian researchers in JAMA Neurology included 2,485 patients aged 18 to 45 years with first-ever acute ischemic stroke. Of these patients 334 or 13% had a dissection and 2151 or 87% had a stroke not caused by dissection. Migraine was more common in the dissection group 31% vs 24% in non-dissection group. These differences are relatively small, but the importance of the study is that it should make doctors consider the possibility of a dissection when a patient with migraines develops a different type of headache or has a new onset of neck pain. If a dissection is suspected, a CT angiogram or an MRA should be done. Luckily, many dissections do not cause strokes and heal on their own. However, we do recommend blood-thinning medications (anticoagulants) for several months after the dissection even in the absence of a stroke. My previous post described a scientific review on this topic, that showed a two-fold increase in the risk of dissection in migraine sufferers. Another practical aspect... --- ### Sensitivity to light (photophobia) and migraine - Published: 2017-04-16 - Modified: 2017-04-16 - URL: https://www.nyheadache.com/blog/sensitivity-to-light-photophobia-and-migraine/ - Categories: Alternative Therapies, Migraine Photophobia, or sensitivity to light is one of the most common symptoms that accompany a migraine attack. Many patients remains photophobic even after the headache has resolved. In some, a prolonged exposure to bright light or as little as a momentary reflection of the sun in the window glass or water surface can bring on a severe attack. It is not unusual for some of my patients to wear sunglasses indoors. Once, when I had a migraine while driving at night I had to put on my sunglasses because the headlights of oncoming cars made the pain worse (luckily, I had a sumatriptan injection with me and as soon as I got off the highway and to a traffic light, I gave myself a shot). Dr. Kathleen Digre, a professor Neurology and Ophthalmolgy at the University of Utah, whose article on dry eyes and migraines I quoted a couple of years ago, recently stated that staying in the dark may actually make photophobia worse. It may be better to gradually expose yourself to more light when you are not in the middle of an attack. A small study suggested that people who suffer from photophobia between migraine attacks are more likely to experience anxiety and depression than those without photophobia between attacks and those without migraines. It is not clear if anxiety and depression in these patients is due to more severe migraines. Treatments for photophobia mentioned by Dr. Digre include botulinum toxin (Botox) injections, nerve blocks, medications such as... --- ### Postconcussion symptoms in teens are relieved by CBT - Published: 2017-04-09 - Modified: 2017-04-09 - URL: https://www.nyheadache.com/blog/postconcussion-symptoms-in-teens-are-relieved-by-cbt/ - Categories: Alternative Therapies, Head trauma, Psychology of headaches Postconcussion symptoms can be debilitating and can persist for long periods of time, both in kids and adults. Persistence of headaches, dizziness, difficulty concentrating and with memory is often compounded by depression and anxiety. The usual care consists of mild exercises, sleep medications, antidepressants, and other drugs. A new study published in Pediatrics shows very promising results from cognitive-behavioral therapy (CBT) in teens with post-concussion symptoms. Children aged 11 to 17 years with persistent symptoms for more than a month after sports-related concussion were randomly assigned to receive collaborative care that included CBT (25 kids) or care as usual (24 kids). The children were assessed before treatment and after 1, 3, and 6 months. Six months after the baseline evaluation 13% of children who received CBT and 42% of control patients reported high levels of postconcussive symptoms. Depression improved by at least 50% in 78% of the CBT group and 46% of control patients. Anxiety symptoms were at the same level in both groups. CBT has been shown to be effective in children and adolescents with chronic migraines, so it is not surprising that it would also help with postconcussion headaches and other symptoms. And the effect is quite dramatic. A major obstacle for wider adoption of CBT is the cost and difficulty in finding a qualified psychologist. In a previous post I mentioned two very effective and scientifically verified online programs, ThisWayUp and moodGYM. These do require persistence and discipline, which in case of teens, parents might be able... --- ### Beta-blockers (e.g. propranolol) prevent migraines, but could also help other pains - Published: 2017-03-27 - Modified: 2017-03-27 - URL: https://www.nyheadache.com/blog/beta-blockers-e-g-propranolol-prevent-migraines-but-could-also-help-other-pains/ - Categories: Pain Beta-blocker propranolol (Inderal) was first approved over 50 years ago for the treatment of hypertension and 10 years later became the first drug to be approved for the prevention of migraine headaches. Beta-blockers that followed, including atenolol, timolol, nebivolol, and other, also work for the prevention of migraines. Beta-blockers are also used to treat benign essential or familial tremor, performance anxiety, and other disorders. A study recently published in Arthritis Care and Research suggests that beta-blockers also reduce arthritis pain. The researchers evaluated 873 patients who suffered from painful osteoarthritis of the hip and/or knee as well as hypertension and who were taking at least one anti-hypertensive medication. Their analysis took into account age, gender, body mass index (BMI), knee or hip osteoarthritis, history of joint replacement, anxiety and depression. The result of this sophisticated analysis showed that patients who were taking beta-blockers had less pain than patients taking other anti-hypertensive medications. Patients taking beta-blockers were also found to be taking less of opioid (narcotic) and other prescription pain medications. This type of study shows a correlation between the use of certain medications and pain, however to prove that beta-blockers are indeed effective for the pain of osteoarthritis or any other type of pain, we need prospective blinded studies. Until we have those kind of studies, which often take years to complete, it seems prudent to consider using beta-blockers as first-line drugs for the prevention of migraines in patients who also suffer from arthritis pain. --- ### Wireless electric patch for migraines - Published: 2017-03-24 - Modified: 2017-03-24 - URL: https://www.nyheadache.com/blog/wireless-electric-patch-for-migraines/ - Categories: Alternative Therapies, Migraine, neurostimulation A new electric device is being tested for the treatment of migraine by an Israeli company, Theranica. Transcutaneous electric nerve stimulation (TENS) has been successfully used for the treatment of musculoskeletal disorders for decades. The theory behind it is the so-called gate theory of pain. It is thought that by stimulating larger nerve fibers we can block pain messages sent by smaller pain-sensing nerve fibers. Cefaly is a TENS device which became available in 2014 and it provides electrical stimulation of the supraorbital nerves in the forehead. Only small studies have been conducted, so it is not clear how well Cefaly relieves migraines. As far as our experience, we at the NY Headache Center usually treat more severely affected patients, so it is possible that the results are better in people with less severe migraines. The new wireless patch that is being developed by Theranica is applied to the upper arm. The results of the first study of this patch were published in Neurology, the medical journal of the American Academy of Neurology. The study author, is a well-known neurologist and pain researcher, Dr. David Yarnitsky of Technion Faculty of Medicine in Haifa, Israel. He was quoted saying, “People with migraine are looking for non-drug treatments, and this new device is easy to use, has no side effects and can be conveniently used in work or social settings. ” The patch device is controlled by a smartphone app. It was studied in 71 patients with episodic migraine who had two... --- ### Cluster headaches are more often misdiagnosed in women - Published: 2017-03-13 - Modified: 2017-03-13 - URL: https://www.nyheadache.com/blog/cluster-headaches-are-more-often-misdiagnosed-in-women/ - Categories: Cluster headaches Cluster headaches are much less common than migraines (less than a million vs 36 million sufferers), but are arguably the most painful type of headaches a man can experience. And it is usually a man because cluster headaches are thought to be 3-5 times more common in men. However, a study just published in Neurology suggests that the ratio of men to women is closer to 2:1. This study by Danish researchers also established that women suffering from cluster headaches are more often misdiagnosed than men - 61% vs 46%. Consequently, it takes a year longer for a woman to be diagnosed than for a man - 6. 5 years vs 5. 5 years. But considering how devastating these headaches can be, these numbers are terrible for both sexes. Cluster headaches get their name from the fact that they occur in clusters - daily or more frequent attacks lasting one to three hours for a period of a month or two, each year and often at the same time of year. One surprising finding of the study is that women are more likely to have chronic cluster headaches (no break from attacks for more than a month) - 44% vs 32%. The reason for such high rates of misdiagnosis and long delays in diagnosing cluster headaches is that it is a relatively rare type of headaches and that it is easy to mistake cluster for a migraine or a sinus headache. Cluster headache is always one-sided and centers in the... --- ### Soccer is not good for your brain, at any age and whether you head the ball or not - Published: 2017-03-08 - Modified: 2017-03-08 - URL: https://www.nyheadache.com/blog/soccer-is-not-good-for-your-brain-at-any-age-and-whether-you-head-the-ball-or-not/ - Categories: Head trauma, Headaches, Headaches in children With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period. The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%. Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive. According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any... --- ### Low dose naltrexone (LDN) for pain - Published: 2017-03-04 - Modified: 2017-03-04 - URL: https://www.nyheadache.com/blog/low-dose-naltrexone-ldn-for-pain/ - Categories: Alternative Therapies, Headache medications, Pain Naltrexone, along with naloxone are narcotic (opioid) antidotes, that is they counteract the effect of narcotics and are used to treat overdoses with heroin, fentanyl, Percocet, Vicodin, and other opioid drugs. Surprisingly, low doses of naltrexone (LDN) seem to be effective in treating pain. LDN has been also used to treat symptom in conditions such as depression, fibromyalgia, Crohn’s disease, multiple sclerosis, complex regional pain syndrome (which used to be called reflex sympathetic dystrophy), and autoimmune disorders. Low dose naltrexone is not a typical pain killer, but may be helping pain by reducing inflammation. Instead of opioid receptors, it works on Toll-like receptor 4 (TLR4) receptors on glial cells. Glial cells surround the nerve cells and play important functions in the brain, beyond just a supporting role that had been assigned to them for many years. Opioid drugs are known to promote inflammation through the brain immune system leading to worsening of pain over time. Recent discoveries have shown that the Toll-like receptors are involved in triggering these inflammatory immune events. These discoveries have led many researchers to look at ways to block TLR4, but so far no such drug has been developed. We do have several existing medications that seem to block TLR4. Besides LDN, amitriptyline (Elavil) and cyclobenzaprine (Flexeril) are two other drugs that block TLR4 and that have been used for years to treat pain. No large controlled studies of LDN for migraines, pain or any other condition have been conducted to date. Despite the fact that... --- ### You’re Overpaying for Drugs and Your Pharmacist Can’t Tell You - Published: 2017-02-24 - Modified: 2017-02-24 - URL: https://www.nyheadache.com/blog/youre-overpaying-for-drugs-and-your-pharmacist-cant-tell-you/ - Categories: Uncategorized 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. --- ### Electronic medical records is a blessing and a curse - Published: 2017-02-15 - Modified: 2017-02-15 - URL: https://www.nyheadache.com/blog/electronic-medical-records-is-a-blessing-and-a-curse/ - Categories: Uncategorized 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... --- ### An update on contraceptives in migraine with aura - Published: 2017-02-09 - Modified: 2017-02-09 - URL: https://www.nyheadache.com/blog/an-update-on-contraceptives-in-migraine-with-aura/ - Categories: Migraine, Science of Migraine Estrogen-based oral contraceptives are usually contraindicated for women who have migraines with aura. In the latest issue of the journal Headache, Dr. Anne Calhoun of the Carolina Headache Institute argues that this contraindication is no longer valid. She analyzes research studies that consistently show that stroke risk is not increased with today's very low dose combined hormonal contraceptives containing 20-25 µg ethinyl estradiol and that continuous ultra low-dose formulations (10-15 µg) may even reduce the frequency of migraine auras. The past prohibitions were mostly based on the risk associated with contraceptives containing over 30 µg and often 50 µg of estradiol. We often use continuous contraception (not having a period for 3 to 12 months) in women with menstrually-related migraines, which usually are not accompanied by aura. There is no doubt that the risk of strokes in women with migraines with aura who take oral contraceptives is significantly increased by smoking and other stroke risk factors, such as hypertension, diabetes, high cholesterol, and other. So, women who have migraine with aura and take estrogen-based contraceptives should not smoke, should exercise regularly, have a healthy diet and have regular check-ups to detect conditions that may augment the risk of strokes. If such risk factors are present, progesterone-only or non-hormonal contraceptives should be used. Dr. Calhoun also points out other benefits of oral contraceptives, besides the reduction of the chance of undesired pregnancy, relief of painful periods, excessive bleeding, acne, and PMS. These include reduction in death rate from any cause, 80%... --- ### Early return to physical activity after concussion may reduce post-concussive symptoms - Published: 2017-02-05 - Modified: 2017-02-05 - URL: https://www.nyheadache.com/blog/early-return-to-physical-activity-after-concussion-may-reduce-post-concussive-symptoms/ - Categories: Head trauma Physical and mental symptoms can persist after a concussion and strangely, mild concussions are more likely to cause persistent symptoms than severe ones. In a previous post, Rest your brain after a head injury I described a study that involved 335 children and young adults. As the title indicates, cognitive rest was associated with a faster recovery. Another post on concussion and post-concussion headaches mentioned that experts advocate physical rest as well. However, a new study of over 3,000 Canadian children between the ages of 5 and 18 with concussion suggests that the recovery is faster in those who get physically active within the first week of an acute concussion. Of the children who engaged in physical activity within the first week 29% had persistent post-concussive symptoms four weeks later compared to 40% of those who did not engage in any physical activity. This was true whether the child participated only in light aerobic exercise (33% of kids), sport-specific exercise (9%), noncontact drills (6%), full-contact practice (4%), or full competition (17%). I am very surprised that kids were allowed to return to full-contact practice and full competition before complete recovery. These finding contradict all of the concussion guidelines, which recommend a period of physical and cognitive rest following a concussion until post-concussive symptoms such as dizziness, fatigue, and headaches have resolved. The guidelines also advise to increase the amount of physical activity only if symptoms do not worsen. These guidelines were developed without the benefit of large controlled studies, but... --- ### Attachment style correlates with headache features and psychological symptoms in children and adolescents with migraines - Published: 2017-02-01 - Modified: 2017-02-01 - URL: https://www.nyheadache.com/blog/attachment-style-correlates-with-headache-features-and-psychological-symptoms-in-children-and-adolescents-with-migraines/ - Categories: Alternative Therapies, Migraine, Science of Migraine Italian researchers published a study in the journal Headache that attempted to correlate the attachment style in children with migraines with headache severity and psychological symptoms. Attachment style typically develops in the first year of life. The premise of the study was derived from the attachment theory which suggests that early interpersonal relationships may determine future psychological problems and painful conditions. Previous studies have shown that people with insecure attachment styles tend to experience more pain than people with secure attachment style. The study involved 90 children with migraines. The mean age was 12 years and there were 54 girls and 36 boys in the study. The kids were divided into a group with very frequent headaches (1 to 7 a week) and those with infrequent attacks - 3 or fewer per month. They also grouped them into those with severe pain, which interrupted their daily activities and those with mild pain that allowed them to function normally. The children were tested for anxiety, depression, and somatization (tendency to have physical complaints as a manifestation of psychological distress). They were also evaluated for the attachment style and were assigned into "secure,” “avoidant,” “ambivalent,” and “disorganized/confused” groups. Interestingly, the researchers found a significant relationship between the attachment style and migraine features. Ambivalent attachment was present in 51% of children with high frequency of attacks and in 50% of those with severe pain. Anxiety, depression, and somatization were higher in patients with ambivalent attachment style. They also showed an association between high... --- ### How to reduce the cost of Botox for migraines - Published: 2017-01-24 - Modified: 2017-01-24 - URL: https://www.nyheadache.com/blog/how-to-reduce-the-cost-of-botox-for-migraines/ - Categories: Botox, injections, Migraine Botox is by far the safest and the most effective preventive treatment for chronic and frequent episodic migraine headaches. The only downside is the cost. A 200-unit vial of Botox costs about $1,200. Most insurance companies cover Botox if you have chronic migraines (15 or more headache days each month) and if you've tried and failed (it did not help or caused side effects) 2 or 3 preventive medications. The copay for a vial of Botox is often as high as $400 or more. If your insurance does not cover Botox at all, or you have "only" 10 to 14 headache days each month, or you do not want to take daily drugs because of potential side effects, you may have to pay the entire cost. To reduce this cost, you may want to ask the doctor to start with 100 units instead of the standard dose of 155 units. Since the manufacturer makes only 100 and 200 unit vilas, the remaining 45 units are discarded. Some doctors are very accommodating, but I've heard of many that will not deviate from the FDA-approved protocol of 155 units injected into 31 spots. I discussed some of this in a recent post. Another way to avoid excessive costs when paying out of pocket for Botox is to avoid large hospitals. A few years ago, while giving lectures at the Mayo Clinic, Cleveland Clinic, and Beth Israel Hospital in Boston, I discovered that they all charged $6,000 for one Botox treatment. What prompted... --- ### A brilliant writer on how we take care of people with difficult-to-treat migraines - Published: 2017-01-19 - Modified: 2017-01-19 - URL: https://www.nyheadache.com/blog/a-brilliant-writer-on-how-we-take-care-of-people-with-difficult-to-treat-migraines/ - Categories: Alternative Therapies, Migraine Atul Gawande is a surgeon at the Brigham and Women's Hospital in Boston and a professor at Harvard Medical School. He is also a very talented writer who has written four books and has been writing for the New Yorker since 1998. I had the privilege of meeting him and found him to be very humble and low-key, despite him being a surgeon, MacArthur "genius" award recipient, famous writer, etc. His last book, Being Mortal should be read by everyone who is dealing with elderly parents, grandparents, or friends. His last article in the New Yorker, The Heroism of Incremental Care describes how headache specialists approach patients with severe and persistent migraine headaches. Fortunately, these are a minority of our patients, but require our unflagging attention and care. Some tell me that they've tried "everything" and ask, "please do not abandon me". My response is to reassure the person that I will never stop trying to help and also that I've never seen anyone who has tried everything - we always find medications, supplements, devices, procedures, and other treatments that the patient has not yet tried. Just like with the man in Gawande's story, some patients improve very slowly and over a long period of time, so patience and perseverance are essential. I must admit that we cannot be sure if it is our treatment or just the passage of time that leads to improvement. However, it may not matter since our support helps avoid a sense of helplessness and... --- ### Vestibular migraine - Published: 2017-01-08 - Modified: 2017-01-08 - URL: https://www.nyheadache.com/blog/vestibular-migraine/ - Categories: Uncategorized 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... --- ### Glaucoma and migraines - Published: 2017-01-02 - Modified: 2017-01-02 - URL: https://www.nyheadache.com/blog/glaucoma-and-migraines/ - Categories: Migraine Severe headache is a common symptom of acute glaucoma. It comes from a sudden increase in the intra-ocular pressure caused by the closure of channels that drain fluid from the eyeball. This headache can be similar to a migraine with nausea and light sensitivity. Acute glaucoma is rarely misdiagnosed as a migraine because typically, there is no history of migraines and the eye often gets red, painful with profuse tearing. Cluster headache is sometimes more similar to acute angle closure glaucoma because it also can cause redness of the eye and tearing. This post was prompted by patient I just saw. This 52-year-old woman has had right-sided migraines for 10 years and about a year ago was found to have mildly elevated intra-ocular pressure (IOP). She has been under my care for almost a year and after receiving three Botox treatments needed only magnesium infusions every 3 weeks. She was still having 2-3 migraines each month, but they were relieved by sumatriptan with naproxen (Treximet). On a recent visit to her ophthalmologist her IOP was higher than usual and she underwent a laser procedure to improve fluid drainage. She reported that it felt as if a balloon was punctured and pressure came out of her eye. The procedure was first done on her right eye where the pressure was higher. Although it's been only a couple of weeks since the procedure, she feels much improved, without any migraines and without constant mild pressure in her eye, which she was barely... --- ### Placebo effect is how chiropractic relieves migraines - Published: 2016-12-22 - Modified: 2016-12-22 - URL: https://www.nyheadache.com/blog/placebo-effect-is-how-chiropractic-relieves-migraines/ - Categories: Alternative Therapies Many chiropractors advertise their success in treating migraine headaches. Norwegian researchers conducted a scientific study of chiropractic manipulation for migraine headaches in 104 patients. They divided patients into three groups: one that received real chiropractic manipulation of the spine, one that received a sham treatment that consisted of just putting pressure over the shoulders and lower back, and one that continued their usual medication. The real and sham chiropractic groups received 12 treatment sessions over 12 weeks and all three groups were followed for a year. After 12 weeks patients in all three study groups reported improvement. However, a year later, only the two chiropractic groups still felt better. On average, they had about four migraine days a month, down from six to eight before the treatment started. Patients who just continued their medications lost all of their improvement and their migraine frequency was back where it was at the baseline. The results published in the European Journal of Neurology suggest that chiropractic is indeed effective in reducing migraine frequency, however, it also suggests that any hands-on treatment is equally effective. This probably explains the popularity of chiropractic, physical therapy, massage, reflexology, Reiki, energy therapies, Feldenkreis, and all other hands-on treatments. All these treatments are worth trying, but avoid high velocity adjustments when undergoing chiropractic treatment as it carries a small risk of serious side effects (see this previous post). I would also pick inexpensive treatments and pick therapists you feel a rapport with. The treatment should be pleasant and... --- ### Vitamin C deficiency is associated with neck and back pain, and possibly headaches - Published: 2016-12-12 - Modified: 2016-12-12 - URL: https://www.nyheadache.com/blog/vitamin-c-deficiency-is-associated-with-neck-and-back-pain-perhaps-migraine-too/ - Categories: Alternative Therapies Vitamin C deficiency appears to be more common in people with back pain, according to a study just published in the journal Pain by Canadian researchers. Vitamin C (ascorbic acid) is important for collagen formation and collagen is one of the main ingredients of ligaments, tendons, and bones. Recent studies have reported that vitamin C deficiency is common in the general population. The authors "hypothesized that lack of vitamin C contributes to poor collagen properties and back pain". They used nationwide data from the U. S. National Health and Nutrition Examination Survey from 2003–2004. Information was available for 4,742 individuals older than 20. Low serum vitamin C levels were associated with one and a half times higher prevalence of neck pain and 1. 3 times higher prevalence of low back pain, as well as low back pain with pain radiating to below the knee in the preceding three months. Deficiency was also associated with the self-described diagnosis of arthritis or rheumatism and related functional limitations. The authors concluded that the association between vitamin C deficiency and spinal pain warrants further investigation to determine the possible importance of vitamin C in the treatment of back pain patients. Neck pain is very common in patients with migraine and tension-type headaches, so it is possible that vitamin C could also play a role in the treatment of headaches. My search revealed no studies looking at vitamin C levels in migraine sufferers. It may be worth checking vitamin C levels in those headache patients... --- ### Women living together have a higher frequency of menstrual migraine - Published: 2016-12-10 - Modified: 2016-12-10 - URL: https://www.nyheadache.com/blog/women-living-together-have-a-higher-frequency-of-menstrual-migraine/ - Categories: Migraine Many women are more likely to have migraines around the time of their menstrual period and in some, those migraines can be more severe. Previous studies have determined that women living together often synchronized their menstrual periods. A group of Brazilian researchers decided to compare the frequency of menstrual migraines in women who live together and those who live alone. The results were just published in the journal Headache. The study looked at female students at a university between the ages of 18 and 30 years, all of whom suffered from migraines. One group of women lived together with two or more other students and the second group lived alone. They were asked to keep a headache diary for three months. The researchers recorded the frequency of headaches, presence of menstrual migraine, intensity of headaches, medications used including contraceptives, and triggering factors such as diet, sleep deprivation, and stress. Half of the women living together had menstrual migraines compared with 17% of women living alone. This finding was not related to the use of a contraceptive, test stress, or sleep deprivation. Women living together also tended to have menstrual cycle at the same time as their roommates. It was a small study - it had 18 women in each group, so the results are not highly reliable. --- ### Restless leg syndrome and migraine - Published: 2016-12-04 - Modified: 2016-12-04 - URL: https://www.nyheadache.com/blog/restless-leg-syndrome-and-migraine/ - Categories: Brain disorders, Migraine Restless leg syndrome (RLS) has been reported to be more common in patients with migraines. I wrote about this association in a previous post about 4 years ago. Another study, just published in The Journal of Headache and Pain confirms this association. RLS is a common condition that often goes undiagnosed. This is in part due to the fact that RLS begins in childhood and it often runs in the family, so it is not perceived as an illness. The new study involved 505 participants receiving outpatient headache treatment. The researchers collected information on experiences of migraine, RLS, sleep quality, anxiety, depression, and demographics. Participants were divided into low-frequency (1–8/month), high-frequency (9–14/month), and chronic (>15/month) headache groups. Analysis revealed that with an increase in migraine frequency the occurrence of RLS also increased, particularly in those who had migraines with auras. Anxiety and sleep disturbance was also associated with RLS. Sometimes the diagnosis of RLS is very easy to make - a person who constantly shakes his or her foot, usually has it. However, in some people the excessive leg or body movements occur only in sleep, so the diagnosis is less obvious to the doctor, but not to the bed partner who is constantly kicked and woken up by these movements. One of my patients could not sleep in the same bed with his wife, because he would move and kick her all night long. After he started taking ropinirole, one of the medications for RLS, he reported that he... --- ### Functional MRI may be less than meets the eye - Published: 2016-11-22 - Modified: 2016-11-22 - URL: https://www.nyheadache.com/blog/functional-mri-may-be-less-than-meets-the-eye/ - Categories: Science of Migraine Functional MRI (fMRI) imaging has been a powerful tool for visualizing processing of information in the brain. This technique is based on the observation that the MRI signal changes with changes in the amount of blood flowing to a particular region of the brain, which correlates with the activity of that brain region. This is a very sophisticated technique that relies on complicated computer algorithms and this is where the problem lies. A review of the three most popular software processing packages suggested that false-positive results are present in up to 70% of studies, which means up to 40,000 published trials may provide erroneous results. This review was published in the Proceedings of the National Academy of Sciences. fMRI reports often provide tantalizing details about the effect of emotions, thoughts, drugs, etc on the brain. I searched through my posts and found three "Expect relief and you will get it", "Botox helps headaches, makes you happier", and "Science of acupuncture". This is not to say that all of this research is worthless. However, I would be skeptical of studies that involve a small number of subjects and from centers not known for rigorous scientific research. --- ### Experts' comments on the recent acupuncture report - Published: 2016-11-18 - Modified: 2016-11-18 - URL: https://www.nyheadache.com/blog/experts-comments-on-the-recent-acupuncture-report/ - Categories: Alternative Therapies Two leading headache experts, Drs. Richard Lipton and Dawn Buse of the Montefiore Headache clinic gave positive comments on the report published in Pain and described in my recent post. Another headache specialist from Texas, Dr. Deborah Friedman was also quoted about this research report in Neurology Today. “Acupuncture studies are difficult because the blinding is difficult,” Richard B. Lipton, MD, FAAN, the Edwin S. Lowe professor and vice chair of neurology at the Albert Einstein College of Medicine, said. He noted that even comparisons using sham procedures may not entirely blind the patient to whether he or she is receiving a real treatment in which needles are inserted in the “meridian” — the points where energy is said to flow. “ That said, the authors in their review show that acupuncture is very substantially better than usual care. I think in aggregate these data demonstrate that real acupuncture is very helpful to people with episodic migraine in terms of reducing the number of headache days. My longstanding practice has been to arrange acupuncture for patients who ask for it, but not to recommend it otherwise,” Dr. Lipton said. “This review is going to impact what I do. It's 22 randomized trials, and the Cochrane review is 150 pages. I think this is an important summary of the best evidence. I think it's quite positive. I want to make my patients better so the imperfect blinding doesn't matter. ” Dawn C. Buse, PhD, associate professor of neurology at Albert Einstein... --- ### Blood pressure drugs prevent migraines but may cause depression - Published: 2016-11-15 - Modified: 2016-11-15 - URL: https://www.nyheadache.com/blog/blood-pressure-drugs-prevent-migraines-but-may-cause-depression/ - Categories: Headache medications, Migraine Beta blockers, such as propranolol (Inderal) and timolol (Blocadren) are the oldest drugs for the prevention of migraine headaches. They've been used for this indication for the past 50 years. Calcium channel blockers are not as effective and never received FDA approval, but are also used treat migraine headaches. Verapamil is more effective for the prevention of cluster headaches, but is not approved for this indication either. A third category of blood pressure drugs effective for the prevention of migraines are ACE receptor blockers (ARBs) such as candesartan (Atacand) and olmesartan (Benicar) and ACE inhibitors such as losartan (Cozaar). Main side effects of these drugs tend to be related to lowering of blood pressure and include fatigue and dizziness. This is a major limitation of blood pressure medications when used in migraine sufferers because they tend to be young women with low blood pressure to begin with. Verapamil is also known to cause constipation. Beta blockers and to a lesser extent calcium channel blockers, have long been reported to cause depression. A new study just published in the journal Hypertension explored the association between blood pressure drugs and admission to to the hospital for mood disorders (depression and bipolar). The researchers examined a large hospital database of 525,046 patients with follow-up for 5 years. Patients on ACE inhibitors or ARBs had the lowest risk for mood disorder admissions, and compared with this group, those on beta blockers and calcium channel blockers showed higher risk, whereas those on no blood pressure... --- ### Cluster headaches, sleep disturbance, and depression - Published: 2016-11-09 - Modified: 2016-11-09 - URL: https://www.nyheadache.com/blog/cluster-headaches-sleep-disturbance-and-depression/ - Categories: Cluster headaches According to large epidemiological studies, migraine sufferers are 2-3 times more likely to develop depression, anxiety and other psychiatric disorders than those without migraines. And it is a bidirectional relationship, meaning that those with depression are 2-3 times more likely to develop migraines than those without depression. Cluster headaches, which have at times been referred to as “suicide headaches,” have been suspected to be also associated with depression. Until now, no similar large studies have been conducted in patients with cluster headaches in part because cluster headaches are much less common than migraines. In a study just published in the journal Neurology, a group of Dutch physicians studied 462 patients with cluster headaches and compared them to 177 control subjects. They evaluated these patients for history of depression during their lifetime, current depression in the midst of a cluster period, and because many cluster attacks occur in sleep, they also looked for sleep disturbances. The results showed that depression was 3 times more likely to occur patients with cluster headaches than in healthy controls. Those with chronic cluster headaches had a higher risk of depression and sleep problems than patients with episodic cluster headaches. Current depression was associated with having active attacks within the preceding month, but this association was only present if the patient also had a sleep disturbance. The authors concluded that cluster headache patients are three times more likely to develop depression in their life time. However, current depression was in part related to sleep disturbances due... --- ### Acupuncture provides long-term relief - Published: 2016-11-04 - Modified: 2016-11-04 - URL: https://www.nyheadache.com/blog/acupuncture-provides-long-term-relief/ - Categories: Alternative Therapies Acupuncture for the treatment of migraines has been studied in dozens of clinical trials. A 2012 study mentioned in a previous blog post described a rigorous trial done in 480 patients with highly positive results. The largest, albeit uncontrolled study was done in Germany and involved over 15,000 patients. A well controlled and randomized study of 960 patients comparing acupuncture with sham acupuncture and drug therapy concluded that "... acupuncture is as effective as drug therapy, but ... sham acupuncture is as effective as 'real' acupuncture. " and "... acupuncture should be offered to patients who do not respond to prophylactic treatment with drugs, terminate drug treatment because of adverse events or have contraindications to drug treatment. " Most headache specialists recommend acupuncture to their patients even if they believe it works only through the placebo effect. I've been a licensed acupuncturist for the past 30 years, but treat a relatively small number of patients with acupuncture. The main reasons are the fact that insurance companies do not pay for it and that it is too time consuming. In the first study mentioned above, which was performed in China, patients were treated five days a week. The minimum frequency of treatments should be once a week. I often recommend that patients find a non-MD acupuncturist (whose rates are usually lower) who is closer to the patient's home or work place. Another concern with acupuncture is that while it might help during the treatment, the effect might subside once the treatment... --- ### Do migraine drugs work in kids? - Published: 2016-10-29 - Modified: 2016-10-29 - URL: https://www.nyheadache.com/blog/do-migraine-drugs-work-in-kids/ - Categories: Chronic migraine, Headaches in children, Migraine About 6% of young children suffer from migraine headaches. After puberty, this number triples to 18% in girls and remains at 6% in boys. Several abortive drugs (drugs taken as needed), such as rizatriptan (Maxalt) and zolmitriptan (Zomig) are approved for migraines in children. Only topiramate (Topamax) is approved for children (over the age of 12) for the prevention of migraines. We do use preventive drugs approved for adults in children as well. These are divalproex sodium (Depakote), propranolol (Inderal), and botulinum toxin (Botox). Many other drugs, such as amitriptyline (Elavil), gabapentin (Neurontin), candesartan (Atacand) are used "off label", meaning that they are not FDA-approved for migraines in adults or children. One of the reasons that more drugs are not approved specifically for children is the difficulty in conducting research in kids. Their are migraines are usually shorter in duration and often stop occurring for long periods of time without treatment. A large multi-center 24-week study just published in the New England Journal of Medicine examined the efficacy of topiramate, amitriptyline and placebo in children between the ages of 8 and 17. It was a double-blind study with neither the children and their parents nor the doctors being aware of who was getting which drug or placebo. The study showed no statistically significant difference among the three groups. The main outcome measure was a 50% or higher reduction of headache days. Placebo achieved this result in 61% of children, while this number was 52% for those on amitriptyline and 55%... --- ### Guidelines for the use of medical marijuana - Published: 2016-10-24 - Modified: 2016-10-24 - URL: https://www.nyheadache.com/blog/guidelines-for-the-use-of-medical-marijuana/ - Categories: Alternative Therapies, Headaches, Migraine, New treatments, Pain Medical marijuana was legalized in New York in February of this year. Since then, I've prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with. Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments: "The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality. " Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed. "The doctor's office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way. " This one is easy for us. "The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine. " I've never tried it.... --- ### Liver damage is often caused by supplements - Published: 2016-10-18 - Modified: 2016-10-18 - URL: https://www.nyheadache.com/blog/liver-damage-is-often-caused-by-supplements/ - Categories: Alternative Therapies We are big proponents of non-drug treatments, including a variety of vitamins, minerals, and herbal supplements. However, potential liver damage by butterbur is why we do not recommend this supplement, even though I was one of the participants in the clinical trial that showed it to be effective in preventing migraines. I also cautioned about risks of some Ayurvedic medications. A recent report in Hepatology, a journal devoted to liver diseases, suggests that 20% of all cases of liver damage are due to herbal and dietary supplements. The main culprits were anabolic steroids (these are banned in professional sports, but are widely used for muscle building), green tea extract, and supplements with multiple ingredients. Anabolic steroids cause prolonged, but not serious liver injury, which resolves when the supplement is stopped. Green tea extract and many other products cause acute liver damage, similar to that seen in hepatitis. The majority of cases of liver injury are due to products that contain multiple ingredients, which makes it difficult to figure out which of the supplements is responsible. Unfortunately, non-prescription supplements are not regulated by the government. This is mostly because it is a $37 billion dollars a year industry with a powerful lobby in Washington. The authors conclude their report by saying that "the ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety. " Until these products come under FDA's supervision, you should buy only products made by reputable American and German companies.... --- ### Another option for the treatment of nausea - Published: 2016-10-14 - Modified: 2016-10-14 - URL: https://www.nyheadache.com/blog/another-option-for-the-treatment-of-nausea/ - Categories: Headache medications, Migraine, New treatments Nausea is a very common symptom that accompanies migraine attacks. Effective treatment of migraine with a drug like sumatriptan often stops the headache, nausea, and other associated symptoms. However, sometimes pain subsides, while nausea does not, or nausea is much more bothersome than the headache. Nausea can also be a side effect of the most effective injectable migraine drug, dihydroergotamine (DHE-45). We often administer this drug in our office after other injectable drugs (magnesium, sumatriptan, ketorolac, dexamethasone, etc) fail. If nausea is already present, we will always give an intravenous injection of a nausea drug such as ondansetron (Zofran) or metoclopramide (Reglan) before giving DHE. Sometimes these drugs are ineffective in preventing nausea and vomiting induced by DHE and we have to look for other options. Phenothiazine family of drugs, including prochlorperazine (Compazine), chlorpromazine (Thorazine), and promethazine (Phenergan) are very old and effective anti-nausea drugs. However, they have a potential for a rare but devastating side effect, which consists of persistent involuntary movements of the face (grimacing and lip smacking) and body. The onset of this side effect can be delayed, which is why it is called tardive dyskinesia. It is not unusual for these drugs to cause an immediate severe and very unpleasant restlessness (akathisia), which patients sometimes describe as wanting to crawl out of one's skin. Metoclopramide (Reglan) can also cause these side effects, but less often. Ondansetron (Zofran) does not cause any such side effects and should be the preferred drug for nausea of migraine, although it... --- ### Thyroid disease and headaches - Published: 2016-10-08 - Modified: 2016-10-08 - URL: https://www.nyheadache.com/blog/thyroid-disease-and-headaches/ - Categories: Headaches, Migraine Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as Synthroid or Armour Thyroid often improves headaches. Researchers at the University of Cincinnati College of Medicine tried to determine if having headaches made one more prone to developing hypothyroidism. They examined 8,412 healthy people and checked their thyroid function every 3 years over a 20 year period. They excluded from the group people with past thyroid disease or abnormal thyroid function tests at the first office visit. The diagnosis of a headache disorder was established based on person's report of "frequent headaches,” by the use of any headache-specific medication, or a physician's diagnosis of a headache disorder. They also recorded age, sex, body mass index, income, smoking, narcotic use, and medicines that could cause thyroid dysfunction. Headache disorders were present in about 26% of the population and new onset hypothyroidism developed in 7%. Those who had a headache disorder had a slightly higher risk (1. 2 times) of developing hypothyroidism. The researchers concluded that headache disorders may be associated with increased risk for the development of new onset hypothyroidism. These results were published in Headache. One of my colleagues tells an embarrassing story of his wife's headaches. She developed them after giving birth to their child, so he attributed them to stress and lack of sleep. When headaches persisted she went to her primary care doctor who discovered that she had an underactive thyroid. The headaches promptly went away with... --- ### Migraine and blood clots in veins (thrombosis) - Published: 2016-10-04 - Modified: 2016-10-04 - URL: https://www.nyheadache.com/blog/migraine-and-blood-clots-in-veins-thrombosis/ - Categories: Migraine Migraine with aura is known to be associated with an increased risk of diseases of arteries, such as strokes, heart attacks and diseases of peripheral blood vessels. This risk is further increased by estrogen-containing contraceptives. A new study by Taiwanese neurologists suggests that migraine with aura also carries a higher risk of blood clots forming in the veins, so called venous thrombosis or deep vein thrombosis (DVT). Venous thrombosis is more likely to occur in obese, people with cancer, smokers, women on birth control pills, and those who are bedridden or sit for a long time, like on a long airplane ride. According to this new study, having migraines with aura increases the risk of this condition by two and half times. DVT, which most commonly occurs in a deep vein in a leg, can completely resolve on its own without any residual effects. However, it can also cause long-term swelling and poor circulation in the leg and in about 10% of cases, a piece of the blood clot can break off and be carried into the lung. This is called pulmonary embolus and it is fatal in 10% of patients. DVT requires urgent treatment with blood thinners, which can prevent pulmonary emboli. So, it is important to recognize symptoms of DVT. These include swelling in a leg or an arm, pain or tenderness in the leg when standing or walking, warmth in the area that is swollen or hurts, redness of the skin, and visible enlargement of the veins... --- ### Common avoidable problems with Botox injections - Published: 2016-09-28 - Modified: 2016-09-28 - URL: https://www.nyheadache.com/blog/common-avoidable-problems-with-botox-injections/ - Categories: Botox, Headaches, Migraine, Pain, TMJ One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man. Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding... --- ### Medical marijuana reduces prescription costs - Published: 2016-09-18 - Modified: 2016-09-18 - URL: https://www.nyheadache.com/blog/medical-marijuana-reduces-prescription-costs/ - Categories: Alternative Therapies, Migraine Medical marijuana reduces the number of prescriptions written by doctors, according to a recent study published in Health Affairs. The researchers at the University of Georgia in Athens looked at all prescriptions filled by Medicare participants over a four year period for nine conditions for which medical marijuana is used for. These included anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders and spasticity. They compared 17 states and Washington, DC where medical marijuana was legalized with those where it was not. In states with legalized medical marijuana the number of prescriptions dropped by 0. 5% providing estimated savings of $165 million a year. Of all approved indications, relief of pain was by far the most common reason medical marijuana was prescribed for. This was a much more dramatic effect than the researchers anticipated. They expected that the mostly elderly patients on Medicare would be more resistant to the idea of using marijuana than younger people. In a February post I mentioned that I started prescribing medical marijuana to my patients with migraine headaches who also have neuropathic pain as part of their headache. While medical marijuana is not approved for migraines per se, it is approved for neuropathic (i. e nerve-related pain), which many migraine sufferers do have. Burning or stabbing pain indicates the presence of neuropathic pain. So far, I've prescribed medical marijuana to about two dozen patients and as expected, the results are mixed. It works well for some, but not other. Most commonly, patients who've had... --- ### CGRP drugs remain highly promising. - Published: 2016-09-11 - Modified: 2016-09-11 - URL: https://www.nyheadache.com/blog/cgrp-drugs-remain-highly-promising/ - Categories: Migraine CGRP migraine drugs remain on track to get an approval from the FDA within two years. My first post on these drugs appeared in 2007. The first product in this family was tested for the prevention and acute treatment of migraines. It reached the final phase 3 trials and was found to be very effective and safe, but a few patients developed minor liver abnormalities on blood tests. In view of these blood test abnormalities, the manufacturer, Merck decided against completing the trials. A similar medicine, also in a tablet form, is now being developed by Allergan (maker of Botox) and it appears to be free of liver problems. CGRP (calcitonin gene-related peptide) is a chemical that is released in the brain during a migraine attack. Four companies are targeting the CGRP molecule in a different way. Instead of taking a pill during an attack or daily to prevent migraines, they are developing monoclonal antibodies which bind to the CGRP molecule or its receptor and block its action. These drugs are given by injection. Three of the companies, Amgen, Eli Lily, and Teva are testing intramuscular injection every month, while the fourth one, Alder is testing intravenous administration every three months. Eli Lily is also testing their compound for the treatment of episodic cluster headaches. To date, there have been several thousand patients exposed to these monoclonal antibodies in clinical trials. What is most surprising to me is their outstanding safety. The side effects have been infrequent and mild. All... --- ### Vitamin B12 is in the news - Published: 2016-09-06 - Modified: 2016-09-06 - URL: https://www.nyheadache.com/blog/vitamin-b12-is-in-the-news/ - Categories: Alternative Therapies, Migraine Vitamin B12 was the subject of an article in the New York Times by Jane Brody entitled, Vitamin B12 as Protection for the Aging Brain. However, she mentions that "insufficient absorption of B12 from foods may even be common among adults aged 26 to 49" and that the advice to take a vitamin B12 supplement may apply to young people as well. This is particularly true for vegans and vegetarians, as well as people with stomach problems and those on PPIs - drugs for ulcers and heartburn, such as Prilosec, Nexium, Aciphex, etc. Vitamin B12 deficiency can cause "fatigue, tingling and numbness in the hands and feet, muscle weakness and loss of reflexes, which may progress to confusion, depression, memory loss and dementia as the deficiency grows more severe". Severe deficiency leads to peripheral and central nervous system damage (so called subacute combined degeneration), which eventually becomes irreversible and leads to death. Jane Brody does not mention that besides Alzheimer's, other chronic diseases, such as multiple sclerosis, diabetes, and cancer are also associated with low vitamin B12 levels. Vitamin B12 with vitamin B6 and folic acid has been shown to help some migraine sufferers You can ask your doctor to check your vitamin B12 level, but unfortunately it is not reliable. Most laboratories cite as normal blood levels of above 200 or 250, but there are reports of rare cases where severe deficiency is present with a level of 700. I recommend taking a supplement if the level is below... --- ### Fracking and Migraines - Published: 2016-09-01 - Modified: 2016-09-01 - URL: https://www.nyheadache.com/blog/fracking-and-migraines/ - Categories: Migraine, Science of Migraine Living in areas where fracking takes place doubles the risk of having migraines, as well as fatigue and sinus symptoms. Fracking, or hydraulic fracturing, is a water-based method of extracting natural gas from deep under the ground. Johns Hopkins researchers described these findings in the journal Environmental Health Perspectives. The study was conducted using questionnaires which were completed by 7,785 adults. Among these people, 1,765, or 23% suffered from migraines, 1,930 people or 25% experienced severe fatigue and 1,850 or 24% had symptoms of chronic sinusitis (three or more months of nasal and sinus symptoms). In the general population the incidence of migraines is about 12%. Previous studies have discovered an association between fracking and increased risk of premature births, asthma attacks and indoor radon concentrations. It is unclear how fracking results in these health problems. Some possible explanations include air pollution, odors, noise, bright lights, and heavy truck traffic. --- ### Men suffer from migraines too, but are often not diagnosed - Published: 2016-08-30 - Modified: 2016-08-30 - URL: https://www.nyheadache.com/blog/men-suffer-from-migraines-too-but-are-often-not-diagnosed/ - Categories: Migraine Three times as many women are afflicted by migraines as men, according to many large studies. However, 6% of men do suffer from migraines and that means 9 million American men. However, in our clinic, instead of 75%, over 90% of patients are women. Men are often dragged into the office by their wife, girlfriend, or mother. A new study presented at the recent meeting of the American Headache Society confirms this observation. Dr. Anne Scher and her colleagues established that men are less likely to see a doctor and when they do see one, they are less likely than women to be given the diagnosis of migraine. Only 59% of men with migraines were given the correct diagnosis, while this number was 77% for women. This is probably due to the perception of migraine as a disease of women. The reasons for misdiagnosis in both sexes include the notion that every migraine sufferer has to have a visual aura (it is present only in about 20%), or that the headache has to be one-sided, or the person has to have nausea. In fact, all of the typical migraine features do not have to be present. It is sufficient to have nausea and throbbing pain or light sensitivity and inability to function normally, or light and noise sensitivity and one-sided throbbing pain, etc. Migraines are often misdiagnosed as sinus headaches because in some people migraine is accompanied by a clear nasal discharge or because the pain is localized in the... --- ### More on intravenous magnesium for migraines, muscle cramps, PMS, and other symptoms - Published: 2016-08-24 - Modified: 2016-08-24 - URL: https://www.nyheadache.com/blog/more-on-intravenous-magnesium-for-migraines-muscle-cramps-pms-and-other-symptoms/ - Categories: Alternative Therapies, Migraine Intravenous magnesium relieves acute migraine attacks in patients with magnesium deficiency, which is present in half of migraine sufferers, according to the study we published in 1995 in the journal Clinical Science. Infusions not only treat an acute attack, but also prevent migraines. Oral magnesium supplementation is not as effective and helps less than 50% of patients because some patients do not absorb magnesium. Most people get enough magnesium from food, but some migraine sufferers have a genetic defect which prevents them from absorbing magnesium or a genetic defect that leads to an excessive loss of magnesium through kidneys. Our experience with thousands of patients suggests that the majority of migraine sufferers who are magnesium deficient do improve with oral supplementation, but about 10% do not. These patients need regular infusions of magnesium and these infusions are often life-changing. Magnesium not only treats and prevents migraines, but also relieves muscle cramps, PMS, palpitations, "brain fog", and other symptoms. There are many mentions of magnesium on my blog and on the nyheadache. com website, so what prompted another post on this topic is a couple of patients with an unusal experience. I would occasionally see such patients but in the past few weeks, I saw several. These patients tell me that when we give them an infusion of magnesium by "slow push" over 5 minutes they get excellent relief, but when they end up in an emergency room or another doctor's office where they receive the same amount of magnesium through... --- ### Cramp Bark - another herb for migraines - Published: 2016-08-11 - Modified: 2016-08-11 - URL: https://www.nyheadache.com/blog/cramp-bark-another-herb-for-migraines/ - Categories: Alternative Therapies, Migraine Recently, a patient of mine reported that cramp bark has significantly improved her menstrual migraines. Cramp bark is a common shrub with red berries. Its bark has been used for over 100 years for muscle cramps, menstrual cramps, fluid retention, and other symptoms. Fortunately, it appears to be very safe and even though no scientific studies have been performed on it, it may be worth trying. I will start recommending it to women with menstrual migraines, menstrual cramping and patients with muscle spasms in their neck and upper back. The two top herbs I recommend to my migraine patients are feverfew and boswellia. Feverfew has been subjected to scientific studies and seems to help some patients while causing almost no side effects. Boswellia has been reported to help even patients with cluster headaches, but no rigorous studies have been done. However, it is safe and because of its anti-inflammatory properties it can also help joint and muscle aches (see my blog post on Boswellia). Butterbur, on the other hand is not always safe, so I haven't been recommending it. Here is one of my blog posts on it. --- ### Vagus nerve stimulation for migraines - Published: 2016-08-05 - Modified: 2016-08-05 - URL: https://www.nyheadache.com/blog/vagus-nerve-stimulation-for-migraines/ - Categories: Alternative Therapies, Migraine, neurostimulation Vagus nerve stimulation (VNS) with an electrode implanted in the neck is an FDA-approved treatment for depression and epilepsy, when these conditions do not respond to medications. Since antidepressant and anti-epilepsy medications help migraines, I had six patients (four with migraines and two with cluster headaches) treated with VNS. Two of the four chronic migraine patients and both cluster patients had good relief - results that were published in the journal Cephalagia in 2005. This publication led to the development of gammaCore, a device to stimulate the vagus nerve through the skin, without the need for surgical implantation of an electrode. The New York Headache Center participated in one of the earliest studies of this device and the results were encouraging. An article published in the current issue of Neurology presents the results of another study of gammaCore. In this first double-blind study 59 adults with chronic migraines (15 or more headache days each month) were given either real VNS or sham treatment for two months. After two months they were all given the real treatment for 6 months. The main goal of the study was to examine the safety and tolerability of this treatment, but the researchers also looked at the efficacy by measuring the change in the number of headache days per 28 days and acute medication use. Both sham and real treatment were well tolerated with most adverse events being mild or moderate and transient. The number of headache days were reduced by 1. 4 days in... --- ### Migraines worsen in perimenopause - Published: 2016-08-03 - Modified: 2016-08-03 - URL: https://www.nyheadache.com/blog/migraines-worsen-in-perimenopause/ - Categories: Migraine, Science of Migraine Menopause often brings relief to female migraine sufferers. However, many women have worsening of their migraines during the transition. This is thought to be due to the fluctuating levels of estrogen, which is also responsible for menstrual migraines. Steady levels of estrogen during pregnancy and in menopause lead to a dramatic relief of migraines in two out of three women. A study published in a recent issue of the journal Headache examined the relationship of headache frequency to the stages of menopause. The study looked at 3446 women with migraines with a mean age of 46. Among women who were premenopausal, 8% had high frequency of headaches (10 or more headache days each month), while during perimenopause as well as menopause, 12% of women had high frequency of migraines. This does not contradict the fact that many women stop having migraines in menopause, but it suggests that among those women who continue having migraines, there are more with high frequency of attacks. By publishing these findings, the authors wanted to draw attention to the fact that many women may need a more aggressive approach to treatment. In women with high frequency of attacks preventive therapies tend to be more effective than abortive ones. These may include magnesium, CoQ10, Boswellia, and other supplements, as well as preventive medications and Botox injections. At the same time, most women may also need to take abortive therapies, such as triptans. --- ### Botox for trigeminal neuralgia: additional case reports - Published: 2016-07-21 - Modified: 2016-07-21 - URL: https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia-additional-case-reports/ - Categories: Botox, Trigeminal and other neuralgias Several of my patients with trigeminal neuralgia (TN) responded to Botox injection (although some have not). My previous post on this topic four years ago discussed a study involving 40 patients with TN, of whom 68% responded to Botox. Recently, two new cases of TN successfully treated with Botox have been reported and in the past month I've treated three additional patients. Two of my patients had excellent relief and one had none. One of the case reports was presented at the recent meeting of the American Headache Society in San Diego. This was a 65-year-old woman who suffered from very severe electric shock-like pain typical of TN. She did not respond to a variety of medications, including carbamazepine (Tegretol), but did respond to Botox injections. Botox did not eliminate her pain, but the severity of it was reduced by 50% and this significantly improved the quality of her life. The current issue of Headache contains a report of a 60-year-old man with severe TN who also did not respond to any medications. He did obtain complete relief from Botox injections and Botox has remained effective for over 2 years. With any new treatment we usually hope to see large double-blind controlled clinical trials and eventually an FDA approval. FDA approval usually compels insurance companies pay for the treatment. Botox injections have received approval for chronic migraines, excessive sweating, twitching of muscles around the eyes (blepharospasm), and several other conditions. Unfortunately, it is not likely that Botox will receive approval... --- ### Capsaicin (hot pepper ingredient) for sinus pain and headaches - Published: 2016-07-19 - Modified: 2016-07-19 - URL: https://www.nyheadache.com/blog/capsaicin-hot-pepper-ingredient-for-sinus-pain-and-headaches/ - Categories: Uncategorized 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. --- ### Learn to meditate with Tara Brach - Published: 2016-07-18 - Modified: 2016-07-18 - URL: https://www.nyheadache.com/blog/learn-to-meditate-with-tara-brach/ - Categories: Alternative Therapies If you are interested in learning to meditate, but don't know how to get started, go to Dr. Tara Brach's website for help. It offers her free weekly podcasts that will guide you through the process. Tara Brach is a psychologist and a buddhist, who after college spent 10 years in an ashram studying yoga and meditation. She has a pleasant voice and her podcasts are full of stories, funny anecdotes and short poems that are sure to inspire you. My wife and I recently attended Tara Brach's workshop on "Radical Acceptance" at the Omega Institute in Rhinebeck, NY. There were frequent sessions of guided meditation as well as exercises and Q & A sessions. Many participants had listened to her podcasts for years and came to hear her in person. One of the questions was, how do you maintain a regular meditation practice? Tara's answer was to meditate daily. If you do not have time for a 20 or 30-minute session, do it for a minute or two. I would also recommend reading books such as Living Fully by Shyalpa Tenzin Rinpoche, Mindfulness by Joseph Goldstein, Peace is Every Step by Thich Nhat Hanh, and Tara's two excellent books, Radical Acceptance and True Refuge. Meditation can bring you relief of anxiety, migraine headaches, and many medical conditions that are made worse by stress. It can also make your life more enjoyable. --- ### Elie Wiesel, Holocaust survivor, Nobel Prize winner and chronic migraine sufferer, dies - Published: 2016-07-03 - Modified: 2016-07-03 - URL: https://www.nyheadache.com/blog/elie-wiesel-holocaust-survivor-nobel-prize-winner-and-chronic-migraine-sufferer-dies/ - Categories: Chronic migraine, Psychology of headaches It was a great privilege to know Elie Wiesel, survivor of Auschwitz, Nobel Peace Prize winner, author of 40 books, university professor, and most importantly, a tireless campaigner for human rights. Mr. Wiesel suffered from severe daily migraines. Both of his parents and many members of his extended family suffered from headaches. The only year in his life without headaches was when he was in Auschwitz. He was highly functional with a very busy schedule despite his chronic migraines. I invited him to speak about his headaches at the First International Headache Summit held in Tel-Aviv, Israel, on November 16, 2008 and he generously agreed (here is a photo from the event). This is an excerpt from his presentation which was published in the journal Headache: "Thank you very much, Dr. Mauskop. I've been thinking a lot about this topic, and when I consider a topic I tend to return to my primary source: do we find headaches in Scripture? Perhaps you remember the prophet Elishah, a very special man, the disciple of Elijah. The woman who was his host in a certain village was barren, and she was embarrassed to tell him this. Elishah's servant knew of her distress, however, and he so informed the prophet whom he served. Elishah blessed her with a son. The son grew, and one day when he was in the fields with his father, he cried out, “My head, my head. I have a headache. ” Thus, for the first time, headache enters... --- ### Tremor can affect not only hands, but voice too - Published: 2016-07-01 - Modified: 2016-07-01 - URL: https://www.nyheadache.com/blog/tremor-can-affect-not-only-hands-but-voice-too/ - Categories: Brain disorders, Migraine Tremor of the hands is usually a benign condition. It is even called, benign essential tremor or, if it runs in the family, benign familial tremor. Patients with tremor are twice as likely to have migraines, so this is why I am writing about it. Tremor is also a symptom of Parkinson's disease, but these two types of tremor can be easily differentiated. Parkinsonian tremor is a resting tremor, which means that hands shake at rest, while essential tremor occurs in action, like when trying to drink from a cup. Even though it is benign, essential tremor can be incapacitating and socially embarrassing. Fortunately, in most people it responds to treatment. We usually start with propranolol (Inderal), a drug that belongs to the beta-blocker family, which is used for the treatment of high blood pressure and migraines. If propranolol or another beta-blocker is ineffective or causes side effects (due to low blood pressure or slow pulse), tremor can be treated with epilepsy drugs such as primidone (Mysoline), gabapentin (Neurontin), zonisamide (Zonegran), or an alpha-2 agonist such as clonidine (Catapres), which is a different type of blood pressure medicine. In rare cases, tremor affects not hands but the voice. I recently treated such a patient. He tried some medications, but when they did not help, he was given Botox injections into the vocal cords. This reduced the tremulousness of his voice, but only partially. Botox can also help with hand tremor, but because there are so many small muscles involved, the... --- ### Post-concussion syndrome responds to intravenous magnesium - Published: 2016-06-25 - Modified: 2016-06-25 - URL: https://www.nyheadache.com/blog/post-concussion-syndrome-responds-to-intravenous-magnesium/ - Categories: Alternative Therapies, Head trauma, Migraine A new report presented at the last annual scientific meeting of the American Headache Society in San Diego showed that post-concussion symptoms can be helped by an intravenous infusion of magnesium. Doctors at the department of neurology at UCLA described six patients with a post-concussion syndrome, who were given an infusion of 2 grams of magnesium sulfate. Three out of six had a significant improvement of their headaches and all had improvement in at least one of the following symptoms: concentration, mood, insomnia, memory, and dizziness. This was a small study, but it is consistent with other studies that show a drop in the magnesium level following a concussion and also studies in animals that show beneficial effects of magnesium following a head trauma. Our studies have shown that intravenous magnesium can relieve migraine and cluster headaches in a significant proportion of patients. Considering how safe intravenous magnesium is and how devastating the effect of a concussion can be, it makes sense to give all patients with a post-concussion syndrome if not an intravenous infusion, at least an oral supplement. I usually recommend 400 mg of magnesium glycinate, which should be taken with food. For faster and more reliable effect, we routinely give patients with migraines, cluster, and post-concussion headaches an infusion of magnesium. Patients who do not absorb or do not tolerate (it can cause diarrhea) oral magnesium, come in to for monthly infusions. --- ### What position to sleep in? - Published: 2016-06-22 - Modified: 2016-06-22 - URL: https://www.nyheadache.com/blog/what-position-to-sleep-in/ - Categories: Alternative Therapies, Brain disorders Should you sleep on the right or on the left side? Researchers led by Dr. Helene Benveniste of Stony Brook University discovered that sleeping on the right side provides better drainage of toxins out of the brain, at least in rats. She presented their findings at the meeting of the American Headache Society in San Diego earlier this month. The lymphatic system, which has been long known to exist throughout the body, was only recently discovered in the brain. It is called a glymphatic system because brain's glial cells form this network of draining channels. According to the latest studies, our brain does housekeeping by removing waste products when we are asleep. Insomnia has been associated not only with more frequent migraine headaches, but also with an increased risk for Alzheimer's disease, which is thought to be at least in part due to accumulation of waste products in brain cells. When you google sleep positions, many sites recommend sleeping on the left side, but no scientific studies have been done to see which position is more beneficial. The rat study mentioned above suggests that sleeping on either side is better than sleeping on your back or on the stomach. Hopefully, Dr. Benveniste and her colleagues will conduct studies in humans, so that we know how to sleep. For now, whatever position you sleep in, try to get enough sleep every night. --- ### The existence of medication overuse headache is debated - Published: 2016-06-20 - Modified: 2016-06-20 - URL: https://www.nyheadache.com/blog/the-existence-of-medication-overuse-headache-is-debated/ - Categories: Alternative Therapies, Headache medications, Headaches, Migraine Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other). Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts. Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS: "It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications... --- ### Why millions of chronic migraine sufferers go untreated - Published: 2016-06-15 - Modified: 2016-06-15 - URL: https://www.nyheadache.com/blog/why-millions-of-chronic-migraine-sufferers-go-untreated/ - Categories: Uncategorized 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... --- ### Zecuity, sumatriptan skin patch can cause burns, is pulled off the market - Published: 2016-06-11 - Modified: 2016-06-11 - URL: https://www.nyheadache.com/blog/zecuity-sumatriptan-skin-patch-can-cause-burns-is-pulled-off-the-market/ - Categories: Uncategorized 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. --- ### Triptans may be safe in basilar and hemiplegic migraine - Published: 2016-05-31 - Modified: 2016-05-31 - URL: https://www.nyheadache.com/blog/triptans-may-be-safe-in-basilar-and-hemiplegic-migraine/ - Categories: Migraine Hemiplegic and basilar migraine are rare types of migraine. Hemiplegic migraine is accompanied by a paralysis of one side of the body. Basilar migraine derives its name from the basilar artery, which supplies blood to the brainstem. Symptoms of brainstem dysfunction (double vision, unsteady gait, vertigo, difficulty speaking) made doctors think that ischemia or lack of blood flow in that artery caused these symptoms. We now know that this is not the case and basilar migraine may be just another form of migraine with aura. The FDA ruled that sumatriptan (Imitrex), other triptans, and ergotamines (DHE-45, Cafergot) are contraindicated in patients with basilar and hemiplegic migraine because of the unsubstantiated fear that these drugs may cause constriction of blood vessels that might be already constricted resulting in a stroke. There is little evidence that symptoms of hemiplegic and basilar migraine are caused by the constriction of blood vessels. It is most likely due to the dysfunction of the brain cells. In addition, constriction of blood vessels by the triptans is very mild. A study just published in the journal Headache examined 67 patients with basilar and 13 with hemiplegic migraines who were treated with triptans and dihydroergotamine (DHE-45). None of these patients suffered a stroke or a heart attack. This is not the first report of the safe use of triptans in the treatment of basilar and hemiplegic migraines. Although the total number of patients reported is small, it appears that triptans and ergots are probably safe in these types... --- ### Pre-Concussion Psychological Symptoms Can Delay Recovery from a Concussion - Published: 2016-05-23 - Modified: 2016-05-23 - URL: https://www.nyheadache.com/blog/pre-concussion-psychological-symptoms-can-delay-recovery-from-a-concussion/ - Categories: Head trauma, Psychology of headaches - Tags: anxiety, Botox, concussion, depression, somatization Post-concussion symptoms have long been thought to be more severe and prolonged in people who have pre-existing psychological problems. This has been shown to be the case in the military personnel. A new study confirmed this observation in the first prospective study. Over 2,000 high school and college athletes in Wisconsin were asked to answer 18 questions (Brief Symptom Inventory-18, or BSI-18) and then were followed for three years. The 18 questions, which are listed below, addressed the presence of anxiety, panic attacks, depression, and somatization (excessive bodily sensations). In the ensuing three years, 127 athletes sustained a concussion. The concussion had to be diagnosed by a licensed athletic trainer according to the Department of Defence definition, which includes alteration of mental status with associated headache, nausea, vomiting, balance difficulties, dizziness, cognitive difficulties, and other. These athletes were again evaluated two and six weeks later. Eighty percent of concussed athletes were men. The mean duration of symptoms was five days. Ninety five percent of them recovered completely within a month. High somatization score on the BSI-18 questionnaire predicted prolonged duration of symptoms, while no correlation was found with the years of playing a sport, the type of sport (most played football), number of prior concussions, migraines, ADHD, or the grade point average. Another factor that delayed recovery was the initial symptom severity after the concussion. Most of the concussions were mild with less than 10% of athletes losing consciousness. An interesting and unexplained fact, not examined in this study, is... --- ### Magnesium in pregnancy - Published: 2016-05-18 - Modified: 2016-05-18 - URL: https://www.nyheadache.com/blog/magnesium-in-pregnancy/ - Categories: Alternative Therapies, injections, Migraine Intravenous magnesium infusions may not be as safe in pregnant women as it has been always thought. The FDA recently moved intravenous magnesium from category A into category D (see category definitions below). This came about after the FDA reviewed 18 cases of babies who were born with serious problems after their mothers received intravenous infusions of large amounts of magnesium for 5 to 7 days in order to stop premature labor. The FDA strongly discourages this practice and states that "Administration of magnesium sulfate injection to pregnant women longer than 5-7 days may lead to low calcium levels and bone problems in the developing baby or fetus, including thin bones, called osteopenia, and bone breaks, called fractures. " However, treatment of choice for eclampsia remains intravenous magnesium. Eclampsia, one of the most serious complications of pregnancy can be treated only with high doses of intravenous magnesium. Without intravenous magnesium eclampsia can lead to epileptic seizures, very high blood pressure, kidney failure and death. The FDA also recommends that "Magnesium sulfate injection should only be used during pregnancy if clearly needed. If the drug is used during pregnancy, the health care professional should inform the patient of potential harm to the fetus. " We do treat many patients, including pregnant women, with intravenous infusions of magnesium if they are deficient in magnesium and if their migraines respond to such infusions. Typically, these infusions are given monthly and the amount is only 1 gram, while for preterm labor the dose is... --- ### The Allergy Solution - a new book you should read - Published: 2016-05-02 - Modified: 2016-05-02 - URL: https://www.nyheadache.com/blog/the-allergy-solution-a-new-book-you-should-read/ - Categories: Uncategorized 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... --- ### Intranasal ketorolac is as good as intranasal sumatriptan (Imitrex) - Published: 2016-04-25 - Modified: 2016-04-25 - URL: https://www.nyheadache.com/blog/intranasal-ketorolac-is-as-good-as-intranasal-sumatriptan-imitrex/ - Categories: Migraine Sumatriptan (Imitrex) and similar drugs (so called triptans) are "designer" drugs that were specifically developed for the treatment of migraine headaches. They are very effective, but do not help all migraine sufferers. Anti-inflammatory pain killers, such as aspirin and ibuprofen work well for some people and sometimes these drugs are combined with triptans to achieve better relief. Many migraineurs experience nausea and sometimes vomiting as part of their migraine, which prevents or delays the absorption of medicine, making it ineffective or less effective. To address this problem, two of the triptans, sumatriptan and zolmitriptan (Zomig) are available in a nasal spray form. Sumatriptan can be also self-administered as an injection and recently a skin patch of sumatriptan (Zecuity) became available. An anti-inflammatory pain medicine, ketorolac is also available as a nasal spray, as does a narcotic pain killer, Stadol (butorphanol). While Stadol is addictive and has other serious side effects, intranasal ketorolac (Sprix) is a very good pain medication. Sprix works much better than the ketorolac tablet, but not as well as an injection of ketorolac (Toradol). Intranasal ketorolac was compared with intranasal sumatriptan in a study that was recently published in the journal Headache. The study showed that ketorolac and sumatriptan nasal sprays were equally effective and both were better than placebo spray. Both drugs caused nasal irritation and unpleasant taste in some patients, but these were not severe. The main problem with intranasal ketorolac is its cost. On GoodRx. com the price of 5 vials of Sprix (with... --- ### Botox is woefully underused in the treatment of chronic migraines - Published: 2016-04-18 - Modified: 2016-04-18 - URL: https://www.nyheadache.com/blog/botox-is-woefully-underused-in-the-treatment-of-chronic-migraines/ - Categories: Botox, Chronic migraine, Migraine The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered that in this period of time only 100,000 chronic migraine sufferers received this treatment. According to the Migraine Research Foundation, 14 million Americans suffer from chronic migraines, so less than 1% of them have recieved this potentially life-changing treatment. There are several possible explanations. 1. Botox is expensive and many insurance companies make it difficult for patients to get it. They require that the patient first try 2 or 3 preventive drugs, such as a blood pressure medicine, (propranolol, atenolol, etc. ), an epilepsy drug (gabapentin, Depakote, Topamax), or an antidepressant (amitriptyline, nortriptyline, Cymbalta). Patients also have to have 15 or more headache days (not all of them have to be migraines) in each of the three preceding months. If these requirements are met, the doctor has to submit a request for prior authorization. Once this prior authorization is granted, the insurer will usually send Botox to the doctor's office. After the procedure is done, the doctor has to submit a bill to get paid for administering Botox. This bill does not always automatically get paid, even if a prior authorization was properly obtained. The insurer can ask for a copy of office notes that show that the procedure was indeed performed. All this obviously serves as a deterrent for many doctors. Some of them find that the amount of paperwork is so great and that the payment is so... --- ### Yoga, chiropractic and my neck - Published: 2016-04-09 - Modified: 2016-04-09 - URL: https://www.nyheadache.com/blog/yoga-chiropractic-and-my-neck/ - Categories: Alternative Therapies Yoga is the most impactful import from India to the US. Yoga has many documented health benefits, including relief of headaches. I have been practicing Bikram yoga about twice a week for nearly 12 years. About a year ago I started having some neck and left upper back pain. I thought that strengthening neck exercises, meditation, occasional massage, which is what I recommend my patients, would eliminate the pain (I probably should have also gone for physical therapy). The pain was never severe and would temporarily improve with massage, but because it persisted and became annoying, I decided to try chiropractic. Many doctors' attitude towards chiropractors is dismissive, disdainful or worse. When I tried to google the number of chiropractic manipulations done in the US, the first item that popped up was Medscape's Deaths After Chiropractic: A Review of Published Cases (there were 26 cases in that report). I have personally treated an elderly patient who developed a subdural hematoma (bleeding inside the head) after chiropractic manipulation. My usual advice to patients has been to go for physical therapy and massage instead of chiropractic. If a patient really wants to see a chiropractor, I advise asking not have any high velocity adjustments. This adjustment is done by suddenly turning and lifting your head to one side and it is responsible for most of the complications. I also tell patients that a good chiropractor will always give you exercises to do, while those who don't, just want you to keep coming... --- ### Sodium intake and migraines - Published: 2016-04-02 - Modified: 2016-04-03 - URL: https://www.nyheadache.com/blog/sodium-intake-and-migraines/ - Categories: Alternative Therapies, Migraine, Science of Migraine I have not been aware of any research indicating a link between salt intake and migraines. A study just published in the journal Headache by researchers at Stanford and UCLA looked at this possible connection. This was a national nutritional study that examined sodium intake in people with a history of migraine or severe headaches. The study included 8819 adults with reliable data on diet and headache history. The researchers classified respondents who reported a history of migraine or severe headaches as having probable history of migraine. They excluded patients with medication overuse headache, that is people who were taking pain medications very frequently. Dietary sodium intake was measured using estimates that have been proven to be reliable in previous studies. Surprisingly, higher dietary intake of sodium was associated with a lower chance of migraines or severe headaches. This relationship was not affected by age or sex. In women, this inverse relationship was limited to those with lower weight (as measured by body mass index, or BMI), while in men the relationship did not differ by BMI. This study offered the first scientific evidence of an inverse relationship between migraines and severe headaches and dietary sodium intake. It is very premature to recommend increased sodium intake to all people who suffer from migraines and severe headaches. However, considering that this is a relatively safe intervention, it may make sense to try increased salt intake. I would suggest adding table salt to a healthy and balanced diet, rather than eating salty... --- ### Caffeine and miscarriages - Published: 2016-03-25 - Modified: 2016-03-25 - URL: https://www.nyheadache.com/blog/caffeine-and-miscarriages/ - Categories: Alternative Therapies Caffeine is a well-know trigger of migraine headaches and I regularly write on this topic (my last post on this topic - caffeine causing headaches in adolescents - was three years ago). Caffeine can help migraines and other headaches, but in large amounts it worsens them due to caffeine withdrawal, which can occur in as little as 3 hours after the last cup of coffee. One of my patients was an extreme case. He told me that he figured out that his early morning migraines were due to caffeine withdrawal and he would set his alarm clock for 4 AM, so that he could wake up, drink some coffee and go back to sleep without the fear of a morning headache. A continuous intravenous drip of caffeine would also solve his problem. Most people opt for stopping caffeine, albeit it can be a difficult process. Going cold turkey is often easier than a gradual reduction in caffeine intake. To avoid severe withdrawal, prescription migraine drugs, such as sumatriptan (Imitrex), intravenous magnesium, nerve blocks and other interventions may be necessary in a small percentage of patients. This post was prompted by a just published study that showed a higher risk of miscarriages in couples where either partner, male or female consumed more than 2 caffeinated beverages prior to conception. Caffeine has been long suspected but not definitively proven to increase the risk of miscarriages in women who drink large amounts of caffeine during pregnancy, but what is surprising is that consumption... --- ### Ketamine for migraine - Published: 2016-03-21 - Modified: 2016-03-21 - URL: https://www.nyheadache.com/blog/ketamine-for-migraine/ - Categories: Alternative Therapies Ketamine is a sedating agent used to induce anesthesia. It is also a drug of abuse with street names such as “Special K” or “Ket”. Ketamine has many advantages, which makes it a very popular choice in anesthesia. It works fast, blocks pain, opens the lungs, it is easy on the heart, and has anti-inflammatory properties. It may also have anti-cancer properties. Ketamine is being extensively tested for the treatment of depression that does not respond to medications. Because ketamine works on a receptor involved in transmitting pain messages in the brain (NMDA receptor), it has been studied in various painful conditions. The amounts being tested for pain are much smaller than those used to induce anesthesia or even those used recreationally. Even though it is a drug of abuse, it appears to be less addictive than heroine and prescription narcotics. There are only few small studies and reports about the use of ketamine for migraine headaches. One such report published in the leading neurological journal Neurology describes 18 patients with prolonged migraine auras who were treated with intranasal ketamine spray. The duration of their auras was not shortened by ketamine, but the severity was reduced. Another study showed that severe disabling aura was relieved in 5 out of 11 patients with hemiplegic migraine. Several anecdotal reports have touted the benefits of ketamine in chronic migraines, cluster headaches, and chronic paroxysmal hemicrania (a rare type of headache that often responds to indomethacin and at times to Botox). While such anecdotal... --- ### Low magnesium and growth factor are found in fibromyalgia - Published: 2016-03-14 - Modified: 2016-03-14 - URL: https://www.nyheadache.com/blog/low-magnesium-and-growth-factor-are-found-in-fibromyalgia/ - Categories: Brain disorders, New treatments, Pain Fibromyalgia is a condition comorbid with migraine, which means that migraine sufferers are more likely to have fibromyalgia and those with fibromyalgia are more likely to have migraines (such relationships are not always bidirectional). One common finding in these two conditions is low magnesium level and both condition often improve with magnesium supplementation or magnesium infusions. A new study by Dr. T. Romano of 60 patients with fibromyalgia showed that those who have low red blood cell (RBC) magnesium levels are likely to have low levels of growth hormone (IGF-1, or insulin-like growth factor 1). RBC magnesium level is a more accurate test than the routine serum magnesium level, which is highly unreliable as most of the body's magnesium sits inside the cells. Dr. Romano recommends magnesium supplementation and a referral to an endocrinologist. It is possible that treatment with growth hormone will help those who are deficient, although it is also possible that magnesium supplementation alone (oral or intravenous, if oral is ineffective) could increase the production of growth hormone. --- ### Nose surgery relieves migraines? - Published: 2016-03-06 - Modified: 2016-03-06 - URL: https://www.nyheadache.com/blog/nose-surgery-relieves-migraines/ - Categories: Alternative Therapies, Chronic migraine, Migraine, New treatments, Trigeminal and other neuralgias A patient of mine just emailed me about a recent segment of the TV show, The Doctors, which featured a woman whose severe chronic migraines were cured by nasal surgery. The segment was shot a few weeks after the surgery, so it is not clear how long the relief will last in her case. The surgery involved removing a contact point, which occurs in people with a deviated septum. The septum, which consists of a cartilage in the front and bone in the back, divides the left and the right sides of the nose. If the bony septum is very deviated, which often happens from an injury, it sometimes touches the side of the nose, creating a contact point between the septum and the bony side wall of the nose. Several small reports by ENT surgeons have described dramatic relief of migraine headaches with the removal of the contact point. If headaches are constant, then the constant pressure of the contact point would explain the pain. However, many of the successfully treated migraine sufferers had intermittent attacks. The theory of how a contact point could cause intermittent migraines is that if something causes swelling of the mucosa (lining) of the nasal cavity, then this swelling increases the pressure at the contact point and triggers a headache. This swelling can be caused by nasal congestion due to allergies, red wine, exercise, and possibly other typical migraine triggers. This is a good theory, but it is only a theory and the dramatic... --- ### Medical marijuana relieves migraines, epileptic seizures - Published: 2016-03-02 - Modified: 2016-03-02 - URL: https://www.nyheadache.com/blog/medical-marijuana-relieves-migraines-epileptic-seizures/ - Categories: Alternative Therapies, Migraine Marijuana has been tried for a variety of medical conditions, including migraines, and in one of my previous post I mentioned dangers of smoking it. Medical marijuana does not have the same dangers since it is not smoked. A study just published in the journal Pharmacotherapy involved 121 adults with migraine headaches who were treated with medical marijuana. The number of migraine headaches per month decreased from 10. 4 to 4. 6 with the use of medical marijuana. Most patients used more than one form of marijuana and used it daily for prevention of migraine headache. Positive results were reported by 48 patients (40%), with the most common effects being prevention of migraine headache and the second most common effect, aborted migraine attacks. Inhaled forms of marijuana were commonly used for acute migraine treatment and were reported to abort migraine headache. Side effects were reported in 14 patients (12%); the most common side effects were somnolence (2 patients) and difficulty controlling the effects of marijuana related to timing and intensity of the dose (2 patients), which were experienced only in patients using edible marijuana. Edible marijuana was also reported to cause more side effects compared with other forms. The authors concluded that the frequency of migraine headaches was decreased with medical marijuana use. New York state just approved medical marijuana for ingestion by mouth or breathing in vapors. Medical marijuana is approved in NY for several medical conditions, including neuropathic pain, but not migraines. However, many migraine sufferers also have... --- ### More science about meditation - Published: 2016-02-26 - Modified: 2016-02-26 - URL: https://www.nyheadache.com/blog/more-science-about-meditation/ - Categories: Alternative Therapies There has been some backlash against meditation with newspapers publishing articles claiming that meditation is overrated. Fortunately, serious scientists continue to publish solid objective data proving that meditation not only relieves pain and headaches and makes you feel better, but in fact changes the structure of your brain. In my recent post I wrote about one such a study published in the Journal of Neuroscience. A new rigorous scientific study was just published in Biological Psychiatry. It looked at the benefits of mindfulness meditation and how it changes people's brains and potentially improves the overall health. The study was conducted at the Health and Human Performance Laboratory at Carnegie Mellon University. The researchers recruited 35 unemployed men and women who were looking for work and were under significant stress. Half of the people were taught mindfulness meditation at a residential retreat center, while the other half were provided sham mindfulness meditation, which involved relaxation and distraction from worries and stress. All participants did stretching exercises, but the mindfulness group was asked to pay attention to bodily sensations, including unpleasant ones. The relaxation group was encouraged to talk to each other and ignore their bodily sensations. After three days, all participants felt refreshed and better able to deal with the stress of unemployment. However, follow-up brain scans showed changes only in those who underwent mindfulness meditation. The scans showed more activity among the portions of their brains that process stress-related reactions and other areas related to focus and calm. By four... --- ### More on dangers of Prilosec and other PPIs - Published: 2016-02-22 - Modified: 2016-02-22 - URL: https://www.nyheadache.com/blog/more-on-dangers-of-prilosec-and-other-ppis/ - Categories: Alternative Therapies Prilosec (omeprazole), Nexium, Prevacid, and other similar drugs in the family of proton pump inhibitors (PPIs) can cause headaches directly, but more often by reducing the absorption of vitamins such as B12 and D, and minerals such as magnesium, over a longer period of time. My previous post described a 26,000 patient study that convincingly showed that PPIs cause vitamin B12 deficiency. We also know that older women on PPIs have a higher risk of bone fractures. A report just published in JAMA Neurology adds another dangerous association. This was also a very large study that involved over 73,000 older people, of whom almost 3,000 were taking PPIs. Those on PPIs had a significantly higher risk of developing dementia. This is possibly due to a direct toxic effect of these drugs, but more likely it is because these drugs cause vitamin and mineral deficiencies. Three month earlier, the same journal published a study that showed that low vitamin D levels are associated with a significantly higher risk of developing dementia. A very important finding of this study was that even those who had what is considered a normal vitamin D level of between 30 and 50 had an increased risk of dementia, compared with those whose level was above 50. This is not surprising because a study of multiple sclerosis (MS) showed that those with low normal levels had many more attacks of MS than those who had high normal levels. Vitamin D seems to protect from many other diseases... --- ### Electric current treats not only migraines, but also malignant brain tumors. - Published: 2016-02-20 - Modified: 2016-02-20 - URL: https://www.nyheadache.com/blog/electric-current-treats-malignant-brain-tumors-what-about-migraines/ - Categories: Alternative Therapies, Brain disorders Treatment of medical conditions with electricity was first used by the ancient Romans who used electric eels to treat headaches, gout and in obstetrics. Electric shock therapy for depression was one of the earliest widespread uses of electricity in medicine and it continues to be used successfully, although with some modifications to reduce side effects. Transcutaneous electric nerve stimulation (TENS) has been shown to relieve pain of neuromuscular disorders (back, muscle and joint pains) as well as headaches (see my blog post on Cefaly). While TENS uses alternating current, direct current has also been widely utilized in treating various conditions, including migraines. Despite billions of dollars spent on research, there has been very little progress in developing more effective therapies for glioblastomas, the most common and the deadliest form of malignant brain tumor. The standard therapy for glioblastoma has consisted of surgery, radiation, and chemotherapy. In October of last year, the FDA approved the use of the Novocure Tumor Treating Fields system for the treatment of patients with newly diagnosed glioblastoma. This device delivers alternating electric fields through scalp electrodes to the tumor, interrupting cell division. The addition of the electrical stimulation to chemotherapy increased progression-free survival to 7. 1 months, compared to 4. 2 months in the group who received chemotherapy alone. There was also an increase in overall survival from 16. 6 to 19. 4 months. Living three months longer does not seem like a lot, but chemotherapy and radiation, which cause severe side effects, are not much... --- ### Pituitary adenoma and headache - Published: 2016-02-15 - Modified: 2016-02-15 - URL: https://www.nyheadache.com/blog/pituitary-adenoma-and-headache/ - Categories: Brain disorders, Headaches Pituitary gland which is located inside the skull and underneath the brain is responsible for secreting various hormones. Pituitary adenoma is a benign tumor of this gland and it often causes increased release of either prolactin, growth hormone, or cortisol. Very often the tumor does not release any hormones. These tumors are extremely common - a microscopic tumor is found in one out of five adults, but they cause symptoms only in a very small proportion of such people. The symptoms are related to the type of hormone that is being released or are caused by the pressure of a growing tumor on the surrounding brain structures, or both. A very small tumor can be treated with medications, while large ones often require surgery. Small tumors have traditionally not been thought to cause headaches. A recent study showed that in a minority of patients small tumors do cause severe headaches and if these headaches do not respond to medications, surgery can provide relief. The study was done by a group of Japanese neurosurgeons who reviewed the records of 180 patients who underwent surgery for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. They found nine patients with intractable headaches as the main complaint, associated with a small, but not microscopic pituitary adenoma (average diameter of 15 mm, or 3/5 of an inch). In eight patients the tumor did not secrete any hormones and in one it secreted prolactin. All nine patients had complete or significant relief of their... --- ### Daily long-term use of sumatriptan injections in cluster headaches - Published: 2016-02-07 - Modified: 2016-02-07 - URL: https://www.nyheadache.com/blog/daily-long-term-use-of-sumatriptan-injections-in-cluster-headaches/ - Categories: Cluster headaches, Headache medications, injections My most commented on blog post (over 150 comments) is on the daily use of triptans. A new report confirms the safety of long-term daily use of sumatriptan injections in cluster patients. Cluster headaches are arguably the most severe type of headaches and the name comes from the fact that they tend to occur in clusters lasting several weeks to several months. However, in some patients headaches become persistent without any remissions and then they are called chronic cluster headaches. The only FDA approved treatment for cluster headaches is injectable sumatriptan (Imitrex). Most patients have one cluster attack in 24 hours, but some have many. A report mentioned in one of my other previous blogs describes a woman (although men are more commonly affected by cluster headaches) who has been injecting sumatriptan daily on average 20 times a day for 15 years. A recent report by Massimo Leone and Alberto Cecchini is entitled, Long-term use of daily sumatriptan injections in severe drug-resistant chronic cluster headache. The authors investigated occurrence of serious side effects in patients with chronic cluster headaches who were using sumatriptan injections continuously at least twice daily (the official limit) for at least 2 years. They found fifty three such patients with chronic cluster headaches seen in their clinic between 2003 and 2014. During the 2-year period, all patients were carefully followed with regular visits at their center. Headaches and sumatriptan consumption were recorded in headache diaries. Patients were questioned at each visit about serious side effects and... --- ### Another way to administer sumatriptan (Imitrex) was just approved by the FDA - Published: 2016-02-01 - Modified: 2016-02-01 - URL: https://www.nyheadache.com/blog/another-way-to-administer-sumatriptan-imitrex-was-just-approved-by-the-fda/ - Categories: Migraine Sumatriptan is now available in a nasal powder form. We already have sumatriptan in a tablet, injection, nasal spray, and a skin patch. I mentioned this product over 5 years ago and finally it was just approved by the FDA. This does not mean it will be available right away as it often takes many months for the company to ramp up production. In some cases, such as with inhaled migraine drug Semprana (formerly called Levadex), it takes years before the manufacturer achieves FDA quality standards of production. OptiNose is the company that developed Xsail Breath Powered Delivery Device which is used to deliver sumatriptan nasal powder. OptiNose licensed the product to Avanir Pharmaceuticals and they named it Onzetra. Onzetra is a fast-acting dry powder that is delivered into the nasal cavity. The patient exhales into the device, which seals the nasal cavity, and this carries the medication from the device directly into one side of the nose. Nasal powder should be much more effective and more consistently effective than the nasal spray. The problem with the nasal spray is that the liquid tends to leak out of the nose or into the mouth, while the powder sticks to the nasal mucosa and all of it gets absorbed. And while the nasal spray contains 20 mg of sumatriptan and Onzetra only 11 mg, Onzetra should be more effective. Similarly, only 6 mg of injected sumatriptan is much more effective than 100 mg of sumatriptan in a tablet. But do we... --- ### Temporal arteritis may be due to shingles virus - Published: 2016-01-25 - Modified: 2016-01-25 - URL: https://www.nyheadache.com/blog/temporal-arteritis-may-be-due-to-shingles-virus/ - Categories: Brain disorders, Headaches Headache is usually the main presenting symptom of temporal arteritis (also known as giant cell arteritis, or GCA), which is caused by inflammation of blood vessels. This condition happens almost exclusively in the elderly. It presents with a severe headache, which is often one-sided. Some, but not all patients have swelling and tenderness of their temporal artery at the temple. This is a serious condition because it damages blood vessels and can cause strokes, loss of vision, and other complications. The diagnosis is made by blood tests (C-reactive protein, or CRP and erythrocyte sedimentation rate, or ESR) and temporal artery biopsy. However, even the biopsy sometimes does not show the inflammation. The treatment consists of steroid medications, such as prednisone. Prednisone is usually very effective. Unfortunately, prednisone needs to be taken for years if not for the rest of the person's life and when it is used for long periods, it has many potentially dangerous side effects. A recent study published in JAMA Neurology showed that many patients with biopsy-proven giant cell arteritis have an infection with varicella-zoster virus. This virus is also responsible for shingles and chickenpox The researchers reviewed samples of temporal arteries for the presence of varicella-zoster virus. It was found in 68 of 93 (73%) of temporal arteries of patients with the disease, compared with 11 of 49 (22%) normals. The authors concluded that in patients with clinically suspected GCA, prevalence of the virus in their temporal arteries is similar independent of whether biopsy results are... --- ### Radiosurgery for trigeminal neuralgia - Published: 2016-01-16 - Modified: 2016-01-16 - URL: https://www.nyheadache.com/blog/radiosurgery-for-trigeminal-neuralgia/ - Categories: Trigeminal and other neuralgias Trigeminal neuralgia is an extremely painful condition which causes jolts of very intense electric-like pains in the face. Fortunately, many trigeminal neuralgia sufferers respond to medications or Botox injections. Several surgical procedures have also been used to treat this condition. One of these procedures is destruction of the trigeminal ganglion. The most effective treatment involves opening the skull and placing a teflon pad between the trigeminal nerve and the blood vessel which compresses the nerve (this procedure is called microvascular decompression). This pressure on the trigeminal nerve by an artery is the cause of pain in the majority of patients. While surgery can be truly curative, it carries a risk of serious complications and should be done only if medications and Botox injections fail. Ideally, it should be performed by a surgeon who has performed hundreds of these operations. Besides medications, Botox, and injections to destroy the trigeminal ganglion, stereotactic radiosurgery, or gamma knife, offers another alternative to brain surgery. This treatment appears to be very effective and a new study published in Neurology suggests that this procedure is more effective if it is done early. If gamma knife radiosurgery is done within a year of the onset of pain, patients remained pain free for an average of 68 months, while if it was done more than 3 years after the onset, the relief lasted only 10 months. Although microvascular decompression is curative, two groups of patients may opt for radiosurgery. One group consists of patients who are poor surgical... --- ### White matter lesions and stroke - Published: 2016-01-10 - Modified: 2016-01-10 - URL: https://www.nyheadache.com/blog/white-matter-lesions-and-stroke/ - Categories: Brain disorders, Migraine, Science of Migraine The little white spots seen on brain MRI scans have long been thought to be benign. A nagging concern has always persisted since their meaning has remained unclear. A recent study by researchers at several medical centers across the US established that even very small brain lesions seen on MRI scans are associated with an increased risk of stroke and death. This is a very credible study since it involved 1,900 people, who were followed for 15 years. Previous studies of these white matter lesions (WML), which are also called white matter hyperintensities (WMH) involved fewer people and lasted shorter periods of time (these are my previous 4 posts on this topic). Migraine sufferers, especially those who have migraines with aura are more likely to have WMLs. One Chinese study showed that female migraine sufferers who were frequently taking ("overusing") NSAIDs, such as aspirin and ibuprofen actually had fewer WMLs than women who did not overuse these medications. Even though most neurologists and headache specialists believe that NSAIDs worsen headaches and cause medication overuse headaches, this is not supported by rigorous scientific evidence (the same applies to triptan family of drugs, such as sumatriptan). Another interesting and worrying finding is that the brain lesions were often very small, less than 3 mm in diameter, which are often dismissed both by radiologists who may not report them and neurologists, even if they personally review the MRI images. The risk of stroke and dying from a stroke in people with small lesions... --- ### Asthma and chronic migraine - Published: 2016-01-04 - Modified: 2016-01-04 - URL: https://www.nyheadache.com/blog/asthma-and-chronic-migraine/ - Categories: Alternative Therapies, Migraine Asthma is more common in migraine sufferers and migraine is more common in those who suffer from asthma (the medical term is co-morbid conditions). A new study published in Headache examines a possible connection between asthma and chronic migraine. Migraine is considered chronic if headache occurs on 15 or more days each month. This co-morbidity between migraine and asthma is thought to be due to the fact that both conditions involve inflammation, disturbance of the autonomic nervous system, and possibly shared genetic and environmental factors. What is not mentioned in the report is the fact that intravenous magnesium can relieve both an acute migraine (in up to 50% of migraine sufferers who are deficient in magnesium) and a severe asthma attack. This suggests another possible explanation for the co-morbidity. Magnesium deficiency may also explain, at least in part, co-morbidity between migraine and fibromyalgia and vascular disorders. The Headache report was one of many based on the outcomes of the large and long-term American Migraine Prevalence and Prevention study (AMPP). Study participants had to meet criteria for episodic migraine in 2008, complete an asthma questionnaire in 2008, and provide follow-up information in 2009. The researchers counted the number of these patients who developed chronic migraine a year later. The sample for this study included 4446 individuals with episodic migraine in 2008 of whom 17% had asthma. The mean age was 50 and 81% were female. In 2009, of the patients who had episodic migraines and asthma, 5. 4% developed chronic migraine,... --- ### Blood thinner for migraine? - Published: 2015-12-25 - Modified: 2015-12-25 - URL: https://www.nyheadache.com/blog/blood-thinner-for-migraine/ - Categories: Migraine, New treatments A hole between the left and the right side of the heart has been suspected to be the cause of migraines in some people. However, closing this hole has not produced dramatic improvement in several blinded studies that have been conducted in the past few years. The hole, called atrial septal defect (ASD) is present in utero but begins to close as soon as the baby is born. In about 1. 5% of the population (in twice as many women than men) the hole does not close completely. In most people this hole is small and does not cause any symptoms. However, if it is big, it requires intervention because it can lead to heart failure and strokes. Smaller ASD may not cause any symptoms, but has been suspected to be related to migraine headaches, especially migraines preceded by a visual aura. The closure of ASD is done by threading up through a vein in the groin an umbrella-like device which is positioned and opened inside the heart to close the hole. A recent study looked at the need for different blood thinners to prevent blood clots from forming in the heart after the procedure. Half of the 171 migraine patients in the study were given aspirin and placebo and the other half aspirin and clopidogrel, another blood thinner. Interestingly, those who were given two blood thinners (aspirin and clopidogrel) had less severe migraine attacks than those on one (aspirin and placebo). This suggests, that the benefit seen in some... --- ### PMS, high blood pressure and magnesium - Published: 2015-12-20 - Modified: 2015-12-20 - URL: https://www.nyheadache.com/blog/pms-high-blood-pressure-and-magnesium/ - Categories: Alternative Therapies, Headache medications, Headaches, Migraine Magnesium deficiency is a regular topic on this blog. Up to half of migraine sufferers are deficient in magnesium, but magnesium levels are rarely checked by doctors. Even when magnesium level is checked, it is usually the serum level, which is totally unreliable. The more accurate test is RBC magnesium or red blood cell magnesium because 98% of body's magnesium resides inside cells or in bones. At the New York Headache Center we often don't bother checking even the RBC magnesium level, especially if other signs of magnesium deficiency besides migraines are present. These include coldness of hands and feet or just always feeling cold, leg muscle cramps, palpitations, anxiety, brain fog, and in women, premenstrual syndrome or PMS (bloating, breast tenderness, irritability). For these patients we recommend daily magnesium supplementation and sometimes monthly magnesium infusions. About 20 to 30 million women suffer from moderate or severe PMS, and a recent study published in the American Journal of Epidemiology indicates that having PMS increases the risk for hypertension (high blood pressure) later in life. This study was done at the University of Massachusetts, Amherst and it involved 1,260 women who suffered from moderate or severe PMS as well as more than 2,400 women with mild or no PMS. Women with moderate or severe PMS were 40 percent more likely to develop high blood pressure than those with mild or no PMS symptoms. The researchers adjusted the risk for other risk for hypertension, such as being overweight, smoking, drinking, inactivity, use... --- ### Meditation is more effective than placebo - Published: 2015-12-18 - Modified: 2015-12-18 - URL: https://www.nyheadache.com/blog/meditation-is-more-effective-than-placebo/ - Categories: Alternative Therapies Meditation is growing in popularity and deservedly so. Several of my previous posts mentioned the benefit of meditation in migraine headaches. Scientists are conducting rigorous studies that repeatedly show the profound effect meditation has on the brain. The most recent study was done at the Wake Forest Baptist Medical Center and it compared the effect of meditation and placebo on pain. The study was published in the recent issue of the Journal of Neuroscience. It showed that mindfulness meditation not only provided greater pain relief than placebo, but the brain scans could differentiate patterns of brain activity during meditation from that induced by placebo. The study involved seventy five healthy, pain-free volunteers who were randomly assigned to one of four groups: mindfulness meditation, placebo meditation ("sham" meditation), placebo analgesic cream or control. Pain was induced by heat applied to the skin. The mindfulness meditation group reported that pain intensity was reduced by 27 percent and the emotional aspect of pain (how unpleasant it was) by 44 percent. In contrast, the placebo cream reduced the sensation of pain by 11 percent and emotional aspect of pain by 13 percent. Mindfulness meditation reduced pain by activating brain regions associated with the self-control of pain while the placebo cream lowered pain by reducing brain activity in pain-processing areas. Another brain region, the thalamus, was deactivated during mindfulness meditation, but was activated during all other conditions. This brain region serves as a gateway that determines if sensory information is allowed to reach higher brain... --- ### Update on Berolina KliniK - Published: 2015-12-15 - Modified: 2015-12-15 - URL: https://www.nyheadache.com/blog/update-on-berolina-klinik/ - Categories: Chronic migraine, New treatments Inpatient migraine headache treatment in the US is usually limited to a five-day course of intravenous DHE and other medications. Even such brief admissions are not always approved by the insurance companies. Many patients improve after these admissions, but often only for a short time because besides some reduction in pain intensity, very little else changes in the patient's life and her brain. It makes sense that longer-term inpatient rehabilitation of chronic migraine and pain patients can lead to a major and lasting improvement, but it is almost unheard of in the US. However, it is available in Germany and other countries. Last November I lectured at one of the leading German inpatient rehabilitation facilities, the Berolina Klinik. My blog post about the Klinik was read by an Englishman with severe chronic migraines who was recently treated there with a three-week program with excellent results. Here is one of the articles that appeared in German press - Westfalen-Blatt 27. 10. 15. And, shockingly to us Americans, the cost of treatment is less than $7,000 for a three-week stay in this top facility. Even with travel costs, it's a bargain. I have been mentioning Berolina Klinik to my patients, although haven't had anyone make the trip yet. --- ### 23andme studies migraine using the power of crowds - Published: 2015-11-28 - Modified: 2015-11-28 - URL: https://www.nyheadache.com/blog/23andme-studies-migraine-using-the-power-of-crowds/ - Categories: Migraine, Science of Migraine 23andMe offers direct-to-consumer genetic testing by analyzing a saliva sample. It provides information on predisposition for more than 90 traits and conditions ranging from acne to Alzheimer's. Health-related results were suspended by the FDA because of the concern was that consumers may not be able to correctly interpret the health data, particularly regarding conditions such as Alzheimer's Parkinson's, various cancers, and other.  What is available is genealogical data and information on several conditions which did receive FDA approval. As of June 2015, 23andMe has genotyped over 1,000,000 individuals. After submitting a saliva sample, consumers are asked to complete a number of surveys about their medical conditions, including migraines, personal habits, and other information. This has led to some important discoveries, which have been published in scientific journals. Here are some results related to migraines. 23andme discovered three genes which make migraines more likely. This discovery is not as important as it seems because these genes increase the risk of migraines by a very small amount and because dozens of other migraine susceptibility genes are being continuously identified. In 2012 23andme acquired CureTogether, a "health research project that brings patients and researchers together to find cures for chronic conditions", where some of the following information comes from. Here is interesting, but also not very surprising information on most commonly reported migraine triggers: stress (85%) insufficient sleep (72%) dehydration (64%) looking at bright sunlight (61%) inhaling smoke/strong odors (57%) staring at a computer screen (56%) flashing or flickering lights (56%) weather changes (50%) low blood sugar (49%) loud environments (48%)... --- ### IV magnesium reduces post-operative pain and opioid use - Published: 2015-11-24 - Modified: 2015-11-24 - URL: https://www.nyheadache.com/blog/iv-magnesium-reduces-post-operative-pain-and-opioid-use/ - Categories: Alternative Therapies, Pain Magnesium infusion given before or during surgery reduces the amount of opioid analgesics (narcotics) needed in the 24 hours following surgery. Doctors at the Saint Barnabas Medical Center in Livingston, NJ reviewed 14 of the most rigorous clinical trials which involved 910 patients. Half of those patients were given intravenous magnesium and the other half, placebo. During the first day after surgery there was a significant reduction in the need for morphine by those receiving magnesium compared with placebo. Another study published in 2013 reviewed 20 clinical trials of magnesium for post-operative pain. These trials included 1,257 patients. This review also concluded that magnesium improved pain and reduced the need for narcotic pain killers. Prescription narcotics are frequently in the news because of the epidemic of prescription drug abuse. However, the advantages of not using as much of these drugs after surgery are far greater than just a reduction of the risk of addiction. These drugs cause constipation, which is a problem after surgery even without opioid drugs, and it makes recovery more difficult. They can also cause confusion, difficulty breathing, and other side effects. There are many possible explanations for the pain-relieving effects of magnesium. We know that it regulates the function of several receptors involved in pain, including serotonin and NMDA. It also relaxes muscles, opens constricted blood vessels, and reduces excitability of the brain and the entire nervous system. Both mental and physical stress depletes magnesium and they are very much present with surgery. Magnesium is a... --- ### Sphenopalatine galnglion block for migraine and cluster headaches - Published: 2015-11-14 - Modified: 2015-11-14 - URL: https://www.nyheadache.com/blog/sphenopalatine-galnglion-block-for-migraine-and-cluster-headaches/ - Categories: Alternative Therapies, Blocks Sphenopalatine ganglion (SPG) block has been used for the treatment of headaches and other pain conditions for over 100 years. The original method involved placing a long Q-tip-like cotton swab dipped in cocaine through the nose and against the SPG. SPG is the largest collection of nerve cells outside the brain and it sits in a bony cavity behind the nasal passages. These nerve cells are closely associated with the trigeminal nerve and include sensory nerves, which supply feeling to parts of the head and autonomic nerves, which regulate the function of internal organs, blood vessels, as well as tearing and nasal congestion. Considering that these nerve cells produce such a wide range of effects, it is logical to expect that blocking these nerves might help headaches. For obvious reasons we no longer apply cocaine, but instead use numbing medicines, such as lidocaine or bupivacaine. A small study suggested that just putting lidocaine drops into the nose can relieve an acute migraine. I've prescribed lidocaine drops to some patients with cluster headaches and a small number reported relief. The problem with nasal drops is that we are not sure if lidocaine actually reaches all the way back to numb the SPG even if they are lying down with the head hanging back over the edge of the bed. Using long Q-tips is uncomfortable and in many patients the Q-tip may also not reach the SPG. To solve the problem, two doctors developed thin intranasal catheters that appear to consistently reach... --- ### About my migraines - Published: 2015-11-09 - Modified: 2015-11-09 - URL: https://www.nyheadache.com/blog/about-my-migraines/ - Categories: Blocks, injections, Migraine Since my early 20s I've been getting visual auras without a headache several times a year. I still get them in my late 50's and they still occur without a headache. In my 40s I started to have migraine headaches without an aura. My migraines are always left-sided and if I don't treat them, I will develop sensitivity to light and nausea. Luckily, my migraines are not at all disabling because they remain mild for hours, so I have plenty of time to take 100 mg of sumatriptan, which works very well. The tablet works within one to two hours. When I want to have faster relief, I take a 6 mg sumatriptan injection. This usually happens at night when I want to go to sleep and I don't want to wait for the pill to start working. I can't fall asleep with a migraine, while for some, sleeps actually relieves the attack. I am not happy about having migraines, but they do not interfere with my life and give me a better understanding of what my patients are going through. Also, I try to subject myself to treatments I offer my patients. I do not need to take a daily preventive medicine, such as topiramate or propranolol or Botox injections. However, since Botox is very safe, I did inject myself with Botox once to see what it feels like. It was not very painful, but obviously everyone has a different pain threshold (here are video 1 and video 2... --- ### Acupuncture and Alexander technique relieve neck pain - Published: 2015-11-03 - Modified: 2015-11-03 - URL: https://www.nyheadache.com/blog/acupuncture-and-alexander-technique-relieve-neck-pain/ - Categories: Alternative Therapies, Pain, Psychology of headaches Acupuncture and Alexander technique appear to be equally effective and significantly more effective for the treatment of chronic neck pain than routine care, according to a study by British researchers published in the latest issue of the Annals of Internal Medicine. The doctors divided 517 patients who suffered from neck pain for at least 6 years into three groups. The first group received an average of 10 50-minute acupuncture treatments, the second had an average of 14 30-minute Alexander technique lessons, and the third group received the usual care. The authors found that acupuncture and Alexander technique both led to a significant reduction in neck pain and associated disability compared with usual care at 12 months. One possible explanation of such good efficacy beyond the direct effect of the treatments was that patients in the active treatment groups had improved self-efficacy. Self-efficacy is the belief that one’s actions are responsible for successful outcomes and it was measured by a standardized questionnaire. It is possible that other forms of therapy that enhance self-efficacy, such as tai chi, meditation, and other can also improve long-standing neck pain, as well as headaches. There are many acupuncture studies that show a significant benefit for migraine headaches (here is one described in a previous post), however unlike this neck pain study most of them did not follow patients for such a long period of time. Alexander technique has been also helpful for some of my patients, but again, good studies are lacking. --- ### Shortage of drugs is a growing problem - Published: 2015-10-17 - Modified: 2015-10-17 - URL: https://www.nyheadache.com/blog/shortage-of-drugs-is-a-growing-problem/ - Categories: Uncategorized 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... --- ### Cluster headaches are on an upsurge in the past 2 weeks. Is sun to blame? - Published: 2015-10-13 - Modified: 2015-10-13 - URL: https://www.nyheadache.com/blog/many-more-cluster-patients-in-the-past-2-weeks-is-sun-to-blame/ - Categories: Cluster headaches Solar activity is high again - NASA's Solar Dynamics Observatory reported a flare on October 1. And in the past two weeks we've been seeing many more patients whose cluster headaches returned. The last time we had a surge in the number of cluster patients was last October, when solar activity was also high (see this post). Unfortunately, there is not a lot we can do about the solar activity, but we do have many treatment options for cluster headaches. These include intravenous magnesium (40% of cluster headache sufferers are deficient), occipital nerve blocks, steroids, daily prevention with verapamil, Botox injections, oxygen inhallation, nasal spray of zolmitriptan (Zomig NS), and sumatriptan (Imitrex) injections. For most cluster patients one more often several of these treatments provide good relief. If these are ineffective, we also use drugs such as lithium, topiramate, and even an herbal supplement, Boswellia. --- ### You can't get magnesium through the skin - Published: 2015-10-11 - Modified: 2015-10-11 - URL: https://www.nyheadache.com/blog/you-cant-get-magnesium-through-the-skin/ - Categories: Alternative Therapies, Migraine A report describing delivery of magnesium through the skin for the treatment of fibromyalgia has just appeared in the Journal of Integrative Medicine. The title of the report is, Effects of transdermal magnesium chloride on quality of life for patients with fibromyalgia: a feasibility study. It was conducted by doctors at the Mayo Clinic, which carries a certain amount of legitimacy. However, close reading of this report shows shockingly poor quality of this study. It is true that magnesium deficiency has been found in patients with fibromyalgia (especially if levels other than serum or plasma are measured, i. e. ionized or RBC) Fibromyalgia is a syndrome of unknown cause, which is characterized by chronic pain, fatigue, depression, and sleep disturbances. Some studies have found that the lower the level of magnesium, the more symptoms patients were having. There is an association between fibromyalgia and migraine headaches and those of our patients who have both conditions often report relief of both migraines and fibromyalgia with oral magnesium supplementation or intravenous infusions. Several companies promote products that promise to deliver magnesium into the body through the skin. The oldest one is Epsom salts, which is magnesium sulfate. Taking a warm bath with Epsom salts surely feels relaxing, but there is no evidence that magnesium penetrates through the skin. The Mayo clinic study enrolled forty postmenopausal female patients with the diagnosis of fibromyalgia. Each was given a spray bottle containing a 31% solution of magnesium chloride (and "a proprietary blend of trace elements")... --- ### Zecuity, a transdermal migraine patch is now available - Published: 2015-10-05 - Modified: 2015-10-05 - URL: https://www.nyheadache.com/blog/zecuity-a-transdermal-migraine-patch-is-now-available/ - Categories: Headache medications, New treatments Zecuity, a skin patch containing a migraine drug sumatriptan was approved by the FDA almost two years ago, but it became available (by prescription) only last month (see my previous post about Zecuity). The product is not available in retail pharmacies, only from a specialty pharmacy. The doctor who prescribes the patch will usually provide information on where to get it. Otherwise, go to zecuity. com, where you can find a section entitled Migraine Support Solutions. At this site you can verify that your insurance covers this product, get it shipped to you, and then get information on how to apply the patch. A discount coupon is also available on the site and it promises that the copay will be as low as $15. That is a good thing, because it looks like (on GoodRx. com) each patch costs $300. Yes, not $30, but $300 a piece, or $1,200 for a box of 4. I don't think too many people will be buying this patch if their insurance does not cover it. So, who is the best candidate for Zecuity? Half of migraine sufferers experience nausea and/or vomiting with their attacks. This makes the absorption of oral drugs, such as triptans (Imitrex, Maxalt, Zomig, etc) so slow as to make them ineffective. In such patients we try to bypass the stomach, which until now was possible to do with a nasal spray, suppository, or an injection. Sumatriptan (Imitrex) is available in the US in tablets, nasal spray and self-administered injections.... --- ### Meditation improves quality of life in drug-resistant epilepsy, reduces seizures - Published: 2015-09-30 - Modified: 2015-09-30 - URL: https://www.nyheadache.com/blog/meditation-improves-quality-of-life-in-drug-resistant-epilepsy-reduces-seizures/ - Categories: Alternative Therapies Epilepsy and migraines share many features and those with epilepsy have a higher risk of developing migraines, while those with migraines are more likely to develop epilepsy. Anti-epilepsy drugs are commonly used for the preventive treatment of migraines. A study just published in Neurology by Hong Kong researchers investigated the effectiveness of mindfulness-based therapy and social support in patients with drug-resistant epilepsy. It was a blinded and randomized trial. Sixty patients with drug-resistant epilepsy were randomly allocated to mindfulness therapy or social support (30 per group). Each group received 4 biweekly intervention sessions. They measured quality of life, as well as seizure frequency, mood symptoms, and neurocognitive functions. Following intervention, both the mindfulness and social support groups had an improved quality of life, but significantly more patients in the mindfulness group had a clinically important improvement. Significantly greater reduction in depressive and anxiety symptoms, seizure frequency, and improvement in delayed memory was observed in the mindfulness group compared with the social support group. The authors concluded that even short-term mindfulness therapy in patients with drug-resistant epilepsy provides significant benefits. It is surprising that even seizure frequency was reduced, although stress and lack of sleep can definitely increase seizure frequency. The study did not evaluate the quality or duration of sleep, but mindfulness meditation is know to improve sleep. It also improves migraine headaches (see my previous post). To start meditating you can download a very popular app, Headspace or read a book by BH Gunaratana, Mindfulness in Plain English or... --- ### Having migraines and fibromyalgia increases the risk of suicide - Published: 2015-09-28 - Modified: 2015-09-28 - URL: https://www.nyheadache.com/blog/having-migraines-and-fibromyalgia-increases-the-risk-of-suicide/ - Categories: Chronic migraine, Migraine, Pain, Science of Migraine About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a higher risk than the general population of additional disability related to depression, anxiety, irritable bowel syndrome, fibromyalgia, and other conditions. Fibromyalgia is a disorder of the central nervous system with increased brain excitability. It often manifests itself not only with muscle pains, but also fatigue, memory problems, and sleep and mood disturbances. Various studies estimate that anywhere from 2% to 8% of the general adult population suffers from fibromyalgia. Just like with migraine, women are more often affected than men. The likelihood of coexisting fibromyalgia increases with increasing frequency and severity of migraine attacks. Both migraine and fibromyalgia have been individually linked with increased risk of suicide. However, it is not clear that the risk is more than additive. A study just published in Neurology, reports that patients with migraine and coexisting fibromyalgia have a higher risk of suicidal ideation and suicide attempts compared with migraine patients without fibromyalgia. The study looked at 1,318 patients who attended a headache clinic. Of these patients, 133 or 10% were found to also have fibromyalgia. Patients with both conditions had more frequent, more severe, and longer-lasting migraine attacks as well as higher use of abortive medications. Compared with migraine patients who did not have fibromyalgia, those with fibromyalgia were more likely to report suicidal ideation (58% vs 24%) and suicide attempts (18% vs 6%). This report suggests that migraine and fibromyalgia may magnify... --- ### Emergency room treatment of migraines - Published: 2015-09-10 - Modified: 2015-09-10 - URL: https://www.nyheadache.com/blog/emergency-room-treatment-of-migraines/ - Categories: Migraine Narcotic (opioid) drugs are still widely prescribed by doctors in offices and emergency rooms. They are not only potentially addictive, but also are not effective for the treatment of migraine headaches. The guidelines of the American Academy of Neurology call for avoidance of opioids for migraine and headache. Doctors at the Cleveland Clinic developed a detailed, step-by-step algorithm that has dramatically reduced the use of narcotics for migraine management in the emergency room and prescribing of them upon discharge. In the three months before the algorithm was implemented 66% of migraine patients had received narcotics in the ER and 44% had discharge prescriptions for these medications. After algorithm implementation, the rates were 19% and 5%, respectively. The results of this study were presented at the 2015 annual meeting of the American Headache Society. The first step of the algorithm involves using a three-question screener for diagnosing migraine. The questions elicited the presence of nausea, sensitivity to light and inability to function normally. If two of these three symptoms were present, migraine diagnosis was made, provided no other serious condition was causing the headache. Doctors then evaluated for potential drug-seeking behavior and repeated ER visits without appropriate follow-up with the patient’s primary care provider. The first step was intravenous or intramuscular injection of a nonsteroidal anti-inflammatory pain medicine ketorolac (Toradol) plus a nausea drug, metoclopramide (Reglan) plus an anti-histamine, diphenhydramine (Benadryl). If the patient did not experience at least 50% pain relief, step 2 was a steroid medication, dexamethasone (Decadron) plus... --- ### Can an MRI scan of the brain diagnose migraine? - Published: 2015-09-05 - Modified: 2015-09-05 - URL: https://www.nyheadache.com/blog/can-a-brain-mri-diagnose-migraine/ - Categories: Migraine, Science of Migraine MRI scans of migraine sufferers are almost always normal. Occasionally we see white spots on the MRI, which can be also found in people with high blood pressure, dementia, and sometimes in perfectly healthy people (see my previous post on this). However, Mayo Clinic neurologists, led by Dr. Todd Schwedt reported being able to diagnose chronic migraines on the MRI scan. The accuracy of the diagnosis of those who had 15 or more headache days each month was fairly high - 84%. Patients with this frequency of attacks are considered to be suffering from chronic migraines. However, they could diagnose only 67% of those with episodic migraines (less than 15 headache days each month). The researchers used sophisticated software (FreeSurfer) that measured the surface area, thickness, and volume of 68 various brain regions and discovered that changes in 6 of these regions were predictive of migraine diagnosis. These 6 regions participate in pain processing in the brain and include the temporal lobe, superior temporal lobe, anterior cingulate cortex, entorhinal cortex, medial orbital frontal gyrus, and the pars triangularis. The software used in the study is freely available, but using it is time consuming and it is utilized only by researchers and not by any hospital or private MRI facilities. Their findings confirmed what until now was an arbitrary decision by headache experts to divide migraines into episodic and chronic ones with a 15 day cutoff. Ahother study by Dr. Richard Lipton and his colleagues at the Montefiore headache clinic has... --- ### Migraine drug may be highly effective for ovarian cancer by reducing stress effects - Published: 2015-08-24 - Modified: 2015-08-24 - URL: https://www.nyheadache.com/blog/migraine-drug-may-be-highly-effective-for-ovarian-cancer-by-reducing-stress-effects/ - Categories: Headache medications Propranolol was first introduced as a blood pressure drug 50 years ago and about 40 years ago it was discovered to be effective for the prevention of migraines. This is quite a remarkable drug because it is also used for rapid heart beat, heart attacks, tremor, and performance anxiety. Public speakers, musicians, and others take a small dose before performances and the drug reduces the physical stress responses such as sweating, tremulousness, weakness, and other. Blinded studies showed that musicians perform better when given a beta blocker compared to musicians who are given a placebo pill. Since the introduction of propranolol, another two dozen beta blockers have been developed. The newer, so called selective beta blockers (they attach to only one type of stress receptor) tend to have fewer side effects than propranolol and other non-selective beta blockers. Selective beta blockers can be given to patients with well-controlled asthma, while non-selective ones can cause an asthma attack. Recent studies have shown that chronic stress promotes the growth and spread of cancers. Researchers at MD Anderson Cancer Center decided to review the records of 1,425 patients who were treated for ovarian cancer at four hospitals between 2000 and 2010. Of these, 268 had been treated with a beta blocker while receiving chemotherapy for their ovarian cancer. The average survival of those who were on a beta blocker was 48 months compared to 42 months for those who were not. A more dramatic difference was found between those who were taking a... --- ### Headaches in pregnancy - when to worry - Published: 2015-08-23 - Modified: 2015-08-23 - URL: https://www.nyheadache.com/blog/headaches-in-pregnancy-when-to-worry/ - Categories: Headaches, Migraine New onset of headaches is always worrisome, but even more so in a pregnant woman. Neurologists at the Montefiore Headache clinic in the Bronx conducted a 5-year retrospective study of pregnant women who presented with an acute headache, were hospitalized, and received a neurologic consultation. The study was published in Neurology. The researchers identified 140 women with a mean age of 29 years. About 56% of these women presented in the third trimester. Primary headaches was present in 65% and secondary (due to an underlying disease) was found in 35% of women. The most common primary headache disorder was migraine and it was found in 91%, while the most common secondary headache disorder present in 51% was high blood pressure. Primary headaches included migraine without aura, seen in 37%, migraine with aura, in 24%, chronic migraine, in 6%, episodic tension-type headache, in 3%, chronic tension-type headache, in 1%, and primary stabbing headache, in 2% (this adds up to more than 65% because some had more than one type of headaches). Besides hypertensive disorders such as preeclampsia and eclampsia (18%), secondary headache diagnoses included pituitary adenoma or apoplexy in 4%, infections in 2%, stroke in 3%. Pregnant women with secondary headaches were less likely to have had headaches in the past (37% in secondary vs 13% in primary) and were more likely to have seizures (12% vs 0%), elevated blood pressure (55% vs 9%), fever (8% vs 0%), and an abnormal neurologic examination (35% vs 17%). Psychiatric comorbidity (presence of depression,... --- ### Smoking increases the risk of strokes in those with migraines - Published: 2015-08-12 - Modified: 2015-08-12 - URL: https://www.nyheadache.com/blog/smoking-increases-the-risk-of-strokes-in-those-with-migraines/ - Categories: Brain disorders, Migraine Migraine with aura is believed to increase the risk of strokes and possibly heart attacks, although the risk estimates vary from study to study. A recent study demonstrated no increase in the risk of strokes in people who suffered from migraine with and without aura, unless they were active smokers. The findings were published last month in the journal Neurology. Among the 1292 participants with an average age of 68 years there were 262 with migraine. There was no relationship between migraine (with or without aura) and stroke or heart attacks during the 11 year follow up period. However, among the 198 current smokers, there was a 3-fold increased risk for stroke. The lack of relationship between migraine with aura and stroke seen in previous studies is probably due to a relatively small sample size. I personally have seen two young women with migraine with aura who suffered a stroke. Both of them were smokers and were taking oral contraceptives. Estrogen contraceptives (even newer ones with lower estrogen content) further increase the risk of strokes in women who have migraine with aura. Progesterone-only pill does not increase the risk of strokes. Some women with severe endometriosis, heavy menstrual blood loss, and severe PMS sometimes have to accept a slight increase in the risk of strokes and take an estrogen-based contraceptive. However, if they smoke, they must stop smoking and also try to reduce other risk factors for strokes, if they are present. These include keeping hypertension and diabetes under control,... --- ### Testosterone and headaches - Published: 2015-08-07 - Modified: 2015-08-07 - URL: https://www.nyheadache.com/blog/testosterone-and-headaches/ - Categories: Chronic migraine, Cluster headaches, New treatments Fluctuations in the female hormone estrogen have been proven to be involved in triggering menstrual and perimenopausal migraine headaches. Testosterone levels have been reported to be low in men and women with cluster headaches. Testosterone replacement therapy seems to help these patients, when other standard treatments for cluster headaches do not. A study presented at the recent annual meeting of the American Headache Society reported on testosterone levels in men with chronic migraine headaches. A significant percentage of men with chronic migraines also have low testosterone levels. This study did not look at the effect of testosterone replacement therapy, but it is possible that it may help chronic migraine sufferers as it does those with cluster headaches. It seems prudent to check testosterone level in men with chronic migraine headaches who do not respond to standard approaches such as medications, Botox injections, magnesium, and other treatments. And if the level is low, replacement therapy should be tried. --- ### The dangers of Ayurvedic medicine - Published: 2015-08-03 - Modified: 2015-08-03 - URL: https://www.nyheadache.com/blog/ayurvedic-medicines-dangers/ - Categories: Alternative Therapies, Headache medications Ayurvedic medicine has many healthy aspects. However, a recent story on NPR described the risks involved with the traditional Ayurvedic medicines from India. A very high percentage of Ayurvedic supplements in the category called bhasmas sold in the US contains large amounts of lead and other toxic elements. There is a lot more to Ayurvedic medicine than these supplements, so it is important to separate dangerous parts from things like healthy diet, yoga, and other. Unfortunately, the US government does not regulate supplements, so there is always a question of safety of these products, especially those made outside the US. The one exception is products made in Germany, where supplements are as strictly regulated as drugs (please note that Petadolex, a butterbur product is made in Germany, but is not allowed for sale there). Many patients ask me about not only Indian but also Chinese herbal medicines, which are often combined with acupuncture and other treatment methods. As a rule, I recommend avoiding products made in China or India, where quality controls are very poor. Instead, you should buy products made by major US manufacturers, although they do not make many traditional Chinese and Indian products. However, you cannot always count on products sold in major US store chains either - recently, herbal products sold at Walgreens, WalMart, Target and GNC were found to have no active ingredients. Thankfully, there were no toxic ingredients in those products. The largest mass poisoning with a Chinese herbal dietary weight loss product occurred... --- ### Headaches are common in Ehlers-Danlos syndrome (lax ligaments, loose joints, etc) - Published: 2015-08-02 - Modified: 2015-08-02 - URL: https://www.nyheadache.com/blog/headaches-are-common-in-ehlers-danlos-syndrome-lax-ligaments-loose-joints-etc/ - Categories: Headaches, Migraine, Science of Migraine Ehlers-Danlos syndrome is a group of inherited disorders that are notable for excessive joint mobility with some people also having lax or stretchy skin, at times heart problems, and other symptoms. Headaches appear to be also very common. We see Ehlers-Danlos syndrome in many of our migraine patients and most of our headache specialist colleagues also notice this association. However, there are very few studies that confirm this observation. One such study was recently presented at the annual scientific meeting of the American Headache Society in Washington, DC. The research was performed at a cardiology clinic in Texas. They looked at the records of 139 patients who were referred to this clinic in a period of one year. Of these 139 patients with Ehlers-Danlos syndrome, 90% were women and the average age was 32. Out of 139 patients, 70% suffered from headaches - 32% had tension-type, 26% had migraines, 9% had chronic migraines and 2% had sinus headaches. These numbers are much higher than what is seen in the general population, confirming clinical observations by headache specialists. One form of Ehlers-Danlos syndrome affects not only joints and ligaments, but also the heart. So, when see a migraine patients who also appears to have Ehlers-Danlos syndrome, we also ask about symptoms related to the heart and if they are present refer such patients to a cardiologist. Another presentation at the same meeting described a 23-year-old woman with Ehlers-Danlos syndrome who suddenly developed headaches that would worsen on standing up and improve... --- ### Botox works for the elderly with headaches - Published: 2015-07-24 - Modified: 2015-07-24 - URL: https://www.nyheadache.com/blog/botox-works-for-the-elderly-with-headaches/ - Categories: Botox, Migraine I recently gave Botox injections to my oldest patient - an 96-year-old man who is otherwise in excellent mental and physical health has been suffering from daily severe cervicogenic (neck-related) headaches for many years. He had tried pain killers, nerve blocks, radiofrequency ablation (destruction) of nerves in his neck, all with no relief. A month after being treated with Botox he reported having almost no headaches. I have also given Botox to a number of patients with chronic migraines in their 70s and 80s. At the last scientific meeting of the American Headache Society Cleveland Clinic neurologists presented a report entitled, Safety and Efficacy of OnabotulinumtoxinA (Botox) for Chronic Migraines in the Elderly. They described 28 patients who were older than 65, had an average age of 73 and who were treated with Botox injections for their chronic migraine headaches. They compared the safety and efficacy of Botox injections in this group with that of 700 patients aged 18 to 65 who participated in PREEMPT II study of Botox for chronic migraine (one of the two studies that led to the FDA approval of Botox for chronic migraines, in which we also participated). There was no significant difference in side effects between the younger and the older groups, except for a slightly higher incidence of neck pain after the injections in the elderly. The improvement was also comparable - after Botox the elderly had 11 fewer headache days a month compared with 9 fewer days in the younger group. In... --- ### Internet self-diagnosing often gives you the wrong diagnosis - Published: 2015-07-23 - Modified: 2015-07-23 - URL: https://www.nyheadache.com/blog/internet-self-diagnosing-often-gives-you-the-wrong-diagnosis/ - Categories: Uncategorized 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... --- ### More warnings about NSAIDs (but not aspirin) - Published: 2015-07-18 - Modified: 2015-07-18 - URL: https://www.nyheadache.com/blog/more-warnings-about-nsaids-but-not-aspirin/ - Categories: Migraine, Uncategorized The Food and Drug Administration (FDA) has just released a new strengthened warning about NSAIDs. Prescription and over-the-counter NSAIDs (ibuprofen, naproxen, nabumetone, diclofenac, and other) are widely used for the treatment of pain including different types of headaches. They are fairly safe, especially in young healthy people who take NSAIDs for an occasional headache. However, the risk of strokes and heart attacks and heart failure is higher in older people, especially those with risk factors such as smoking, diabetes, hypertension, high cholesterol, and other. These risks are present with all NSAIDs, except for aspirin, which in fact can sometimes lower these risks. So, when in doubt, take aspirin, which is the main ingredient of my product, Migralex. Migralex is fast acting and is less likely to upset your stomach because of the buffering effect of magnesium. You can buy Migralex on Migralex. com, Amazon. com, and CVS stores. Here is the full text of FDA's announcement: Safety Announcement The U. S. Food and Drug Administration (FDA) is strengthening an existing label warning that non-aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) increase the chance of a heart attack or stroke. Based on our comprehensive review of new safety information, we are requiring updates to the drug labels of all prescription NSAIDs. As is the case with current prescription NSAID labels, the Drug Facts labels of over-the-counter (OTC) non-aspirin NSAIDs already contain information on heart attack and stroke risk. We will also request updates to the OTC non-aspirin NSAID Drug Facts labels. Patients taking... --- ### If you migraine requires injectable medicines, decline intravenous Benadryl - Published: 2015-07-06 - Modified: 2015-07-06 - URL: https://www.nyheadache.com/blog/if-you-migraine-requires-injectable-medicines-decline-intravenous-benadryl/ - Categories: Headache medications, injections, Migraine Hopefully, your doctor has given you many treatment options, so that you can manage even the most severe attacks at home (including Compazine or Phenergan anti-nausea suppositories for when you are very nauseated or vomit and Imitrex or sumatriptan injection pen for severe pain). However, many people end up in an ER, where they are usually given an injection or intravenous medications. Unfortunately, there is no standard protocol for the best way to treat an acute migraine that does not respond to oral medications. Ideally, the first step should be an infusion of magnesium, which can provide fast relief for up to 50% of patients. Some ER doctors give an injection of sumatriptan or a non-narcotic pain killer ketorolac (Toradol). Others will give a nausea drug which can also help pain such as metoclopramide (Reglan) or prochlorperazine (Compazine). An allergy medicine, diphenhydramine (Benadryl) is also a popular choice. A study by Dr. Benjamin Friedman and his colleagues at the Albert Einstein COllege of Medicine in the Bronx compared the efficacy of intravenous Reglan combined with Benadryl and Reglan without Benadryl. This was a double-blind study, meaning that neither the doctor giving the medicine nor the patient knew what was being given. They recruited 208 patients, which is a high enough number to produce reliable results. And the results showed that Reglan without Benadryl provided as much relief as with Benadryl. Benadryl is not a dangerous drug, but can make you drowsy, so if you can, ask the doctor not to... --- ### A new class of migraine drugs is on the horizon - Published: 2015-07-03 - Modified: 2015-07-03 - URL: https://www.nyheadache.com/blog/a-new-class-of-migraine-drugs-is-on-the-horizon/ - Categories: Migraine, New treatments For years researchers have tried to find ways to block various chemicals (neurotransmitters) released during a migraine attack, including serotonin, CGRP, nitric oxide, substance P, glutamate, and other. Triptans (such as IMitrex or sumatriptan), the first "designer" drugs for migraine, which were developed over 20 years ago, bind to a very specific subtype of serotonin receptor and are very effective in stopping a migraine attack. A very promising new type of migraine medications is being developed by at least four different companies - Alder, Amgen, Eli Lily, and Teva. These drugs are monoclonal antibodies against the CGRP molecule or the CGRP receptor. CGRP (calcitonin gene-related peptide) is widely distributed in the body and is involved in regulating blood vessel opening and in the function of the nervous system. All four companies developing these drugs recently presented the results of their phase II clinical trials and the data looks very promising. The antibody tightly binds to its target (CGRP molecule or receptor) with the effect lasting a month, or in case of the Alder drug, up to 6 months. The Alder drug is given every six months intravenously, while the other three, are given every month by an injection into the muscle. All four drugs appear to be very effective in preventing migraine attacks when compared to a placebo injection. And fortunately, at least so far, they all look very safe. However, in phase II trials only a couple of hundred patients are treated and we need to await the results... --- ### An update on closing PFO (a heart defect) to treat migraines - Published: 2015-06-24 - Modified: 2015-06-24 - URL: https://www.nyheadache.com/blog/an-update-on-closing-pfo-a-heart-defect-to-treat-migraines/ - Categories: Migraine, New treatments An opening between the left and the right side of the heart, called patent foramen ovale (PFO), is found in 25% of the general population. It has been found to be more common in people who suffer from migraines. A large PFOs can cause shortness of breath, heart failure, and strokes and they are usually closed surgically. Several companies developed a device to close this opening without open heart surgery, but rather by inserting an umbrella-like device through a vein in the groin. The manufacturers of these devices have conducted clinical trials in the hope of preventing migraines by closing the PFO. The results so far have been mixed with some studies showing improvement in migraines and some showing no benefit. A study just presented at the annual meeting of the American Headache Society by Dr. Andrew Charles of UCLA and his colleagues reported on one such trial. This study was blinded, with 107 patients having a sham procedure (the catheter was inserted into the groin vein, but the PFO was not closed) and 123 having their PFO closed. Overall, there was a significant reduction in headache days in the closure group (-3. 4 days) compared with the sham group (-2. 0 days), however there was no difference in the primary efficacy endpoint of the number of patients with 50% or more reduction in migraine attacks. A subset of patients did particularly well compared to the sham group - patients who had migraine aura with the majority of their migraine... --- ### Treating concussion in children - Published: 2015-06-22 - Modified: 2015-06-22 - URL: https://www.nyheadache.com/blog/treating-concussion-in-children/ - Categories: Alternative Therapies, Botox, Chronic migraine, Head trauma Several presentations at the annual meeting of the American Headache Society held in Washington DC last weekend discussed the treatment of post-concussion symptoms in children (everything below also applies to adults). Among many topics, the speakers addressed the question of aerobic exercise after the concussion. Most experts agree that starting physical exercise too early can worsen the symptoms and delay recovery. At the same time, because aerobic exercise has so many benefits for the brain, it is prudent to begin aerobic exercise 2 to 4 weeks after the concussion. The child should begin exercising for short periods of time and at low intensity. Exercise should be stopped as soon as symptoms, such as headache or dizziness worsen. Brisk walking could be the first activity to be tried. The ideal duration is about 30 minutes and when this goal is achieved, the intensity of exercise can be gradually increased. As far as the very common cognitive problems after a concussion, the experts also agreed that complete cognitive rest is not helpful. Just like with physical exercise, it is best to begin mild activities, such as reading for pleasure, and then slowly increase the load, as tolerated. Several scientific presentations reported that the most common type of headaches that occurs after a concussion is migraine. When these post-concussion migraines last for more than 3 months and occur on more than 15 days each month, they are considered to be chronic migraines. The treatment of post-concussion chronic migraines is the same as the... --- ### Zomig nasal spray is also approved for adolescents - Published: 2015-06-21 - Modified: 2015-06-21 - URL: https://www.nyheadache.com/blog/zomig-nasal-spray-is-also-approved-for-adolescents/ - Categories: Headaches in children Zolmitriptan is one of seven triptans available in the US and it comes in tablets (Zomig), orally disintegrating tablets, that is tablets that melt in your mouth (Zomig ZMT), and nasal spray (Zomig NS). The nasal spray was just approved for children 12 and older. It is available in 2. 5 mg and 5 mg strength and the 2. 5 mg is the starting dose, but kids are allowed to take 5 mg dose up to twice a day. My previous post mentioned the approval of Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) in adolescents. However, Zomig is the only triptan in a nasal spray form (the second triptan available in a nasal spray is sumatriptan or Imitrex) approved in the US for children. The advantages of this form of drug delivery is that it tends to have faster onset of action and it can be taken when severe nausea or vomiting precludes the use of oral medications. Sumatriptan nasal spray is approved in kids in Europe, so there is no reason not to use it as well, however Zomig spray seems to be better than Imitrex spray. The amount of fluid in a single dose of Zomig is less than that in Imitrex and the spray droplets are of smaller size, leading to better retention of fluid in nasal passages and better absorption. Also, many patients complain of a very unpleasant taste with Imitrex spray, although this can be avoided by sucking on a hard candy while... --- ### Another existing drug is approved for pediatric migraine - Published: 2015-06-08 - Modified: 2015-06-08 - URL: https://www.nyheadache.com/blog/another-existing-drug-is-approved-for-pediatric-migraine/ - Categories: Headaches in children A combination pill containing 10 mg of sumatriptan with 60 mg of naproxen sodium was just approved by the FDA for children aged 12 to 17. This combination in a higher dose (85 mg of sumatriptan and 500 mg of naproxen) has been available for adults for the past 7 years. This recent FDA approval allows children to take up to one adult strength tablet a day. It is good to have a smaller size tablet for kids. However, there is a big issue of cost. We don't yet know what the pediatric strength tablet will cost, but a single tablet of the adult strength Treximet is $75. Yes, $75 for one tablet, even with a coupon you can get at GoodRx. com and $80 or more without a coupon. Very few insurance companies will pay for Treximet because you can get a generic tablet of sumatriptan (Imitrex), 100 mg for $1. 50 and a tablet of naproxen, 500 mg for 7 cents. So, make-your-own Treximet will cost you $1. 57. A very rare patient will tell me that they get better relief from the branded pill, which is possible because of the inactive ingredients, speed of onset and occasionally poor quality generics (I wrote about this problem in a previous post). However, such patients are very few. Besides Treximet, we have two other triptans approved for migraines in children. Rizatriptan (Maxalt, Maxalt MLT) is approved by the FDA for children and adolescents 6 to 17 years of age and... --- ### Transcranial magnetic stimulation for migraine with medication overuse headache - Published: 2015-06-01 - Modified: 2015-06-01 - URL: https://www.nyheadache.com/blog/transcranial-magnetic-stimulation-for-migraine-with-medication-overuse-headache/ - Categories: Alternative Therapies, Migraine Transcranial magnetic stimulation (TMS) was approved by the FDA at the end of 2013 (see my earlier post) but it has not yet become available. This approval was for the treatment of acute migraine. A new study just presented at the International Headache Congress suggests that TMS could be effective for the preventive treatment of migraines with medication overuse headache. The study included only 28 patients and it was not a blinded study. However, these patients were severely affected and failed several other treatments. They were instructed to use the TMS device twice a day every day with an additional treatment at the time of a headache. Treatment lasted for at least 3 months, with an option to continue for another 3 months. Of the 28 patients, 24 (86%) reported a reduction in their days of acute medication use per month, while 2 patients reported an increase in acute medication use. Nineteen patients (68%) experienced fewer migraine days per month, and 7 of the 19 had a 50% or greater reduction in migraine days. The number of patients with pain severity rated as excruciating or severe dropped from 19 at baseline to 3 at 3 months (84% reduction). Headache attack duration decreased in 15 patients, remained unchanged in 9, and increased in 4. The disability score (HIT-6) was severe at the beginning of the study in 26 of 28 participants. After 3 months, only 18 had severe disability. The benefit was seen in patients who had migraines with and without... --- ### Neuro-psychological effects of cluster headaches - Published: 2015-05-29 - Modified: 2015-05-29 - URL: https://www.nyheadache.com/blog/neuro-psychological-effects-of-cluster-headaches/ - Categories: Cluster headaches We are again in a cluster season. We do not see any cluster headache patients for months and then dozens come in within weeks. It is not allergies, barometric pressure or any other earth phenomena that trigger cluster headaches in so many people at once. It has been speculated that solar activity may be the trigger and I just checked the NASAs Solar Dynamics Observatory website and found that the sun has "active regions galore". I wrote about solar activity as a possible culprit last October when we had another wave of cluster patients. Unfortunately, there is not much we can do about the sun, but we do have many effective treatments for cluster headaches, including intravenous magnesium, occipital nerve blocks, oxygen, injectable sumatriptan, verapamil, and for chronic cluster headaches, Botox injection. A recent study by British neurologists in the journal Headache described the severe impact of cluster headaches on quality of life and neuro-psychological symptoms. The researchers found that cluster headache patients had normal intelligence and executive functions, but had worse working memory, disturbance of mood, and poorer quality of life compared with healthy controls. Similar findings have been found in patients with other chronic pain conditions as well. It is most likely that cognitive impairment and mood changes can be reversed with effective treatment of pain. --- ### Anti-histamine diamine oxydase for the prevention of migraines - Published: 2015-05-22 - Modified: 2015-05-22 - URL: https://www.nyheadache.com/blog/anti-histamine-diamine-oxydase/ - Categories: Alternative Therapies Another supplement to consider for the preventive treatment of migraine headaches is diamine oxidase (DAO). It is an enzyme that breaks down histamine. Histamine is released during an allergic reaction and is present in many foods. It is one of the neurotransmitters that is involved in the process of migraine. A quarter of the population has insufficient amounts of DAO, which leads to inefficient metabolism of histamine. The largest amounts of DAO in the body are found in the intestines and the kidneys. A group of Spanish neurologists published a study that showed that of 137 patients with migraines, 119 (87%) showed impaired activity of the enzyme. The normal enzyme activity is a score of at least 80 histamine-degrading units /mL. In a survey which was conducted in 2006 and again in 2012, migraine symptom scores correlated with enzyme activity. Symptom scores rose progressively as enzyme activity dropped below 80 HDU/mL, with scores almost twice as high in the 30-40 HDU/mL range compared with enzyme activity >80 HDU/mL. Dr. Izquierdo and his colleagues in Barcelona conducted a double-blind, placebo-controlled trial of DAO oral supplementation, for the prevention of migraines in patients with DAO activity less than 80 HDU/mL. Participants were men or women age 18 to 60 years old with an attack within the previous 6 months. Most of the patients were women, with only 8 men in each group. The supplement contained 4. 2 mg of DAO which participants took with a glass of water before breakfast, lunch, and... --- ### Neck weakness and tension-type headaches - Published: 2015-05-13 - Modified: 2015-05-13 - URL: https://www.nyheadache.com/blog/neck-weakness-and-tension-type-headaches/ - Categories: Alternative Therapies, Botox, Headaches - Tags: Botox, headache tension-type headache, isometric exercise, migraine, neck muscles, neck pain, shoulder muscles Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia. Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness. The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month). The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness. Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers. This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to... --- ### New research on how Botox relieves chronic migraines and how to predict who will respond to Botox - Published: 2015-05-09 - Modified: 2015-05-09 - URL: https://www.nyheadache.com/blog/new-research-on-how-botox-relieves-chronic-migraines-and-how-to-predict-who-will-respond-to-botox/ - Categories: Botox, Migraine While Botox (OnabotulinumtoxinA) has been shown to be effective in treating chronic migraines, its exact mechanism of action is not clear. Initially, we thought that it works by relaxing muscles in the forehead, temples and the back of the head and neck. However, this is not likely for several reasons. One reason is that some people have pain at the top of their heads, where there are no muscle, and injecting those areas leads relief of pain. Another reason is that Botox seems to be effective in relieving different nerve pains, such as that of shingles (post-herpetic neuralgia), trigeminal neuralgia, and other. Botox blocks the release of acetylcholine, a neurotrasmitter that is normally released into the space between the nerve ending and the muscle (synapse), making the muscle contract. We also know that Botox blocks the release of other neurotransmitters, which may be responsible for its pain-relieving properties. One of these chemical messengers is CGRP (calcitonin gene-related peptide). A study just published in the journal Pain by Spanish researchers showed that CGRP level is increased in blood of patients with chronic migraine even when they are not having a migraine attack. CGRP levels were determined in 83 patients with chronic migraines (average age 44 years; 94% females) before and 1 month after treatment with 155 to 195 units of Botox. CGRP levels after Botox treatment were significantly lower as compared with CGRP levels obtained before Botox treatment. Pretreatment CGRP levels in responders were significantly higher than those seen in nonresponders.... --- ### Topical cream for migraine - Published: 2015-05-05 - Modified: 2015-05-05 - URL: https://www.nyheadache.com/blog/topical-cream-for-migraine/ - Categories: Alternative Therapies, Migraine, New treatments A topical cream seems to be effective in treating migraine headaches. Achelios Therapeutics announced results from a Phase IIa placebo-controlled clinical trial in moderate and severe migraine sufferers treated with Topofen, the company’s proprietary topical anti-migraine therapy. This is a well-known non-steroidal anti-inflammatory drug (NSAID) ketoprofen, which is applied to the face and seems to provide relief for patients suffering from acute migraine. The results of the clinical trial were presented at the American Academy of Neurology annual meeting in Washington, D. C. Surprisingly, this study showed that it may be possible to relieve severe migraine with a topical application to facial nerve endings. Topical application avoids potentially serious side effects of NSAIDs, such as stomach bleeding and ulcers. The randomized, crossover, double-blind, placebo-controlled study involved only 48 adults with a history of episodic migraine with and without aura. Of the severe migraine patients, 77 percent experienced relief of pain and migraine-associated symptoms and 45 percent had sustained pain relief from two to 24 hours compared to 15 percent on placebo. Also, 50 percent of patients who treated their severe pain with Topofen were pain free at 24 hours compared to 25 percent of placebo-treated patients. Some patients experienced application-site irritation, which was mild or moderate in severity. That was the only reported side effect, which resolved quickly. Such a small study does not prove that this treatment is in fact effective. A typical drug trial required for an FDA approval usually involves hundreds of patients. However, you do not... --- ### Video of Botox injections for chronic migraine with TMJ - Published: 2015-05-01 - Modified: 2015-05-01 - URL: https://www.nyheadache.com/blog/video-of-botox-injections-for-chronic-migraine-with-tmj/ - Categories: Botox, injections, Migraine, TMJ The FDA-approved protocol for Botox injections for chronic migraines calls for 31 injections with 155 units of Botox. This is the protocol we teach young doctors and new injectors. However, just like with any other medication, doctors are allowed to go "off label", meaning that we can inject Botox for headache types and pain conditions other than chronic migraine (in which case insurance will usually not pay) and we can also adjust the number of injection sites and the total dose of Botox when treating patients with chronic migraines. I have a fair number of patients who need up to 200 units and on a very rare occasion even 300. The maximum dose allowed during a single treatment is 400 units, which is usually needed when injecting large muscles in arms and legs, like in cerebral palsy or spasticity due to strokes. This YouTube video shows injections for chronic migraines with additional injections into the masseter muscles (at the corner of the jaw) to treat TMJ syndrome, which is also called temporomandibular disorder. Injections of the temporalis muscles in the temples, which are also involved in chewing and which are always injected for chronic migraines, also helps relieve TMJ syndrome. --- ### Everyone should check their Vitamin D level - Published: 2015-04-22 - Modified: 2015-04-22 - URL: https://www.nyheadache.com/blog/everyone-should-check-their-vitamin-d-level/ - Categories: Alternative Therapies Low vitamin D level predicts larger stroke size and poor outcome, according to a new study by University of Massachusetts researchers. They examined data on 96 consecutive patients with stroke and found a strong inverse correlation between the level of vitamin D and the size of the stroke. This is not surprising since vitamin D seems to be very important for the normal functioning of the nervous system. In a previous post I mentioned a study that showed an inverse correlation between vitamin D level and relapses of multiple sclerosis. Such correlation has been also found with migraine headaches and other major diseases. Yes, all these studies are correlational and do not prove that taking vitamin D will prevent any of these conditions. But there is no evidence at all that taking vitamin D to maintain your blood level in the normal range has any side effects. The stroke study was done only in caucasian patients and we know that blacks may need lower levels of vitamin D than caucasians, at least as measured by the standard blood test. This test is not very reliable since it measures the total level of vitamin D, while only the free portion of it is biologically active. To be safe, try to aim to have vitamin D level at least in the middle of normal range, which is from 30 to 100. Many people take the recommended 400 unit dose of vitamin D, but still have low levels in their blood. It is... --- ### Yet another side effect of Topamax - Published: 2015-04-20 - Modified: 2015-04-20 - URL: https://www.nyheadache.com/blog/yet-another-side-effect-of-topamax/ - Categories: Headache medications, Migraine Topiramate (Topamax) is a drug used for the prevention of migraine headaches (and epilepsy) in adults and last year it was also approved for adolescent migraine sufferers. This drug is notorious for causing cognitive side effects, kidney stones,osteoporosis, overheating, and many other side effects. It is contraindicated (just like another migraine drug, Depakote) in pregnancy because of the risk of birth defects. A new report published in the journal Pediatrics documents an increased risk of eating disorders in adolescents who take Topamax. This report describes 7 female teenagers who developed an eating disorder or whose eating disorder got worse on topiramate. Considering that we have many other effective preventive drugs for migraine headaches, topiramate should be used only when several other treatments fail. --- ### Chronic migraine is associated with dry eyes - Published: 2015-04-12 - Modified: 2015-04-13 - URL: https://www.nyheadache.com/blog/chronic-migraine-is-associated-with-dry-eyes/ - Categories: Alternative Therapies, Migraine, Science of Migraine Chronic migraine sufferers appear to be more likely to have dryness of their eyes, according to a study by ophthalmologists at the University of Utah, which was published in the journal Headache. The researchers used sophisticated techniques to measure tear production, corneal sensitivity, dry eye questionnaire, and other tests. The results of these tests were compared in migraine sufferers and healthy control subjects. A total of 19 chronic migraine patients and 30 control participants completed the study. The nerve fiber density was significantly lower in the corneas of migraine patients compared with controls. All migraine sufferers had symptoms consistent with a diagnosis of dry eye syndrome. The researchers plan to continue studying the interrelationships between migraine, corneal nerve architecture, and dry eye. Similar findings in patients with episodic migraine were published by a group of Turkish doctors in the journal Cornea in 2012. Migraine sufferers and their doctors should be aware of this correlation since irritation caused by dry eyes could potentially trigger a migraine. It is possible that some migraines can be prevented by using over-the-counter and prescription eye drops or, in severe cases, eye inserts (Lacrisert). High doses of omega-3 fatty acids have been reported to help dry eyes and omega-3 fatty acids have also been reported to relieve migraines. --- ### A fertility drug relieves cluster headaches - Published: 2015-04-04 - Modified: 2015-04-04 - URL: https://www.nyheadache.com/blog/a-fertility-drug-relieves-cluster-headaches/ - Categories: Cluster headaches Cluster headaches cause more severe pain than any other type of headaches. Some patients even call them suicide headaches because they provoke thoughts of suicide. The name comes from the fact that they occur in clusters - every day for a couple of months and then they go away for a year or longer. In those with chronic cluster headaches they never go away. The headaches are brief - anywhere from 30 minutes to 3 hours. They are always one-sided, with pain usually around the eye, and are accompanied by tearing, nasal congestion, and sometimes restlessness. More men than women suffer from them. Treatment of cluster headaches can be very effective. A 10-day course of prednisone or an occipital nerve block can abort the entire cluster. We also have preventive drugs, such as a blood pressure medicine, verapamil (used in high doses), epilepsy drugs, and lithium. These are taken daily to prevent headaches. To treat individual attacks, inhalation of 100% oxygen under high flow, zolmitriptan nasal spray (Zomig NS), and sumatriptan (Imitrex) injections can be true life savers. Some of the alternative therapies that have been reported to help include melatonin, intranasal capsaicin (hot pepper extract), and an herbal product, Boswellia (Nature's Way is a good brand for herbals). Unfortunately, there are some cluster headache sufferers who do not respond to any of these treatments. We even treated some patients with intravenous histamine, which requires hospital admission and two of my patients were implanted with a vagus nerve stimulator (with... --- ### A new name for chronic fatigue syndrome - Published: 2015-04-01 - Modified: 2015-04-01 - URL: https://www.nyheadache.com/blog/a-new-name-for-chronic-fatigue-syndrome/ - Categories: Brain disorders, Chronic migraine, Migraine, Science of Migraine Chronic fatigue syndrome sufferers have endured years of neglect and sometimes ridicule. The condition has even been called "yuppie flu". Informal surveys indicate that half of the doctors do not believe that this is a true physical disease. This is despite the fact that 1 to 2 million Americans have been diagnosed with this condition. In a previous post I mentioned that patients with chronic fatigue are much more likely to suffer from migraines - they occur in 84% of patients. Tension-type headaches were found in 81% and only 4% had no headaches at all. There is an overwhelming amount of evidence that chronic fatigue syndrome is a physical condition and one of the names that has been used by doctors is Myalgic Encephalomyelitis. The Institute of Medicine recently issued a report, Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness, which proposes a new name - Systemic Exertion Intolerance Disease, or SEID. The name indicates that the main characteristic of the disease is the fact that exertion of any kind - physical, cognitive, or emotional - can affect many different body organs and impair normal functioning and reduce quality of life. The report also states that to make this diagnosis, the symptoms have to be chronic, frequent and moderate or severe in intensity. The experts suggest that patients could be diagnosed with both SEID and Lyme disease, fibromyalgia, or another disease that causes fatigue. Currently, if a patient suffers from Lyme disease or another fatiguing condition, chronic fatigue is not... --- ### Opiates (narcotics) increase ER stay in patients with headaches - Published: 2015-03-25 - Modified: 2015-03-25 - URL: https://www.nyheadache.com/blog/opiates-narcotics-increase-hospital-stay-in-patients-with-headaches/ - Categories: Headaches, injections, Migraine Narcotics are not only ineffective for the treatment of headaches, but they can also make headaches worse and transform an episodic migraine into chronic. A study mentioned in a previous post showed that more than half of migraine sufferers who went to an ER were given a narcotic. A new study recently published in the journal of the International Headache Society, Cephalalgia showed that if patients presenting with a headache to an ER are treated with an injection of opiates (narcotics) they will stay in the hospital longer than if no narcotics are given. This treatment also leads to an increased risk of return visits to the emergency department within seven days. The study was conducted by two neurologists, Dr. McCarthy at Puget Sound VA Healthcare System in Seattle and Dr. Cowan at Stanford University in California. They examined charts of 574 people and discovered that 23% received a narcotic when they were seen at an emergency department. Only 53% were given an injection of a drug recommended by a published consensus of headache experts. These include sumatriptan (Imitrex, the only injectable triptan), prochlorperazine (Compazine), metoclopramide (Reglan), chlorpromazine (Thorazine), ketorolac (Toradol), aspirin, acetaminophen, and dihydroergotamine. The remaining 24% were given an injection of another non-narcotic drug. Patients who were given opiates were 4 times more likely to have a long stay, compared with patients given first-line recommended medications. 69 participants had at least one readmission for headache, of whom 20 returned to the emergency department within seven days. Interestingly, patients... --- ### More evidence that non-celiac gluten sensitivity is real - Published: 2015-03-18 - Modified: 2015-03-18 - URL: https://www.nyheadache.com/blog/more-evidence-that-non-celiac-gluten-sensitivity-is-real/ - Categories: Alternative Therapies The existence of gluten sensitivity has been long denied by the mainstream medical establishment. A study described in a previous post over two years ago documented higher incidence of migraine headaches in people with gluten sensitivity than in those with celiac disease (56% vs 30%). Celiac disease, which is a severe autoimmune disease caused by wheat allergy, affects about 3 million Americans, but the estimates of gluten sensitivity run as high as 18 million. Billions of dollars of gluten-free products are sold in the US and they can be found in almost every grocery store. A recent study by the National Institutes of Health led by Dr. Sabatino examined 59 patients who did not have celiac disease, but believed gluten-containing food was causing them intestinal and other symptoms. Every day for one week these people were randomly given capsules containing 5 grams of gluten or a placebo of rice starch. After only one week, those who were taking the gluten pills reported a significant difference in symptoms compared to those who took non-gluten placebo pills. In addition to intestinal pains, they felt abdominal bloating, a foggy mind, depression, and canker sores. Clearly, they didn’t know if they were taking the gluten pill or the placebo, but their symptoms were very revealing and proved the existence of gluten sensitivity. The bottom line is, if you have stomach pains, bloating, foggy mind, depression, headaches, malaise, and other symptoms, it may be worth going on a gluten-free diet for a couple of weeks... --- ### Migraine headaches in children are poorly treated - Published: 2015-03-11 - Modified: 2015-03-11 - URL: https://www.nyheadache.com/blog/migraine-headaches-in-children-are-poorly-treated/ - Categories: Headaches in children Doctors in St. Louis, MO examined how well headaches are treated in children. There has been little research about how well doctors in the US care for children and teens with migraine and if the treatment is consistent with evidence-based guidelines. They also assessed how often opioids (narcotics) are prescribed for children with migraines. The study used Electronic Health Record data to look at how almost 40,000 children and teens with migraine who presented to primary care providers, specialty care, or Emergency Room or Urgent Care (ER/UC) across four states in metropolitan and non-metropolitan areas were treated from 2009-2014. The results showed that among children and teens presenting for care for migraine or likely migraine, nearly half (46%) were not prescribed or recommended any medication. Only one in six (16%) were prescribed or recommended an evidence-based medication. Among those who received medication, nearly one in six (16%) were prescribed an opiod (narcotic), and these numbers are even higher among teens 15-17. The findings also revealed that the odds of getting an evidence-based medication were significantly higher if migraine was diagnosed, and the odds of getting any medication (evidence-based or not) were higher in non-metropolitan areas. Children and teens treated in a specialty care setting or the ER/UC were twice as likely to be prescribed an opioid than if treated in primary care. The authors concluded that "Too many children who present for migraine or likely migraine are not getting any medication for their pain. Too few are receiving care consistent... --- ### Effective treatment of migraine attacks prevents chronic migraines - Published: 2015-03-06 - Modified: 2015-03-06 - URL: https://www.nyheadache.com/blog/effective-treatment-of-migraine-attacks-prevents-chronic-migraines/ - Categories: Chronic migraine, Headache medications, Migraine Several million Americans suffer from chronic migraines, headaches that occur on at least half of the days and often daily. A new study suggests one of the way to prevent this disabling disease. In the American Migraine Prevalence and Prevention Study, people with episodic migraines (those occurring on less than half of the day each month) completed the Migraine Treatment Optimization Questionnaire and provided outcome data in 2006 and in 2007. They were asked four questions about the efficacy of their acute migraine therapies and the responses were divided into: very poor, poor, moderate, and maximum treatment efficacy. Among 5,681 study participants with episodic migraine in 2006, 3. 1% progressed to chronic migraine in 2007. Only 1. 9% of the group with maximum treatment efficacy developed chronic migraine. Rates of new-onset chronic migraine increased in the moderate treatment efficacy (2. 7%), poor treatment efficacy (4. 4%), and very poor treatment efficacy (6. 8%) groups. The very poor treatment efficacy group had a more than 2-fold increased risk of new-onset chronic migraine compared to the maximum treatment efficacy group. The authors concluded that inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of 1 year. They speculated that improving acute treatment outcomes might prevent chronic migraine. However, they also said that reverse causality cannot be excluded, meaning that it is possible that those who would go on to develop chronic migraine had poor response to acute treatment because their headaches were worse and... --- ### New dietary guidelines can lead to more headaches - Published: 2015-02-22 - Modified: 2015-02-22 - URL: https://www.nyheadache.com/blog/new-dietary-guidelines-can-lead-to-more-headaches/ - Categories: Alternative Therapies, Chronic migraine The new dietary guidelines issued by a government advisory committee have many positive changes from the old guidelines. These include a focus on food rather than nutrients. For example, there is no proposed limit on the intake of cholesterol and eating eggs is encouraged. There is an emphasis on eating less meat and more fruits and vegetables and on limiting sugar intake. All these recommendations apply to headache sufferers as well. However, the guidelines are advising people to increase their consumption of coffee. They suggest that 3 to 5 cups a day can be part of a healthy diet because there is evidence that coffee may reduce risk of type 2 diabetes and heart disease (and possibly Parkinson's disease). This is because coffee contains flavonoid compounds that have health benefits. However, coffee and caffeine in general are proven to cause worsening of headaches. As little as 2-3 cups a day can worsen headaches by causing caffeine withdrawal. Flavonoids are present in many fruits and vegetables, so it is not necessary to drink coffee to benefit from these compounds. If you are prone to having headaches it is better to limit your caffeine intake to one cup of coffee a day. --- ### Multivitamins reduce mortality in women, but only if combined with minerals. - Published: 2015-02-18 - Modified: 2015-02-18 - URL: https://www.nyheadache.com/blog/multivitamins-reduce-mortality-in-women-but-only-if-combined-with-minerals/ - Categories: Alternative Therapies, Migraine The Journal of Nutrition just published a study that suggests life-extending benefits of taking vitamin and mineral supplements. Multivitamin with minerals products are the most commonly used supplements in the United States, followed by multivitamin products without minerals. While prior studies did not show an effect of such supplements in preventing deaths from cardiovascular disease, however, no previous trial looked for potential benefits just in women. This new study examined the effect of a multivitamin with or without minerals on 8678 men and women. An adjustment was made for many potential confounders, that is factors that could have influenced the results, including age, race, education, weight (body mass index), alcohol, aspirin use, serum lipids (cholesterol, etc), blood pressure, and blood glucose. The researchers observed no significant association between mortality due to cardiovascular disease in users of supplements compared with nonusers. However, when users were classified by the reported length of time products were used, a significant association was found with the use of multivitamins with minerals if they were taken for more than three years, compared with nonusers. This finding applied only to women and only to multivitamin products that also included minerals. Magnesium is one of the minerals which is always included in combination vitamin products. Many studies have shown a beneficial effect of magnesium on cardiovascular and other causes of death in both women and men. And, of course, taking magnesium prevents migraine headaches since magnesium deficiency is found in up to 50% of migraine sufferers. --- ### More salt leads to more headaches - Published: 2015-02-13 - Modified: 2015-02-13 - URL: https://www.nyheadache.com/blog/more-salt-leads-to-more-headaches/ - Categories: Alternative Therapies Eating more salt leads to more headaches, according to a study published in BMJ Open last December. In a multicentre feeding study with three 30-day periods, 390 participants were randomised to the DASH (a healthy diet that was expected to lower blood pressure) or control (regular, not very healthy) diet. On their assigned diet (DASH and regular), participants ate food with high sodium during one period, intermediate sodium during another period and low sodium during another period, in random order. The occurrence and severity of headache were recorded at the end of each feeding period. The researchers did not attempt to determine which type of headaches people were suffering from, but it is safe to assume that the majority suffered from tension-type and migraine headaches. The average age was 48 and 57% were women. The occurrence of headaches was similar in DASH versus control, at high, intermediate and low sodium levels. By contrast, there was a lower risk of headache on the low, compared with high sodium level, both on the control and DASH diets. Obviously, there are many reasons to eat a healthy diet, but prevention of headaches is not one of them. Interestingly, there was no correlation between elevated blood pressure and headaches. The authors concluded that reduced sodium intake was associated with a significantly lower risk of headache, while dietary patterns had no effect on the risk of headaches in adults. This study showed that reducing dietary sodium intake offers a new approach to preventing headaches. P.... --- ### Don't take migraine drugs Depakote and Topamax when pregnant - Published: 2015-02-10 - Modified: 2015-02-10 - URL: https://www.nyheadache.com/blog/dont-take-migraine-drugs-depakote-and-topamax-when-pregnant/ - Categories: Alternative Therapies, Botox, Headache medications Epilepsy drugs Depakote and Topamax are two of only four drugs approved by the FDA for the prevention of episodic migraines (the other two are blood pressure medications in the beta blocker family, propranolol and timolol, while Botox is the only drug approved for the preventive treatment of chronic migraines). However, these two drugs are contraindicated in pregnancy. Considering that the majority of migraine sufferers are young women, this is a topic that needs to be revisited regularly, especially when additional data appears. A new study just published in the journal Neurology followed children in the British National Health Service whose mothers suffered from epilepsy and who were taking Depakote (valproate) or Tegretol (Carbamazepine) or Lamictal (lamotrigine). Only Depakote caused a significant drop in IQ in children whose mother was taking more than 800 mg of Depakote a day. Children whose mother took less than 800 mg (the usual dose for migraines is 500 mg, but sometimes 1,000 mg is needed) did not have a lower IQ, but had impaired verbal abilities and a 6-fold increase in needing educational intervention. Unfortunately, Tegretol and Lamictal are not effective for the prevention of migraine headaches, while Topamax which is effective, can cause birth defects. Neurontin (gabapentin) is a relatively benign medication, which is safe in pregnancy and it is somewhat effective in the prevention of migraines, including chronic migraines. Ideally, all drugs should be avoided in pregnancy. We usually advise non-drug approaches, including regular sleep, healthy diet, exercise, biofeedback or meditation, and... --- ### Be careful where you buy your herbal products! - Published: 2015-02-09 - Modified: 2015-02-09 - URL: https://www.nyheadache.com/blog/be-careful-where-you-buy-your-herbal-products/ - Categories: Alternative Therapies I recommend several supplements to my headache patients. However, the supplement industry is not regulated by the FDA and a few days ago another scandal has erupted. The attorney general of New York ordered Walgreens, WalMart, Target and GNC to stop selling their store brand herbal supplements. His investigation revealed that most of the supplements contained no active ingredients. In case of WalMart, only 4% of their herbal products contained an active ingredient. The tests involved Gingko biloba, St. John’s Wort, Ginseng, Garlic, Echinacea, Saw Palmetto, and Valerian root. Of the herbal supplements for headaches, I recommend Boswellia and Feverfew made by a high quality manufacturer, Nature's Way. I do not recommend butterbur, even though I participated in a large study that showed its efficacy in preventing migraine headaches. Butterbur contains several toxic chemicals, which can cause liver damage and other serious problems. Petadolex brand of butterbur claims to be free of these toxic ingredients, but the product is not allowed to be sold in Germany where it is manufactured. Here is my previous post on Petadolex. Non-herbal supplements such as CoQ10 could also present a problem. For years, I have been recommending WalMart's brand because it was much less expensive than any other brand and because I assumed that such a large company will have strict quality controls. Now I am thinking that it is possible that the price is so low because there is not much CoQ10 in it. CoQ10 by Nature's Way costs more than twice as... --- ### Magnesium and migraines. - Published: 2015-01-29 - Modified: 2018-01-08 - URL: https://www.nyheadache.com/blog/magnesium-and-migraines/ - Categories: Alternative Therapies, Migraine An email I just received, which is attached at the end of this post, prompted me to write again about magnesium. In my opinion, every migraine sufferer should try taking magnesium. It's been 20 years since we published our first study of magnesium, in which we showed that during an attack, half of migraine sufferers have a magnesium deficiency. In that study, patients who were deficient had dramatic relief of their acute migraine with an intravenous infusion of magnesium. Subsequent studies by other researchers have shown that oral magnesium supplementation can also help. The results of those studies were not as dramatic because many people do not absorb magnesium taken by mouth. One large double-blind study used a salt of magnesium that was caused diarrhea in almost half of the patients. The magnesium salts that are better absorbed include magnesium glycinate, gluconate, aspartate (these are so called chelated forms), but some people do well with magnesium oxide, citrate, or chloride. The recommended daily dose of magnesium for a healthy adult is 400 mg a day, but some people need a higher dose. However, higher doses can cause diarrhea, while in others, even a high dose does not get absorbed. In these cases, monthly intravenous injections can be very effective. To establish who is deficient, a special blood test can help. The regular blood test is called serum magnesium level, but it is highly unreliable. A better test is RBC magnesium, but even with this test, if the value is normal,... --- ### Childhood emotional abuse increases the risk of migraine. - Published: 2015-01-27 - Modified: 2015-01-27 - URL: https://www.nyheadache.com/blog/childhood-emotional-abuse-increases-the-risk-of-migraine/ - Categories: Migraine, Psychology of headaches Many medical and pain conditions, including migraines, are more likely to occur in people who were abused in childhood. A new study by Richard Lipton and his colleagues compared the risk of developing migraines with the risk of developing episodic tension-type headache in people who experienced emotional abuse, emotional neglect, or sexual abuse. Episodic tension-type headaches are relatively mild and are experienced by most people from a variety of triggers, such as stress, sleep deprivation, hunger, and acute medical illness. Migraines, on the other hand, are much more severe and often cause inability to function and interfere with the quality of life. Incidence of history of abuse was compared in 8,305 migraine sufferers and 1,429 people who had tension-type headaches. Emotional neglect and sexual abuse was more common in those with migraines but with these two types of abuse the development of migraine was linked to the development of anxiety and depression. Only those with emotional abuse had an increased risk of having migraines even without having anxiety and depression. All three forms of maltreatment were also associated with an increase in migraine headache frequency, but only when anxiety and depression was also present. This study also showed that having two or three forms of abuse was more likely to cause migraines than if only one type of abuse was reported. Previous studies have also shown a correlation between the number of maltreatment types and pain conditions. These pain conditions include fibromyalgia, irritable bowel syndrome, interstitial cystitis, and temporo-mandibular joint... --- ### Folic acid intake and migraines - Published: 2015-01-24 - Modified: 2015-01-24 - URL: https://www.nyheadache.com/blog/folic-acid-intake-and-migraines/ - Categories: Alternative Therapies A study by Australian doctors led by Dr. Lyn Griffiths confirmed a previous observation that higher dietary intake of folic acid leads to lower frequency of migraine headaches. A 2009 study by Spanish doctors showed that patients with migraine with aura are more likely to have high homocysteine levels in their blood, a condition that can be corrected by taking folic acid and other B vitamins. The authors of this new study have shown before that folic acid, vitamin B6, and B12 supplementation reduces migraine symptoms in patients with a certain genetic mutation (MTHFR gene), which leads to high homocysteine levels. However, the influence of dietary folate intake on migraine has been unclear. The aim of their current study was to analyze the association of dietary folate intake with migraine frequency, severity, and disability. They studied 141 adult caucasian women with migraine with aura who had the MTHFR gene C677T variant. Dietary folate information was collected from all participants. Folate consumption was compared with migraine frequency, severity, and disability. A significant correlation was observed between dietary folate consumption and migraine frequency. The conclusion of this study was that folate intake may influence migraine frequency in female sufferers with migraine with aura. Good dietary sources of folic acid include spinach, lettuce, avocado, and other vegetables. If you suffer from migraine with aura you may want to ask your doctor to check your homocysteine level, as well as levels of folic acid and vitamin B12. Vitamin B12 level is not a reliable... --- ### Vitamin D levels in blacks and whites - Published: 2015-01-21 - Modified: 2015-01-21 - URL: https://www.nyheadache.com/blog/vitamin-d-levels-in-blacks-and-whites/ - Categories: Alternative Therapies Vitamin D deficiency has received wide attention and many doctors now check for this deficiency during routine check-ups. I've posted about the importance of vitamin D in migraine headaches and for general health. Vitamin D deficiency seems to increase the risk of cancer, other serious diseases and death. However, just like with vitamin B12 and magnesium, the regular blood test for vitamin D can be misleading. It appears that while blacks have lower levels of vitamin D than whites, they have healthier bones. A study by R. Thadhani of Massachusetts General Hospital explained this paradox. It appears that some of vitamin D circulates in the blood in a free form, while the rest is bound to protein. Only the free form is active, but the blood test measures only the total amount of vitamin D. Blacks appear to have much less of the protein-bound vitamin D, so the amount of the active form can be higher in blacks even if the overall amount of vitamin D is lower. These researchers are developing a more sensitive test for vitamin D levels. To be on the safe side, most people should aim to have their vitamin D level at least in the middle of normal range. The normal range is 30 to 100 and some studies (for example, in multiple sclerosis) suggest that the higher the level (within the normal range), the better. So, I would recommend getting your level up into the 40s and 50s. Many multivitamins, calcium with vitamin D... --- ### Bariatric surgery can improve migraines, but can also cause a new type of headaches. - Published: 2015-01-19 - Modified: 2015-01-19 - URL: https://www.nyheadache.com/blog/bariatric-surgery-can-improve-migraines-but-can-also-cause-a-new-type-of-headaches/ - Categories: Alternative Therapies, Brain disorders, Migraine While being overweight doese not cause migraines, in those who do suffer with migraines there is an inverse relationship between person's weight and the frequency and severity of migraine headaches. Weight loss, including that due to weight loss (bariatric) surgery, has been reported to reduce the frequency of migraine headaches and migraine-related disability. Obesity is also associated with headaches due to increased intracranial pressure (also called pseudotumor cerebri) and losing weight improves such headaches as well. However, while bariatric surgery may improve migraines, in a small number of people it can cause a different type of headaches. This rare type of headache is caused by a spontaneous leak of cerebro-spinal fluid (CSF), the fluid which surrounds the brain and the spinal cord. Such leaks are common after a spinal tap or can be a complication of epidural anesthesia. Loss of CSF can cause severe headaches, which are strictly positional. They are severe in the upright position, sitting or standing, but quickly improve upon lying down. A study of 338 patients who underwent bariatric surgery at the Cedars-Sinai Medical Center in Los Angeles detected 11 patients who developed a spontaneous CSF leak with severe headaches. Headaches started anywhere within three months and 20 years after surgery. Clearly, headaches starting 20 years later are not likely to be related to surgery, which suggests that this link between bariatric surgery and headaches is far from proven. Of these 11 patients, 9 improved with treatment. The typical treatment for a CSF leak is a... --- ### Cure yourself of vertigo - Published: 2015-01-04 - Modified: 2015-01-04 - URL: https://www.nyheadache.com/blog/cure-yourself-of-vertigo/ - Categories: Alternative Therapies, Migraine Vertigo and dizziness are more common in migraine sufferers than in people without migraines. A patient I am treating for migraines emailed me a few days ago complaining of vertigo. Dizziness is a term which can mean unsteadiness, lightheadedness, or vertigo. Vertigo is a sensation of spinning, which is most often caused by a disturbance of the inner ear. One type of vertigo is called benign positional vertigo (BPV). BPV usually causes very severe vertigo. One patients told me that while lying on the floor he felt as if he was falling off the floor. BPV is caused by a loose crystal in the inner ear. As the name implies, this type of vertigo occurs only when turning to one side, but not the other. If turning in bed to the right causes vertigo, then the problem is in the right inner ear. A simple (Epley) maneuver can quickly cure this problem by stopping this loose crystal from rolling around and causing havoc. I emailed my patient a link to a YouTube video showing how to do the Epley maneuver and half an hour later she emailed back saying that the vertigo was gone. Sometimes this maneuver needs to be repeated a few times before vertigo completely disappears. Here is the link to the Epley maneuver https://www. youtube. com/watch? v=llvUbxEoadQ&authuser=0 --- ### Bell's palsy (facial paralysis) is twice as common in migraine sufferers - Published: 2014-12-29 - Modified: 2014-12-29 - URL: https://www.nyheadache.com/blog/bells-palsy-facial-paralysis-is-twice-as-common-in-migraine-sufferers/ - Categories: Botox, Brain disorders, Science of Migraine A report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk of Bell’s palsy. Several medical conditions, such as asthma, anxiety, depression, irritable bowel syndrome, epilepsy, and other occur with higher frequency in migraineurs, but until now, no one suspected an association between migraines and Bell's palsy. The researchers compared two groups of 136,704 people aged 18 years and older - one group with migraine and the other without. They followed these two groups for an average of 3 years. During that time, 671 people in the migraine group and 365 of the non-migraine group developed Bell’s palsy. This association persisted even after other factors such as sex, high blood pressure, and diabetes were taken into account. The authors speculated that the inflammation and the blood vessel problems seen in both conditions may explain this association. This study appears to be of purely academic interest since we do not know how to prevent Bell's palsy. However, I decided to write about it because a couple of my colleagues (one in our office and at least one other on a doctors' discussion board) reported seeing Bell's palsy soon after administering Botox injections for chronic migraines. This report by Taiwanese doctors suggests that Bell's palsy might have been not due to Botox, but rather a coincidence since Bell's palsy is more common in migraine sufferers. --- ### A new study of trigeminal neuralgia - Published: 2014-12-24 - Modified: 2014-12-24 - URL: https://www.nyheadache.com/blog/a-new-study-of-trigeminal-neuralgia/ - Categories: Trigeminal and other neuralgias Trigeminal neuralgia is a very painful and debilitating condition (Here is a review article I wrote for physicians). Fortunately, it is relatively infrequent - affecting 0. 3% of the population, compared to 12% afflicted by migraines. This explains relative paucity of studies of this condition. A group of neurologists at the Danish Headache Center studied 158 consecutive patients with trigeminal neuralgia (TN) seen at their center over a period of one year. They published their findings in the journal Headache. Average age of onset of pain was 53 years. TN was more common in women than men (60% vs 40%) and more common on the right side (56%). When only one of the three branches of the trigeminal nerve were affected, the first and the second were involved in 69% of cases and the third branch (lower third of the face) alone was involved in only 7% of sufferers. The pain of trigeminal neuralgia is described the same way by almost all sufferers - it feels like a strong electric shock. It can be triggered by chewing, brushing teeth, speaking, air movement from wind or air conditioner, and at times it occurs without any provoking factor. In this study, half of the patients reported having a more persistent but milder pain in addition to the typical stabbing, electric-like pain. One fifth of patients reported to have some tearing on the side of pain and in 17% there was some loss of sensation over the area of pain. Treatment of TN... --- ### Treating chronic migraines with Botox is cost-effective - Published: 2014-12-22 - Modified: 2014-12-22 - URL: https://www.nyheadache.com/blog/treating-chronic-migraines-with-botox-is-cost-effective/ - Categories: Botox, New treatments Cost is the only major issue with Botox injections, which is the only FDA-approved treatment for chronic migraines and which is now covered by almost all insurance companies. It is very safe and highly effective, relieving headaches in 70% of migraine sufferers. A study just published in the journal Headache suggests that Botox may be not only clinically effective, but also cost-effective. Researchers from the Renown Neurosciences Institute in Reno, Nevada analyzed data from 230 chronic migraine sufferers who did not respond to two or more prophylactic drugs and were given Botox injections. Botox was given twice, three months apart. Compared with the 6 months before Botox, there were 55% fewer emergency room visits, 59% fewer urgent care visits, and 57% fewer admissions to the hospital. In those 6 months the savings amounted to half of the cost of Botox treatments. Considering that improvement tends to get more pronounced with each subsequent Botox treatment, it is very likely that the costs savings would grow with additional treatments. Obviously, besides saving money, Botox provides a significant improvement in the quality of people's lives, which is much harder to measure. At our Center we give Botox to more than a quarter of our patients and see a dramatic improvement in the majority. Botox is not only much more effective for chronic migraines, but it is also much safer than any oral medication. --- ### Cyclic vomiting syndrome can be a migraine variant in adults - Published: 2014-12-13 - Modified: 2014-12-13 - URL: https://www.nyheadache.com/blog/cyclic-vomiting-syndrome-can-be-a-migraine-variant-in-adults/ - Categories: Headache medications, Science of Migraine Cyclic vomiting syndrome (CVS) is usually seen in children. The attacks of vomiting often stop as the child gets older, but then they usually go on to develop migraine headaches. A recent report in Headache describes three adults with CVS. The article also mentions a previous report which described another 17 adults with this syndrome. CVS typically consists of recurrent stereotypical attacks of incapacitating nausea and vomiting, separated by symptom-free periods. Supporting evidence that helps diagnose this condition include personal or family history of migraine and other symptoms, such as headaches, motion sickness, and sensitivity to light. Just like in children, CVS in adults is a diagnosis of exclusion, meaning that other causes of vomiting must be considered and ruled out. I mentioned in a previous post that one out of three children with CVS turned out to have another medical problem rather than migraine. CVS in adults seems to respond well to an injection of sumatriptan (Imitrex). This allows for a quick relief of symptoms and makes this debilitating condition very manageable. Besides Imitrex injections, Zomig (zolmitriptan) nasal spray can sometimes be effective as well. --- ### Migraine is not taken seriously by doctors, especially in children - Published: 2014-12-08 - Modified: 2014-12-08 - URL: https://www.nyheadache.com/blog/migraine-is-not-taken-seriously-by-doctors-especially-in-children/ - Categories: Headaches in children Placebo effect is a well-documented phenomenon, which is particularly pronounced when treating migraine headaches. Intravenous (IV) infusion of saline water is a placebo commonly used in studies where placebo is compared to a medication also given IV. It is baffling why a group of Canadian physicians decided to test the effect of (IV) fluids on migraines in children and adolescents seen in an emergency room (the study was just published in Headache). They compared a group of children who were told that they will get only IV fluids with another group who was told that they might also get a medication with the IV fluids. The second group actually watched a nurse add something to the bag of IV fluid, but the children were not told that it was just more of the saline water. The researchers thought that the expectation of getting a medicine will help relieve their migraine headache. In fact neither group, the one who received IV fluids without expecting any medicine and the group who thought that they may be getting medicine had much relief. Strangely, the doctors concluded that additional studies using larger volumes of IV fluids are warranted. As if there is a chance that giving more fluids will stop a severe migraine. Sadly, intravenous fluids are often used in emergency rooms as a treatment for migraines in adults and children and we did not need this study to show that it is an ineffective approach. Doing more such studies seems unethical. Imagine a... --- ### Meditation relieves migraine headaches - Published: 2014-12-06 - Modified: 2014-12-07 - URL: https://www.nyheadache.com/blog/meditation-relieves-migraine-headaches/ - Categories: Alternative Therapies Considering that meditation can literally change your brain, it is not at all surprising that it can also prevent migraine headaches. A study by doctors at Wake Forest School of Medicine and Harvard Medical School published in the journal Headache confirmed that meditation can prevent migraine headaches. I've written before about studies showing that meditation reduces negative perception of pain and that even three daily 20-minute meditation sessions reduce pain. Stress is one of the most common triggers for migraine headaches. Many studies of various mind/body interventions have been shown to be helpful for migraine. The researchers in the latest study used a standardized 8-week mindfulness-based stress reduction program that teaches mindfulness meditation and yoga. This approach has been shown to be effective for chronic pain syndromes, but this was the first time it was tested for migraines. The study included 9 adults who received their usual care and 10 who were enrolled in the meditation program. The program consisted of 8 weekly 2-hour sessions, plus one mindfulness retreat day (6 hours) led by a trained instructor. All 10 patients completed the program. The program participants had on average 1. 4 fewer migraines per month. The reduction ranged from 3. 5 to 1. 0 migraines, while in the control group the improvement ranged from 1. 2 to 0 migraines per month. Headaches were less severe and shorter in those who meditated compared to those who did not. Disability also improved (measured by Migraine Disability Assessment and Headache Impact Test-6) in... --- ### Inpatient headache management in Germany - Published: 2014-11-24 - Modified: 2014-11-25 - URL: https://www.nyheadache.com/blog/inpatient-headache-management-in-germany/ - Categories: Uncategorized 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... --- ### More on migraine surgery - Published: 2014-11-14 - Modified: 2014-11-14 - URL: https://www.nyheadache.com/blog/more-on-migraine-surgery/ - Categories: Chronic migraine, New treatments A new report by Drs. Gfrerer, Maman and their colleagues at the Massachusetts General Hospital in Boston entitled Non-Endoscopic Deactivation of Nerve Triggers in Migraine Headache Patients: Surgical Technique and Outcomes was recently published in the journal Plastic & Reconstructive Surgery. Surgery for refractory migraine headaches was developed by Dr. Bahman Guyuron and others and was reported to benefit between 68 and 95% patients. This surgery involves cutting or freeing up nerves in the scalp that appear to be responsible for triggering migraines. Some surgeons use a laparascopic technique, which involves making only a few small incisions while others do this surgery through conventional incisions. The authors of this new study argue that endoscopic techniques may not be appropriate in many cases since some surgeons have little experience or limited access to the endoscope and in some patients this technique is not practical because the nerves could run in an unusual pattern, which would make them hard to find through a small incision. This study involved 43 consecutive procedures in 35 patients. All patients completed questionnaires before and 12 months after surgery. The overall positive response rate was 91%. Total elimination of migraine headaches was reported in 51%, greater than 80% resolution of symptoms in 21%, and 28% had resolution between 50-80%. No improvement was reported after 9% of procedures. There were no major adverse events. The authors concluded that non-endoscopic surgery was safe and effective treatment in select migraine headache patients. Most headache experts agree that until proven effective... --- ### More on benefits of fish oil - Published: 2014-11-13 - Modified: 2014-11-14 - URL: https://www.nyheadache.com/blog/more-benefits-from-fish-oil/ - Categories: Alternative Therapies Fish oil, or rather omega-3 fatty acids, seem to reduce the risk of Lou Gehrig disease or ALS (amyotrophic lateral sclerosis). An article in JAMA Neurology by Dr. Fitzgerald and her colleagues analyzed 1,002,082 participants in 5 different large-scale studies. A total of 995 ALS cases were documented. A greater omega-3 intake was associated with a reduced risk for ALS. Consumption of both linolenic acid and marine (fish oil-derived) omega-3s contributed to this inverse association. The researchers concluded that consumption of foods high in omega-3s may help prevent or delay the onset of ALS. Omega-3s may also relieve migraine headaches, help cope better with stress, prevent damage to nerve endings by chemotherapy, prevent mental decline, and provide other benefits. I usually recommend (and take it myself) Omax3 brand, which is very pure and concentrated. --- ### Cluster headaches and solar activity? - Published: 2014-10-29 - Modified: 2014-10-29 - URL: https://www.nyheadache.com/blog/cluster-headaches-and-solar-activity/ - Categories: Cluster headaches Cluster headaches usually occur once or twice a year for a period lasting from a few weeks to a few months. During those periods, they occur daily or more than once a day. Interestingly, these episodes of cluster headaches tend to occur at the same time of year in many patients, but not always at the same time of year. Looking at our data, we have found that in some years many cluster patients developed their attacks in August, another year, in November, and this year, it has been September - October. This year, we are also seeing many patients whose cluster headaches are not responding to usual treatments. It does not appear that barometric pressure or allergies are responsible for triggering cluster headaches. One unsubstantiated theory is that the solar activity is responsible for bringing on cluster headaches. This report in the Wall Street Journal indicates that we are currently going through a period of an unusually intense solar activity. Perhaps this is why some of our cluster patients are having unusually severe headaches. --- ### Stem cells for headaches - Published: 2014-10-16 - Modified: 2014-10-16 - URL: https://www.nyheadache.com/blog/stem-cells-for-headaches/ - Categories: Alternative Therapies, New treatments, Science of Migraine The first time I heard of the potential benefit of stem cells for migraine headaches was last year from one of my patients. This 55-year-old woman had been having some improvement from intravenous magnesium and nerve blocks, while Botox was ineffective. However, she reported a dramatic improvement in her headaches after receiving an intravenous infusion of stem cells in Panama. The stem cells were obtained from a donated umbilical cord. Stem cell research has been controversial because most of the early research used stem cells obtained from an aborted fetus. Since then, stem cells have been obtained from the bone marrow, umbilical cord, placenta, and artificial fertilization. Another rich source of stem cells is body's fat tissue. Most of the stem cell procedures are not yet approved in the US. The main concern is that when you obtain stem cells from another person's umbilical cord or placenta, there is a risk of transmitting an infection. There are relatively few stem cells in the bone marrow, placenta or the umbilical cord, which means that after isolating them, they need to be grown in a petri dish. This process involves adding various chemicals, which may not be safe, according to the FDA. A group of doctors in Australia recently reported relief of migraines using stem cells from patients' own fat. These doctors did not grow these cells, but infused them intravenously right after separating them from fat. The infused cells were not only stem cells, but so called stromal vascular fraction, which... --- ### Eye drops to treat an acute migraine - Published: 2014-10-07 - Modified: 2014-10-07 - URL: https://www.nyheadache.com/blog/eye-drops-to-treat-an-acute-migraine/ - Categories: Headache medications, New treatments Beta blockers (Inderal or propranolol and similar drugs) are used for the preventive treatment of migraine headaches. Over the years, a few patients have told me that they take a beta blocker only when they have an attack of migraine with very good results. A report published in Missouri Medicine describes seven patients whose acute migraine headache went away with eye drops containing a beta blocker. These eye drops are used for the treatment of glaucoma. The authors argue that having medicine go into the eye allows it to get absorbed quickly into the blood stream. This is certainly true, but my first thought was that there is too little medicine in eye drops to produce an effect outside the eye. However, beta blocker eye drops can worsen asthma, lower the blood pressure and slow the heart rate, suggesting that the amount of medicine in eye drops is sufficient to cause effects beyond the eye. Oral beta blockers used daily for the preventive treatment of migraines are also contraindicated in those medical conditions. Considering that eye drops are probably safer than many oral medications used to treat an acute migraine attack and that they most likely work faster, this treatment is worth trying. --- ### Migraine raises the risk of Parkinson's - Published: 2014-10-01 - Modified: 2014-10-01 - URL: https://www.nyheadache.com/blog/migraine-raises-the-risk-of-parkinsons/ - Categories: Science of Migraine Parkinson's disease (PD), parkinsonian symptoms, and restless leg syndrome (RLS) are more common in people who in middle age suffered from migraines with aura. Those suffering from migraine without aura in their midlife had increased risk of having symptoms of Parkinson's and RLS, but not PD. These are the findings of a large study of residents of Reykjavik, Iceland who were born between 1907 and 1935. These residents had been followed since 1967. Headaches were classified based on symptoms assessed in middle age. From 2002 to 2006, 5,764 participants were reexamined to assess symptoms of parkinsonism, diagnosis of PD, family history of PD, and RLS. People who suffered from migraines, particularly migraine with aura, were in later life more likely than others to report parkinsonian symptoms and diagnosed to have PD. Women with migraine with aura were more likely than others to have a parent or sibling with PD. Late-life RLS was increased in those with headaches generally. The authors concluded that there may be a common vulnerability to, or consequences of, migraine and multiple indicators of parkinsonism. There are no proven ways to prevent PD, but eating more fruits and vegetables, high-fiber foods, fish, and omega-3 rich oils (or taking an omega-3 supplement, such as Omax3) and avoiding red meat and dairy may have some protective effect against PD. Intensive research into the causes and treatment of Parkinson's disease, supported by Michael J. Fox and Sergey Brin of Google among others, should lead to true breakthroughs in the next... --- ### Stabbing headaches as a sign of MS - Published: 2014-09-22 - Modified: 2014-09-22 - URL: https://www.nyheadache.com/blog/stabbing-headaches-as-a-sign-of-ms/ - Categories: Headaches Stabbing headaches can be a sign of acute multiple sclerosis, according to a report by German doctors in the journal Headache. Stabbing headache is a rare type of headache, although patients with migraines often report having occasional "ice pick" headaches. Some call these headaches "jabs and jolts". In some people, stabbing headaches can be quite disabling. The pain lasts only a couple of seconds but can occur up to 100 times a day. Treatment usually involves indomethacin or another non-steroidal anti-inflammatory medication in the aspirin family (including our own Migralex). However, in this case where stabbing headaches were associated with MS, treating MS relieved headaches as well. In a prior report in Clinical Neurology and Neurosurgery Italian physicians also found that of 26 patients with stabbing headaches they had seen over 10 years, more than half had autoimmune disorders, including multiple sclerosis, Sjögren's disease, lupus, Behçet's disease, autoimmune vasculitis, and antiphospholipid antibody syndrome. The authors speculated that stabbing headache may develop as a result of inflammation in the brain with loss of myelin around the nerve fibers, which is seen with MS and other auto-immune disorders. --- ### Peripheral nerve blocks for an acute migraine - Published: 2014-09-15 - Modified: 2014-09-15 - URL: https://www.nyheadache.com/blog/peripheral-nerve-blocks-for-an-acute-migraine/ - Categories: Alternative Therapies, neurostimulation, New treatments Peripheral nerve blocks can be very effective in stopping a severe migraine attack. We utilize them when a patient does not respond to oral or injected medications or when medications are contraindicated because of a coexisting disease or pregnancy. Dr. Jessica Ailani and her colleagues at the Georgetown University in Washington, D. C. presented their experience with nerve blocks at the last annual meeting of the American Headache Society in Los Angeles. The study included 164 patients. Most patients received occipital and trigeminal nerve blocks using lidocaine or a similar local anesthetic. Most patients were satisfied with the results, which lasted from several days up to 2 weeks. Only a small number of participants experienced side effects such as soreness at the site of injections, nausea and vomiting, and head and neck pain. Dr. Ailani noted that more than 71% of patients rated their pain as 4 to 8 out of 10 before treatment with a nerve block. After a nerve block, nearly half (47. 2%) said the pain had reduced to 1 out of 10. "This is a very well-tolerated procedure and patients are very satisfied with the procedure," said Dr. Ailani. Nerve blocks can help keeps headache sufferers out of the emergency room and provide an alternative to systemic drugs, that is drugs that are injected or ingested. Systemic drugs affect the entire body while nerve blocks exert only local effects (unless one is allergic to local anesthetics). Dr. Robert Kaniecki, a headache specialist in Pittsburgh uses nerve... --- ### Antidepressants for migraines - Published: 2014-09-11 - Modified: 2014-09-11 - URL: https://www.nyheadache.com/blog/antidepressants-for-migraines/ - Categories: Headache medications Frequent attacks of migraine are best treated with preventive measures. Several categories of medications have been shown to be effective for the prevention of migraine headaches. These include Botox injections (for chronic migraine), epilepsy drugs (gabapentin, topiramate, divalproex), blood pressure medications (propranolol, atenolol, lisinopril, losartan, and other), as well antidepressants. Antidepressants, like most other preventive drugs, were discovered to be effective for pain and headaches by accident. We have good scientific proof that you do not need to be depressed to obtain pain and headache relief from these drugs. The effect on pain and on anxiety or depression are independent of each other. However, many patients who have pain and headaches have higher rates of depression and anxiety and these drugs can relieve both conditions. The oldest category of antidepressants are tricyclic antidepressants. Elavil or amitriptyline was introduced in the US in 1961. Amitriptyline has been extensively tested for a variety of painful conditions, including low back pain, neuropathy pain, migraines, and other. The main side effects of amitriptyline are dry mouth, drowsiness, constipation, and sometimes, weight gain. Other drugs in the family of tricyclic antidepressants often have fewer side effects. Many doctors always begin with nortriptyline or Pamelor, which is a derivative of amitriptyline and may have fewer side effects. Amitriptyline is broken down in the body into nortriptyline, which is less sedating. We also prescribe other tricyclics, desipramine (Norpramine), doxepin (Sinequan), and protriptyline (Vivactil), which also tend to have fewer side effects. When a patient has insomnia and... --- ### Online cognitive-behavioral therapy - Published: 2014-09-01 - Modified: 2014-09-01 - URL: https://www.nyheadache.com/blog/online-cognitive-behavioral-therapy/ - Categories: Alternative Therapies Severe persistent migraines can affect emotional, interpersonal, social, and work-related functioning. It is difficult to learn how to cope with pain and improve your functioning on your own. Cognitive-behavioral therapy (CBT) has been proven to improve lives of people with pain, including migraine headaches and not only in adults, but also in children. One major problem with CBT is that it is not readily available in many areas and when available, it is expensive. I've written about two online programs for CBT, which offer help to patients with anxiety and depression. Another online service painACTION. com offers free resources that have been shown to improve coping with pain, to decrease anxiety and depression, and to provide other benefits. The site offers help to patients with migraine, as well as cancer pain, back and arthritis pain, and neuropathic pain. The migraine section has five modules: communication skills, emotional coping, self-management skills, knowledge base, and medication safety. I do have a problem with their medication safety section in that it does not mention caffeine and caffeine-containing drugs when describing rebound, or medication overuse headaches. These drugs include Excedrin, Anacin, Fiorinal, Fioricet, Esgic, and other. At the same time, they list aspirin, which actually may prevent medication overuse headaches and triptans, which rarely cause such headaches (one of my most popular posts is devoted to daily intake of triptans, which is not something I encourage, but which is the only solution for some patients). But overall, this is a very useful resource for... --- ### Do not throw away expired medications - Published: 2014-08-28 - Modified: 2014-08-28 - URL: https://www.nyheadache.com/blog/do-not-throw-away-expired-medications/ - Categories: Headache medications Expiration date on medications does not indicate that the medication is no longer effective or safe after that date. Having had extensive experience with the production and testing of Migralex, I can reassure you that medications remain safe and effective for years after the expiration date. An article just published in the Wall Street Journal's "Burning Question" column addresses this issue. The FDA has conducted a study for the Department of Defense testing 122 different drugs. The conclusion of the study was that 88% of the drugs remain effective for an average of 5 and 1/2 years after the expiration date. The main problem with expired drugs is not that they become dangerous to use, but that their efficacy slowly declines. A doctor quoted in the WSJ article says that there have been no reported cases of toxicity from expired medications. But a decline in efficacy could be a problem with life-saving drugs, such as nitroglycerin for heart, EpiPen for allergies, or insulin for diabetes. It is very important to store the medications in a dry cool place, rather than in a medicine cabinet in the bathroom, which periodically gets hot and humid. Also, do not leave drugs in a car during the summer - the temperature in a locked car left in the sun can rise to 130 degrees and higher. I usually advise not to use drugs beyond two years of the expiration date even if they were kept in a dry and cool place. Before using an... --- ### Botox relieves new daily persistent headaches. - Published: 2014-08-15 - Modified: 2014-08-15 - URL: https://www.nyheadache.com/blog/botox-relieves-new-daily-persistent-headaches/ - Categories: Botox, Chronic migraine, Headaches A report from the Cleveland Clinic and Case Western Reserve describes 22 patients with new daily persistent headaches (NDPH) who were treated with Botox injections. NDPH is a condition in which the headache begins suddenly without an obvious trigger and persists continuously without a break. Because NDPH is relatively uncommon, there have been no large studies of this condition. Patients with NDPH usually do not exhibit symptoms of migraine, such as throbbing pain, nausea, sensitivity to light, noise or physical activity. Because of its sudden onset, we suspect that these headaches may be the result of a viral or another type of infection. There are no treatments that consistently relieve these headaches, but we usually try all of the drugs and approaches we use in migraines. A group of doctors from Cleveland, Ohio discovered that while Botox seems to help, only 32% of patients with NDPH showed improvement, confirming the refractory nature of this type of headaches. Twenty one of the 22 patients underwent more than one treatment with Botox and most were given a standard migraine treatment protocol with 155 units injected into 31 sites. The improvement was modest but it did result in headache-free days, which were not observed prior to this treatment. The disability improved slightly and when the improvement did occur, it lasted about 8 weeks. Some of our chronic migraine patients also require Botox injections every 8 to 10 weeks, instead of the usual 12. Considering that we do not have any better treatments, Botox... --- ### A new drug combination for trigeminal neuralgia. - Published: 2014-08-10 - Modified: 2014-08-10 - URL: https://www.nyheadache.com/blog/a-new-drug-combination-for-trigeminal-neuralgia/ - Categories: Trigeminal and other neuralgias A new combination of two old drugs seems to provide relief for some trigeminal neuralgia (TN) sufferers. The first line drugs for TN are epilepsy drugs, carbamazepine (Tegretol) or oxcarbazepine (Trileptal). A presentation at the last annual scientific meeting of the American Headache Society by Saudi physicians described successful use of another epilepsy/pain drug, pregabaline (Lyrica) with an antidepressant/pain drug duloxetine (Cymbalta). Both Lyrica and Cymbalta are approved by the FDA for the treatment of some pain conditions, although not TN. The doctors compared Lyrica alone with Lyrica and Cymbalta in combination in 200 patients. The combination resulted in an 80% reduction of pain, which was observed within 10 days, while Lyrica alone produced a 60% reduction that started within 20 days. The dose of Lyrica was 150 mg twice a day (after a one week build up from 75 mg twice a day) and the dose of Cymbalta was 60 mg a day. Since both Cymbalta and Lyrica have pain relieving properties, this appears to be a rational combination of medications to use in TN and possibly other painful conditions, including various types of headaches. However, as a general rule, we try to use a single drug whenever possible to reduce the potential for side effects. TN is such a severe and debilitating condition, that it may be justified to use a combination early, especially if the first line drugs, such as oxcarbazepine fail. In my previous posts I have described the use of intravenous medications, Botox and other... --- ### Post-concussion symptoms could be due to PTSD - Published: 2014-08-06 - Modified: 2014-08-06 - URL: https://www.nyheadache.com/blog/post-concussion-symptoms-could-be-due-to-ptsd/ - Categories: Head trauma Post-concussion syndrome, which often includes headaches, can persist for many months especially after a minor injury (yes, mild injury is more likely to cause post-concussion syndrome than a severe one). However, little is known about prognosis after the injury. The symptoms fall into three categories - cognitive (such as memory, concentration difficulties), somatic (headaches, dizziness, etc), and emotional (irritability, anxiety, depression). A study by French physicians recently published in JAMA Psychiatry, also took into account the fact that injuries are often sustained during psychologically distressing events (car accidents, assaults, falls) and looked for symptoms of post-traumatic stress disorder (PTSD) in those patients. The authors conducted a study of patients seen at an emergency department for a mild head injury. They checked on these patients for persistent symptoms three months after the concussion. The study included 534 patients with head injury and 827 control patients with non-head injuries. The study showed that three months after the injury, 21. 2 percent of head-injured and 16. 3 percent of nonhead-injured patients had post-concussion syndrome, while 8. 8 percent of head-injured patients met the criteria for PTSD compared with only 2. 2 percent of control patients. Their conclusion was that it is important to differentiate post-concussion syndrome from PTSD because it has important consequences, in terms of treatment, insurance resource allocation and advice provided to patients and their families. They also stressed the importance of considering PTSD in all patients with mild traumatic brain injury who suffer persistent symptoms. --- ### Botox helps post-traumatic headaches. - Published: 2014-08-04 - Modified: 2014-08-04 - URL: https://www.nyheadache.com/blog/botox-helps-post-traumatic-headaches/ - Categories: Botox, Headaches Botox is FDA-approved only for chronic migraine headaches, however, it is being used "off-label" for other types of headaches as well. We find that frequent episodic migraines, cluster headaches, numular, and cervicogenic (neck-related) headaches improve with Botox. In our practice, post-traumatic headaches also seem to respond to Botox. A report by neurologists from Stony Brook University describes five patients suffering from post-traumatic headaches, who responded to Botox. These patients sustained a traumatic brain injury and had suffered from post-traumatic headaches for years, despite trials of various prophylactic medications. After treatment with Botox, all of their five patients had greater than 50% improvement of their disability as measured by the MIDAS (MIgraine Disability Assessment Scale) questionnaire. This is not a surprising observation because in many patients with a traumatic brain injury headaches have migraine features, suggesting similar underlying mechanisms. People with a family history of migraines who sustain a head injury seem to be more likely to develop post-traumatic headaches than those without such family history, which also suggests a link with migraines. Some patients with post-traumatic headaches and especially those with overt whiplash injury (almost all head injuries, to a varying degree, involve a whiplash neck injury) may respond to Botox because Botox relaxes tight muscles. We no longer think that this is the reason Botox helps migraines because there is evidence that in migraines Botox works by blocking sensory nerve endings rather than by relaxing muscles. Because of the cost, insurance companies are often unwilling to pay for Botox... --- ### Sumatriptan appears safe in pregnancy - Published: 2014-07-30 - Modified: 2014-07-30 - URL: https://www.nyheadache.com/blog/sumatriptan-appears-safe-in-pregnancy/ - Categories: Headache medications Acetaminophen is what most obstetricians recommend pregnant women take for their headaches. However, it is not very effective for migraine headaches and it is not as safe as we thought (see my recent post). Fioricet is another drug favored by some obstetrician and it is also not very effective and not very safe. Sumatriptan (Imitrex) was introduced 20 years ago and the manufacturer has maintained a registry of women who took the drug while pregnant. The final results of this registry were just published in the journal Headache. The registry included 626 women who were exposed to sumatriptan during their pregnancies. They also followed women who took two other migraine drugs, naratriptan (Amerge) and a combination of sumatriptan with naproxen (Treximet). However, there were too few women in those groups to make any conclusions about the drugs' safety. As far as sumatriptan, the risk of major birth defects was not increased. The authors also reviewed several other large studies which assessed the risk of taking migraine medications during pregnancy. One of the studies were from the Swedish Medical Birth Register, which included 2257 births following first trimester sumatriptan exposure. No risk was found in this study either. In summary, pregnant women suffering from severe migraines should be prescribed sumatriptan. Most women respond to an oral form (tablet), but those with very severe attacks should be offered an injection. --- ### Fasting, stem cells, migraine headaches - Published: 2014-07-27 - Modified: 2014-07-27 - URL: https://www.nyheadache.com/blog/fasting-stem-cells-migraine-headaches/ - Categories: Alternative Therapies, Science of Migraine Skipping meals, for some people, is a sure way to get a migraine headache. Even those who do not suffer from migraines can get a headache from not eating breakfast and lunch. However, fasting has remained popular for the treatment of various conditions. Migraine sufferers who suspect that some foods may be triggering their headaches are sometime advised to try an elimination diet. This diet often begins with a fast and then one type of food is introduced at a time to see if it triggers a negative reaction. Anecdotal reports describe relief of migraine headaches with fasting for periods of up to five days. Some programs recommend five-day fasts twice a year, while others are advocating five days each month. A 5:2 diet involves eating a normal amount of calories for five days and the following two days eating 1/4 of that amount. The problem is that some people will have worsening of their headaches in the first day or two. However, most patient reports that after having headaches for a day or two the head becomes very clear. It is not clear if fasting helps various medical conditions, if indeed it does, which remains an open question. One potential mechanism may involve stem cells. Recent studies suggest that fasting causes proliferation of stem cells. The study was published in the journal Cell Stem Cell. The research was done in mice and showed that prolonged fasting protects against immune system damage and induce immune system regeneration. The researchers speculated... --- ### Predicting response to Botox in chronic migraine. - Published: 2014-07-08 - Modified: 2014-07-08 - URL: https://www.nyheadache.com/blog/predicting-response-to-botox-in-chronic-migraine/ - Categories: Botox, Chronic migraine, New treatments Botox is a very effective treatment for chronic migraines and possibly other types of headaches and pain. However, Botox is an expensive and somewhat unpleasant treatment. Even though Botox helps a high percentage of patients (about 70%) it would be useful if we could predict who is going to respond and who is not. One of the predictors seems to be the directionality of pain. That is, if patients with migraine who have constricting (imploding) pain or pain localized to the eye seem to respond better than those who have pain that seems to be pushing from inside out (exploding). This is not a very reliable predictor because some people have difficulty categorizing their pain in that way and because even if they do describe it clearly one way or another, this predictor is far from 100% accurate. In a study just published in the journal Headache a group of Spanish neurologists claim that they have found a predictor with 95% accuracy. They measured blood levels of calcitonin gene-related peptide (CGRP) and found that those with levels of CGRP above a certain number were 28 times more likely to respond to Botox than those with levels below that level. CGRP has been shown to be very involved in the process of migraine and several drugs and antibodies which block the CGRP receptor appear to be very promising (see my recent blog post on such antibodies). So, it is not very surprising that this correlation between the response to Botox and... --- ### Bullying in school causes headaches. - Published: 2014-07-06 - Modified: 2014-07-06 - URL: https://www.nyheadache.com/blog/bullying-in-school-causes-headaches/ - Categories: Headaches in children Besides many other mental and physical problems, bullying in school causes headaches. This is the conclusion of a group of psychologists at the University of Padua in Italy who published their findings in the last issue of the journal Headache. They looked at 20 published studies on bullying, which included 173,775 children, and found that 14 of these studies recorded the presence of headaches. While 19% of kids who were not bullied suffered from headaches, this number was 33% in those who were. There was no difference in the incidence of headaches between kids in Europe compared to other countries. This study confirms what has been reported for health problems in bullied kids in general. It is well known that psychological stress causes physical symptoms. Social pain is a term that psychologists use to describe the effect of peer rejection, ostracism, or loss. Recent studies have shown that physical and social pain share many physiological mechanisms in the brain. The authors also speculate that lack of coping skills, low self-esteem or lack of assertiveness may lead to more psychological and physical problems. They also call on pediatricians, school nurses and others to become more aware of the physical symptoms, such as headache, as a manifestation of bullying. I have seen a number of children with severe persistent headaches, which required home schooling. In some of these kids bullying was a definite contributing factor, although many children are reluctant to admit this even to their parents. --- ### Another delay for a long awaited drug - Published: 2014-07-01 - Modified: 2014-07-01 - URL: https://www.nyheadache.com/blog/another-delay-for-a-long-awaited-drug/ - Categories: New treatments The introduction of Levadex has been delayed again, this time for a year. It seems like deja vu all over again - I wrote the same thing on this blog in April of last year. Levadex, which the manufacturer (Allergan) just renamed as Semprana, is an inhaler containing DHE. DHE, or dihydroergotamine is one of the most effective injectable drugs for migraine. It should be even better in an inhaled form because it works faster and causes much less nausea than the injection. The FDA is again delaying the launch because of manufacturing problems. Apparently, the particle size of the drug when it comes out of the inhaler is not uniform enough. Many patients are unhappy, but I am sure that the Allergan is very unhappy too since they spent almost a billion dollars to acquire this drug from a small company that developed it. --- ### Migraine aura can start in pregnancy - Published: 2014-06-27 - Modified: 2014-06-27 - URL: https://www.nyheadache.com/blog/migraine-aura-can-start-in-pregnancy/ - Categories: Brain disorders, Science of Migraine Migraine aura precedes the headache in about 20% of patients. The most common type of aura is visual. It consists of flashing lights, sparkles, partial loss of vision, and other visual distortions, which can move across the visual field. Typical duration of the aura is 20 to 60 minutes and it can occur without a headache. Many people get frightened when experiencing an aura for the first time. Thoughts of a brain tumor spring to their minds. Although auras rarely indicate a serious problem, an MRI scan is usually indicated when an aura occurs for the first time. MRI scans are considered to be safe in pregnancy, but the current guidelines of the FDA require labeling of the MRI devices to indicate that the safety of MRI with respect to the fetus "has not been established". Not surprisingly, most expecting mothers instinctively try to avoid any testing. So, what to do if a pregnant woman develops an aura? A study by headache specialists at the Montefiore Headache Center in the Bronx suggests that this is not an uncommon occurrence. Of 121 pregnant women presenting with an acute headache, 76 had migraines and a third of these had an aura for the first time in their lives. Two thirds of auras occurred in the third trimester. This report should be reassuring and may help avoid unnecessary MRI scans. However, MRI may still be needed if there are other signs of a more serious neurological problem on examination or by history. --- ### "Visual snow" and migraine - Published: 2014-06-22 - Modified: 2014-06-22 - URL: https://www.nyheadache.com/blog/visual-snow-and-migraine/ - Categories: Brain disorders, Science of Migraine "Visual snow" is a continuous TV-static-like visual disturbance experienced by some people who suffer from migraines and by some without migraines. A group of British doctors examined 120 patients with persistent "visual snow" and found that 70 of them also suffered from migraines. Of these 70, 37 had migraine with aura and 33 had migraine without aura. Many of these patient had other visual complaints: some had a trailing after-image when shifting their gaze, saw sparkles, were always sensitive to light, and had poor night vision. Fifty two of them also complained of noise in their ears (tinnitus). Seventeen of these patients underwent PET scans of their brain, which were compared to PET scans of 17 normal control subjects. Those with "visual snow" had increase brain activity in two parts of the brain, indicating that this is not a psychological or an eye problem, but a brain disorder. Unfortunately, the authors did not provide any ideas as to how to treat these patients. However, the fact that some areas of the brain were overactive, suggests that using epilepsy drugs, which suppress excessive brain cell activation and are proven to help migraines, may help. These drugs include gabapentin (Neurontin), topiramate (Topamax), and divalproate (Depakote). Before using drugs though, I would suggest trying magnesium orally or intravenously because magnesium also reduces excitability of the nervous system and because half of migraine sufferers have low magnesium levels. See an article on magnesium and migraines here. --- ### More about white spots on brain MRIs - Published: 2014-06-15 - Modified: 2014-06-15 - URL: https://www.nyheadache.com/blog/more-about-white-spots-on-brain-mris/ - Categories: Headache medications, Science of Migraine The benign nature of white matter lesions (WML) on MRI scans of patients with migraine was noted in a post last year. While they appear to be benign, they are disconcerting nevertheless. It is possible that we haven't yet discovered the negative effects they may have. A study by Chinese researchers published in the Journal of Neurology reported on MRI scans in 141 people, including 45 healthy controls without migraines, 38 chronic migraine sufferers who were not overusing acute migraine medications and 58 patients with chronic migraines who were overusing these medications. They found that women, but not men, who were not overusing acute medications had more WML compared with controls and those who were overusing medications. As reported by other researchers, the number of WML increased with age. Interestingly, most patients who overused medications were taking non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen and naproxen. The authors concluded that taking NSAIDs may have a preventive effect on the development of WMLs, possibly because of their anti-inflammatory properties. Previous studies have shown that aspirin does not even cause medication overuse headaches, unlike drugs with caffeine (Excedrin, Fiorinal, Fioricet), opioid analgesics (Vicodin, Percocet, codeine, etc), and to a lesser extent NSAIDs. --- ### Headaches due to increased pressure in the head - Published: 2014-06-09 - Modified: 2014-06-09 - URL: https://www.nyheadache.com/blog/headaches-due-to-increased-pressure-in-the-head/ - Categories: Brain disorders Idiopathic intracranial hypertension is also called pseudotumor cerebri because just like with a brain tumor, the pressure is increased inside the skull. This condition usually presents with a headache and sometimes with visual symptoms. Increased intracranial pressure is not only a very painful condition, but also, if left untreated, can cause loss of vision and strokes. An observational study just published in JAMA Neurology reports on 165 patients with pseudotumor seen by a group of neurologists and ophthalmologists across the country. The mean age of these patients was 29 and only 4 were men. The vast majority of them were obese with an average body mass index of 40, while normal is below 25. Headache was present in 84% of patients and 68% reported transient loss of vision. Half of them had back pains and pulse-like noise in the ears (pulsatile tinnitus) was reported by 52%. Visual loss was found in 32% and it was usually loss of the peripheral vision with an enlarged blind spot in the middle. The authors concluded that pseudotumor cerebri mostly occurs in young obese women. The importance of this report is in reminding physicians to consider this diagnosis in young obese women with headaches. The diagnosis is confirmed by performing a lumbar puncture (spinal tap), which is the only way to measure intracranial pressure. An MRI scan is also always done (before the spinal tap), to make sure that it is not a real tumor that is causing increased pressure and to visualize ventricles... --- ### Wikipedia has wrong information - Published: 2014-06-01 - Modified: 2014-06-01 - URL: https://www.nyheadache.com/blog/wikipedia-has-wrong-information/ - Categories: Uncategorized 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. --- ### LSD, 'shrooms, psilocybin for cluster headaches - Published: 2014-05-27 - Modified: 2014-05-27 - URL: https://www.nyheadache.com/blog/lsd-shrooms-psilocybin-for-cluster-headaches/ - Categories: Alternative Therapies, Cluster headaches, New treatments Cluster headache patients have been coming to our office in increasing numbers in the past few weeks. We seem to be in a cluster season - many patients with cluster headaches come within the same month or two and then, for several months we see very few cluster patients. Many cluster headache sufferers ask about the efficacy of LSD, hallucinogenic mushrooms and seeds. The use of hallucinogens for cluster headaches was first reported by a Scottish man in 1998. He started using LSD for recreation and for the first time in many years had a year without cluster headaches. The first report in scientific literature appeared in 2006 in the journal Neurology. Dr. Sewell and his colleagues surveyed 53 cluster headache sufferers, of whom 21 had chronic cluster headaches. Half of those who tried LSD reported complete relief. Researchers are trying to study a version of LSD (brominated LSD) that does not cause hallucinations. This form of LSD was reported in the journal Cephalalgia to stop cluster attacks in all five patients it was given to. It is not clear if any additional studies are underway, but one American doctor, John Halpern is trying to bring this product to the market in the US. Trying to obtain LSD or hallucinogenic mushrooms carries legal risks, including incarceration. According to Dr. McGeeney, who is an Assistant Professor at Boston University School of Medicine, it is legal to buy, cultivate, and sell seeds of certain hallucinogenic plants, such as Rivea Corymbosa, Hawaiian baby... --- ### New migraine drugs in the pipeline - Published: 2014-05-26 - Modified: 2014-05-26 - URL: https://www.nyheadache.com/blog/new-migraine-drugs-in-the-pipeline/ - Categories: New treatments Two new migraine drugs are about to be released on the market. They were mentioned in this blog in their earlier stages of development. Another two drugs are more interesting, but are several years away from becoming available (if at all). Zecuity is a patch that delivers sumatriptan (active ingredient in Imitrex) through the skin. The patch contains a small battery and the electric current it generates helps the medicine penetrate through the skin. The patch is particularly useful when migraine is accompanied by nausea and vomiting. The main side effect of the patch, compared to the tablet, is that it causes irritation of the skin in one third of patients. This product was already approved by the FDA and will be soon available in pharmacies from its manufacturer, Teva Pharmaceuticals. Levadex is a drug inhaled into the lungs using a device similar to those used for asthma drugs. It contains dihydroergotamine - a very old and very effective injectable drug. Dihydroergotamine does not work well in a nasal spray (Migranal) or when taken by mouth. Levadex causes less side effects, such as nausea, than the injection of this drug. The main target population for this drug is also migraine sufferers who experience nausea and vomiting and for whom tablets do not work. Because it works very fast it may be also very effective for those whose headache starts and escalates to a severe intensity very quickly, which includes not only migraine, but also cluster headache sufferers. Levadex is manufactured... --- ### Botulinum toxin may help even the heart - Published: 2014-05-17 - Modified: 2014-05-17 - URL: https://www.nyheadache.com/blog/botulinum-toxin-may-help-even-the-heart/ - Categories: New treatments The versatility of botulinum toxin continues to amaze. The use of botulinum toxin (Botox) for the treatment of migraine headaches (pioneered at the New York Headache Center) is becoming widespread in the US. The original FDA-approved indications for botulinum toxin was a rare eye condition, blepharospasm as well as strabismus. The number of indications (not all of them yet FDA-approved) for botulinum toxin has increased very quickly - from cosmetic use for wrinkles to gastrointestinal disorders (narrowing of the esophagus, rectal fissures), excessive sweating, muscle spasticity of cerebral palsy and following a stroke, neuropathic pain (neuropathy, trigeminal neuralgia, shingles), spastic bladder (which causes frequent urination), and other. Injecting botulinum toxin into the fat pads around the heart after coronary bypass surgery seems to reduce the incidence of atrial fibrillation, an irregular hear beat. This is the conclusion of a randomized and blinded study of 60 patients, half of whom were injected with saline water and the other half with botulinum toxin (not Botox, but one of the other 3 botulinum toxin products, Xeomin). Patients who received injections of botulinum toxin instead of saline water had a significantly lower rate of irregular heart beats in the first 30 days (30% versus 7%), according to Evgeny Pokushalov, MD, PhD, of the State Research Institute of Circulation Pathology in Novosibirsk, Russia. Injections of botulinum toxin around the heart did not cause any complications or side effects. These irregularities of heart rhythm can be dangerous and if these findings are confirmed, botulinum toxin injections... --- ### Narcotics (opioids) are still overused in ERs for migraines - Published: 2014-05-11 - Modified: 2014-05-11 - URL: https://www.nyheadache.com/blog/narcotics-opioids-are-still-overused-in-ers-for-migraines/ - Categories: Headaches, New treatments - Tags: aura, ER, Imitrex, ketorolac, migraine, narcotic, opioid, Reglan, sumatriptan, Toradol Triptans, such as Imitrex or sumatriptan and similar drugs are "designer" drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers. In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn't changed. Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx. In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients. Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not... --- ### Antibodies bode well for migraines - Published: 2014-05-06 - Modified: 2014-05-06 - URL: https://www.nyheadache.com/blog/antibodies-bode-well-for-migraines/ - Categories: New treatments Antibodies blocking a specific neurotransmitter involved in migraines appear to relieve migraine headaches. Two studies presented at the annual meeting of the American Academy of Neurology reported on the use of antibodies to CGRP (calcitonin gene-related peptide) for the treatment of migraine headaches. These were relatively small, but highly scientific (randomized, double-blind, and placebo-controlled) studies. The studies was conducted in patients with frequent migraines. The two studies used two different antibodies developed by different companies. The results of the trials suggest that this approach is both effective and safe in preventing migraine, at least according to these preliminary studies. If these antibodies are proven to be indeed safe and effective, they will be the first specific migraine therapy since the introduction of triptans over 20 years ago. Triptans (sumatriptan and other) are abortive drugs, meaning that abort a migraine attack, while CGRP antibodies are used for the preventive (prophylactic) treatment. While Botox was approved three years ago for the preventive treatment of chronic migraines it was not specifically developed for the treatment of migraines. Instead, Botox was found to have this effect accidentally. One phase II proof-of-concept trial enrolled 218 people with 4 to 14 migraine headache days per month and randomly assigned them to get the antibody or a placebo. The study medication was given every 2 weeks by subcutaneous injection. Active treatment resulted in reduction of an average of 4. 2 migraine days per month in the third month for those on the active drug and a drop... --- ### FDA warning on epidural steroid injections. - Published: 2014-04-29 - Modified: 2014-04-29 - URL: https://www.nyheadache.com/blog/fda-warning-on-epidural-steroid-injections/ - Categories: New treatments, Pain Epidural steroid injections are popular for persistent neck and back pains. Patients with migraine and other headaches often have neck pain as well and if they happen to visit an anesthesiologist/pain specialist instead of a neurologist, there is a good chance they will be offered a cervical epidural steroid injection. If you or someone you know are offered such injections, just say no. Despite the widespread use of this procedure, there is no good scientific evidence that these injections help. Not only they probably do not help, they can cause serious side effects. The US Food and Drug Administration (FDA) is warning that injection of corticosteroids into the epidural space of the spine may result in rare but serious adverse events, including loss of vision, stroke, paralysis, and death. The FDA is requiring the addition of a warning to the drug labels of injectable corticosteroids to describe these risks. The FDA said that "Injectable corticosteroids are commonly used to reduce swelling or inflammation. Injecting corticosteroids into the epidural space of the spine has been a widespread practice for many decades; however, the effectiveness and safety of the drugs for this use have not been established, and the FDA has not approved corticosteroids for such use. " The FDA reviewed cases of serious neurological adverse events associated with epidural corticosteroid injections. Serious adverse events included death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, and brain edema. Some doctors perform these injections under X-ray guidance, but even then... --- ### It is not stress, but relaxation after is what triggers a migraine - Published: 2014-04-22 - Modified: 2014-04-22 - URL: https://www.nyheadache.com/blog/it-is-not-stress-but-relaxation-after-is-what-triggers-a-migraine/ - Categories: Alternative Therapies, Science of Migraine Stress is considered to be one of the main migraine triggers. However, a study just published in the journal Neurology suggests that it is the period after stress when people are more likely to develop a migraine. A group of doctors at the Montefiore Hospital in the Bronx led by Dr. Richard Lipton enrolled 22 participants, of whom 17 completed their diaries. These migraine sufferers made 2,011 diary entries including 110 migraine attacks eligible for statistical analysis. Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with an increased chance of migraine over the subsequent 6 to 18 hours. The authors concluded that the reduction in stress from one day to the next is associated with migraine onset the next day. They said that "The decline in stress may be a warning sign for an impending migraine attack and may create opportunities for preemptive drug or behavioral interventions. " What they meant is that people could try meditation and other relaxation techniques or, if that is ineffective, they could take a medication ahead of time. Taking medication before headache starts is often more effective and requires milder and fewer drugs than if a migraine is already in full bloom. Many migraine sufferers know that changes in sleep, meal intake, weather, and stress can trigger an attack. So, it is important to keep your life stable as much as possible. Biofeedback, meditation and other relaxation techniques, as... --- ### Nasal sprays for migraines are underprescribed. - Published: 2014-04-16 - Modified: 2014-04-16 - URL: https://www.nyheadache.com/blog/nasal-sprays-for-migraines-are-underprescribed/ - Categories: New treatments An oral tablet is the most convenient way to take medicine. However, many migraine sufferers wake up with a headache that is in full bloom and severe nausea or vomiting makes it difficult to take oral medications. Others find that tablets are ineffective or take too long to work. Sumatriptan (Imitrex), the miracle migraine drug which has changed lives of millions of migraine and cluster headache sufferers, was first released in an injection. The injection is still available and is the most effective way to stop a migraine. The injection comes in a variety of pre-filled syringes and cartridges, which are very easy to self-inject. The problem with injections is that some people don't like the idea of injecting themselves, which is surprising, considering how much pain and suffering they endure from migraine. Another problem is the cost - even in a generic form a shot costs $35 (see GoodRx. com for cheapest prices). The biggest reason why injections are underutilized is that doctors fail to offer this option to patients, many of whom would be happy to use it. Nasal sprays offer a middle ground option - not as fast or effective as an injection, but faster and sometimes more effective than a tablet. There are several medications available in a nasal spray. The same triptan medication, sumatriptan comes in a nasal spray. However, another triptan, zolmitriptan (Zomig NS) in my experience is more effective. The disadvantage of Zomig is that it is very expensive if not covered by... --- ### Lack of sleep may not only cause headaches, but also shrink your brain. - Published: 2014-04-09 - Modified: 2014-04-09 - URL: https://www.nyheadache.com/blog/lack-of-sleep-may-not-only-cause-headaches-but-also-shrink-your-brain/ - Categories: Science of Migraine Sleep deprivation is a very common trigger of migraine and tension-type headaches. Scientists have always wondered about the purpose of sleep. We know that sleep helps strengthen our memories. New research suggests that sleep is also needed for other housekeeping chores, such as cleaning junk out of our brains. Literally, the brain rids itself of damaged proteins during sleep. It appears that poor sleep quality leads to accumulation of these proteins, which can lead to a higher risk of Alzheimer's disease. Another recent study showed that people with insomnia tended to have smaller brain volume in certain regions of the brain, particularly frontal lobes. Other research showed that a variety of psychiatric illnesses also lead to a reduced brain volume. The frontal lobes are necessary for planning our actions, mood, and affect. Veterans with post-traumatic stress disorder (PTSD) frequently complain about sleep difficulties and have documented high rates of sleep disorders In the latest study, the researchers scanned the brains of 144 veterans using magnetic resonance imaging (MRI). The participants with poor sleep quality had less frontal lobe gray matter than vets who reported sleeping well. These veteran had other psychological disorders, in addition to the sleep disorder. Half of them abused alcohol, 40 percent had depression and 18 percent had PTSD. The connection between sleep disorders and the brain volume was not affected by psychiatric medications. The researchers speculated that these findings are not necessarily limited to veterans. However, they were careful to stress that their findings do not... --- ### Vitamin D is again in the news. Enough already. - Published: 2014-04-07 - Modified: 2014-04-07 - URL: https://www.nyheadache.com/blog/vitamin-d-is-again-in-the-news-enough-already/ - Categories: Uncategorized There is no debate about the fact that there is an epidemic of vitamin D deficiency in the United States - it affects about two thirds of the population. However, it is bewildering why scientists are still debating if people should be taking vitamin D supplements. You would think that this is a pretty obvious, common sense conclusion. But common sense is far from common, especially in academia (and obviously not just in medicine - it is much worse in the "soft" social sciences). Two major studies published in the highly respected British Medical Journal reviewed studies that involved data on more than a million people. Both studies showed that vitamin D provided significant benefits. Vitamin D appears to protect against major diseases. Adults with lower levels of vitamin D had a 35% increased risk of dying from heart disease,14% greater risk of dying from cancer, and a higher risk of dying from any cause. Taking vitamin D reduced the risk of dying from all causes by 11%. The authors estimate that 13% of all deaths in the US are due to low vitamin D levels. This is an astonishing discovery, on the par with the discovery that aspirin dramatically reduces the risk of different types of cancer. So, a reasonable person would expect the medical community to begin recommending vitamin D supplementation, at least for those with low levels. But here is what one of the authors said:: "Based on what we found, we cannot recommend widespread supplementation". He... --- ### Predicting response to Botox injections - Published: 2014-04-01 - Modified: 2014-04-01 - URL: https://www.nyheadache.com/blog/predicting-response-to-botox-injections/ - Categories: New treatments - Tags: Botox, cgrp, chronic migraine A good predictor of response to Botox injections in chronic migraine patients has been found by Spanish researchers. While Botox is a very effective treatment for chronic migraines and possibly other types of headaches and pain, it does not help everyone. Approximately 30% of patients with chronic migraine headaches do not respond to Botox. We usually try at least two sets of injections three months apart before considering the patient to be a non-responder. Considering that Botox is an expensive treatment, it would be very useful to know beforehand which patients will respond and which will not. Besides the cost, it would also save patients time, during which they could be trying other treatments. Some studies show that having a constricting headache or pain in the eye is usually a positive predictor of response to Botox. On the other hand, exploding headache (that is when the pain is felt pushing from the inside out), is less likely to respond to Botox injections. However, these are very subjective descriptions and predictions based on them are not that reliable. A new study by Spanish researchers just published in the journal Headache reported that the levels of CGRP (calcitonin gene-related peptide) and VIP (vasoactive intestinal peptide) in patients' blood are good predictors of response to Botox in chronic migraine sufferers. These two chemicals, which circulate in the blood and perform various important functions in the brain have long been the subject of scientific research. Actually, we think that Botox works by blocking the... --- ### Topiramate (Topamax) is approved by the FDA for adolescents. - Published: 2014-03-29 - Modified: 2014-03-29 - URL: https://www.nyheadache.com/blog/topiramate-topamax-is-approved-by-the-fda-for-adolescents/ - Categories: Headache medications, New treatments Yesterday, the FDA approved the first preventive (prophylactic) treatment for migraines in adolescents - kids between the ages of 12 and 17. Topamax (topiramate) was first approved by the FDA in 1996 to prevent seizures. It was approved for migraine prevention in adults in 2004. As the FDA stated in its announcement, “Migraine headaches can impact school performance, social interactions, and family life. Adding dosing and safety information for the adolescent age group to the drug’s prescribing information will help to inform health care professionals and patients in making treatment choices. ” The announcement also stated that "About 12 percent of the U. S. population experiences migraine headaches. Migraine headaches are characterized by episodes of throbbing and pulsating pain in the head, and may occur several times per month. Other common symptoms include increased sensitivity to light, noise, and odors, as well as nausea and vomiting. Many patients experience their first migraine attack before reaching adulthood, and migraine can be just as disabling in teens as it is in adults. The safety and effectiveness of Topamax in preventing migraine headaches in adolescents ages 12 to 17 was established in a clinical trial that enrolled 103 participants. Those treated with Topamax experienced a decrease in the frequency of migraine of approximately 72 percent compared to 44 percent in participants that took an inactive drug (placebo). The most common adverse reactions with the approved dose of Topamax (100 milligrams) were paresthesia (a burning or prickling sensation felt in the hands, arms, legs,... --- ### More evidence that Botox relieves not only migraine headaches, but also depression. - Published: 2014-03-21 - Modified: 2014-03-21 - URL: https://www.nyheadache.com/blog/more-evidence-that-botox-relieves-not-only-migraine-headaches-but-also-depression/ - Categories: New treatments The beneficial effect of Botox on mood has been reported for years. I mentioned this in one of my blog posts in 2011. Now, a new and highly scientific study (double-blind, placebo-controlled) which is about to be published in the Journal of Psychiatric Research confirms that Botox relieves depression. The study is described in today's New York Times. I have also heard from many of my own patients who receive Botox for chronic migraines that their mood improves, although in their case it could be to a great extent because their headaches improve. --- ### What to ask for if your migraine lands you in the emergency room. - Published: 2014-03-19 - Modified: 2014-03-19 - URL: https://www.nyheadache.com/blog/what-to-ask-for-if-your-migraine-lands-you-in-the-emergency-room/ - Categories: Headache medications, Headaches, New treatments A severe migraine attack can sometimes land you in an emergency room. With its bright lights, noise, and long waits, it is the last place you want to be in. To add insult to the injury, some doctors will think that you are looking for narcotic drugs and treat you with suspicion, while others will offer ibuprofen tablets. It is hard to think clearly when you are in the throes of a migraine, so you need to be prepared and have a list of treatments you may want to ask for, just in case the ER doctor is not good at treating migraines. If you are vomiting, first ask for intravenous hydration and insist on having at least 1 gram of magnesium added to the intravenous fluids. Everyone with severe migraines should have sumatriptan (Imitrex) injection at home since it often eliminates the need to go to an ER in the first place. If you haven't taken a shot at home, ask for one in the ER. The next best drug is a non-narcotic pain medicine, ketorolac (Toradol) and if you are nauseous, metoclopramide (Reglan). Do not let the doctor start your treatment with divalproex sodium (Depakene, drug similar to an oral drug for migraine prophylaxis, Depakote) or opioid (narcotic drugs) such as demerol, morphine, hydromorphone and other. This post was prompted by an article just published in the journal Neurology by emergency room doctors at the Montefiore Hospital in the Bronx. It was a double-blind trial which compared intravenous... --- ### Cefaly is approved by the FDA for sale in the US. - Published: 2014-03-11 - Modified: 2014-03-14 - URL: https://www.nyheadache.com/blog/cefaly-if-approved-by-the-fda-for-sale-in-the-us/ - Categories: Alternative Therapies, Headaches Cefaly, a TENS unit specifically developed for the treatment of migraine headaches, was cleared for sale in the US. It was available last year for a short time on Amazon. com, but because it was not yet approved, it was taken off the market. I mentioned in my previous post that TENS units have been in use for muscle and nerve pain for decades. TENS has good proof of efficacy in musculo-skeletal pain, but studies in migraines have been relatively small. Even Cefaly was tested in only 67 migraine patients. So, while it is not definitely proven effective, TENS is safe and is worth a try if usual treatments do not help. Cefaly is easy to use but it is expected to cost around $300. The old-fashioned TENS units are not as convenient to use, but sell for as little as $50. Both Cefaly and regular TENS units require doctor's prescription, although many websites sell TENS units without one. These devices are usually powered by a 9 volt battery and, unless you have a pacemaker or another electrical device in your body, the risk of side effects is low. --- ### The role of hormones in headache - Published: 2014-03-10 - Modified: 2014-03-10 - URL: https://www.nyheadache.com/blog/the-role-of-hormones-in-headache/ - Categories: Science of Migraine Imbalance of many hormones produced by our endocrine system can lead to headaches. Here is a brief summary of the hormones linked to headaches. --- ### Invasive treatments for trigeminal neuralgia - Published: 2014-03-05 - Modified: 2014-03-05 - URL: https://www.nyheadache.com/blog/invasive-treatments-for-trigeminal-neuralgia-2/ - Categories: New treatments, Trigeminal and other neuralgias - Tags: invasive, neuralgia, percutaneous, trigeminal Trigeminal neuralgia (TN) is an excruciatingly painful disorder which affects about one in a thousand people. Patients describe the pain of TN as an electric shock going through the face. Eating and talking often triggers the pain, so some patients become malnourished and depressed. The pain is brief, but can be so frequent and severe that it causes severe disability, weight loss, severe anxiety, and depression. The good news is that most people can obtain relief by taking drugs, such as Tegretol (carbamazepine), Trileptal (oxcarbazepine), Dilantin (phenytoin), or Lioresal (baclofen). I have successfully treated several patients who did not respond to these medications with Botox injections. Patients who do not respond to medications or Botox injections have several surgical options available. According to a new Dutch "Nationwide study of three invasive treatments for trigeminal neuralgia" published in journal Pain shows that every year about 1% of those suffering from TN undergo surgery. Of the three most common types of surgery, percutaneous radiofrequency thermocoagulation (PRT) is by far most popular - in a three year period in Holland, 672 patients underwent PRT, 87 underwent microvascular decompression (MVD), and 39 underwent partial sensory rhizotomy (PSR). The latter two procedures a performed by neurosurgeons (MVD requires opening of the skull), while PRT is usually done by anesthesiologists (a probe is inserted through the cheek to the nerve ganglion under X-ray guidance). MVD was most effective, but caused more complications than PRT, although fewer than with PSR. More patients having PRT had to have... --- ### Acetaminophen (Tylenol) in pregnancy is not as safe as thought. - Published: 2014-02-26 - Modified: 2014-02-26 - URL: https://www.nyheadache.com/blog/acetaminophen-tylenol-in-pregnancy-is-not-as-safe-as-thought/ - Categories: Brain disorders, Headache medications - Tags: acetaminophen, adhd, aspirin, pregnancy, sumatriptan, Tylenol Tylenol (acetaminophen, or in Europe it is called paracetamol) is the go-to drug for pain, headaches, and fever during pregnancy. A new study just published in the journal JAMA Pediatrics indicates that this drug may not be as safe as previously thought. Animal research has long suggested that acetaminophen is a so called hormone disruptor, a substance that changes the normal balance of hormones. It is a well-established fact that an abnormal hormonal exposures in pregnancy may influence fetal brain development. Danish researchers decided to evaluate whether prenatal exposure to acetaminophen increases the risk for developing attention-deficit/hyperactivity disorder (ADHD) in children. They studied 64,322 live-born children and mothers enrolled in the Danish National Birth Cohort during 1996-2002. The doctors used parental reports of behavioral problems in children 7 years of age using a specific questionnaire, retrieved diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry, and identified ADHD prescriptions (mainly Ritalin) for children from the Danish Prescription Registry. More than half of all mothers reported acetaminophen use while pregnant. Children whose mothers used acetaminophen during pregnancy were at about 1. 3 times higher risk for receiving a hospital diagnosis of ADHD, use of ADHD medications, or having ADHD-like behaviors at age 7 years. Stronger associations were observed with use in more than 1 trimester during pregnancy and with higher frequency of intake of acetaminophen. The researchers concluded that maternal acetaminophen use during pregnancy is associated with a higher risk for ADHD-like behaviors in children. This presents... --- ### Topiramate caused osteoporosis in my patient. - Published: 2014-02-23 - Modified: 2014-02-23 - URL: https://www.nyheadache.com/blog/topiramate-caused-osteoporosis-in-my-patient/ - Categories: Headache medications One of my patients I saw last week developed osteoporosis while taking Topamax (topiramate). Topiramate is known to cause osteoporosis by causing loss of calcium through the kidneys. While osteoporosis is not common, we don't know if it is really that rare. A side effect that was thought to be rare (less than 1%, according to the manufacturer) when the drug was launched, is kidney stones. Now we know that close to 20% of people taking topiramate for a long time, develop kidney stones. Both kidney stones and osteoporosis occur through similar mechanisms, so it is possible that osteoporosis is also much more common than doctors think. This patient had no other side effects and topiramate was very effective in controlling her migraines. Since osteoporosis is a very serious and potentially dangerous condition, she will have to stop taking topiramate. However, she does have other options because she has never tried Botox injections and several other drugs for the prevention of migraines. Another very serious side effect that is not obvious to women taking Topamax, is the potential for serious problems in the fetus. The FDA designates topiramate as belonging to category D: "Pregnancy Category D drugs are those with positive evidence of human fetal risk based on human data, but still may be used in pregnant women in certain situations when its benefits are thought to outweigh potential risks". Drugs in category B are considered to be safe in pregnancy, while category C means that there is not enough... --- ### Vitamin D and migraine headaches. - Published: 2014-02-19 - Modified: 2014-02-19 - URL: https://www.nyheadache.com/blog/vitamin-d-and-migraine-headaches/ - Categories: Alternative Therapies Vitamin D has been reported to be low in patients with migraines as well as a host of other medical conditions. The big question is whether this is just a coincidence or a cause-and-effect relationship. In some conditions, such as multiple sclerosis, people with higher vitamin D levels have fewer relapses than those with lower levels, indicating a direct benefit of vitamin D. In other diseases, such as Alzheimer's, strokes, and migraine this relationship is not clear. A new study by Iranian doctors published in BioMed Research International shows that vitamin D deficiency is found in about half of 105 migraine patients they tested. However, when they looked at 110 matched controls without migraines, they found that half of them were also deficient. They also found that those with more severe migraines did not have lower levels than those with milder ones. This strongly suggests that vitamin D has no effect on migraine headaches. So if you suffer from migraines, do not expect vitamin D to improve your headaches. However, if your blood test shows a deficiency, you should definitely take a vitamin D supplement to avoid some known and possibly some yet unknown problems. Taking the daily recommended dose of 600 units may not be sufficient and you may need to recheck your level to make sure that you are absorbing it. Some of my patients have needed as much as 5,000 units daily to get their vitamin D level to normal range. --- ### Beware of some generic drugs. - Published: 2014-02-15 - Modified: 2014-02-15 - URL: https://www.nyheadache.com/blog/beware-of-some-generic-drugs/ - Categories: Headache medications Generic drugs provide significant savings and 80% of all prescriptions in the US are filled with generic drugs. Many doctors are skeptical when patients complain that the generic is not as good as the brand. But not all generics are created equal, literally. For example, there are about 10 generic manufacturers of Imitrex (sumatriptan). I've had patients tell me that certain generics, particularly the ones made by an Indian company Ranbaxy, are much less effective than the brand or generics made by other manufacturers. This problem is widespread and one of my previous posts described a study of the use of generic Topamax (topiramate) in epilepsy patients (this drug is also approved for the prevention of migraines). Patients on a generic were admitted to the hospital more often, had longer hospital stays, and were three times more likely to sustain head injury or a bone fracture. Yesterday, The New York Times published an expose on the generic manufacturers in India. Ranbaxy was one of the generic drug makers that was reported to have the most problems. Its plants are being repeatedly shut down by the American FDA, who also imposed a $500 million fine. The article cites understaffed regulatory bodies and corruption as the main reasons for poor quality controls. One survey showed that 12% of medications sold in India contained no active ingredients, including life-saving drugs such as antibiotics and cancer drugs. It is not clear what percentage of drugs entering the US is adulterated. At least in India... --- ### Magnesium improves response to Tylenol and Advil in kids with migraines. - Published: 2014-02-10 - Modified: 2014-02-10 - URL: https://www.nyheadache.com/blog/magnesium-improves-response-to-tylenol-and-advil-in-kids-with-migraines/ - Categories: Headaches in children - Tags: acetaminophen, children, ibuprofen, magnesium, migraine, migralex, sumatriptan Children with migraine headaches are usually given acetaminophen (Tylenol) or ibuprofen (Advil). A group of Italian doctors compared responses to these two drugs in kids with migraines who took a daily magnesium supplement to those who did not. Results of their study were published in the latest issue of the journal Headache. One hundred sixty children (80 boys and 80 girls) aged 5-16 years were enrolled and assigned to four groups to receive a treatment with acetaminophen or ibuprofen without or with magnesium. The dose of each drug was adjusted according to the child's weight. Those children who were in the magnesium arm were given 400 mg of magnesium (the article does not mention which salt of magnesium was given - oxide, glycinate, citrate, or another). Migraine pain severity and monthly frequency were similar in the four groups before the start of the study. Both acetaminophen and ibuprofen produced a significant decrease in pain intensity, but not surprisingly, did not change the frequency of attacks. Magnesium intake induced a significant decrease in pain intensity in both acetaminophen- and ibuprofen-treated children and also significantly reduced the time to pain relief with acetaminophen but not ibuprofen. In both acetaminophen and ibuprofen groups, magnesium supplementation significantly reduced the attack frequency after 3 and 18 months of supplementation. This study was not the most rigorous because it did not include a placebo group as the authors felt that placing children on a placebo would be unethical. However, it was rigorous in other respects and... --- ### White matter lesions on MRIs of children with migraine. - Published: 2014-02-05 - Modified: 2014-02-05 - URL: https://www.nyheadache.com/blog/white-matter-lesions-on-mris-of-children-with-migraine/ - Categories: Headaches in children - Tags: aura, migraine, MRI children, white matter lesion, WML White matter lesions that often seen on MRI scans of adult migraine sufferers were also found in children. A study by Washington University researchers inn St. Louis examined MRI scans of 926 children 2 to 17 years of age (mean age was 12. 4 and 60% were girls) who were diagnosed with migraine headaches. They found white matter lesions (WMLs) in about 4% or 39 of these children, which is not much higher than in kids without migraines. Just like in the adults, these WMLs were slightly more common in kids with migraine with aura. None of these lesions were big enough to be called a mini-stroke or an infarct. There was no correlation between the number of lesions and the frequency or the duration of migraines. In conclusion, WMLs in children with migraines do not appear to be caused by migraines and are most likely benign in origin. The origin, however remains unknown, which often causes anxiety in parents of these children. Unlike in children, adults with migraines and especially those with migraines with aura, are much more likely to have WMLs than adults without migraines. But even in adults, these appear to be benign as I mentioned in my previous post. --- ### More on daily intake of triptans (sumatriptan or Imitrex and other similar drugs) - Published: 2014-01-27 - Modified: 2014-01-27 - URL: https://www.nyheadache.com/blog/more-on-daily-intake-of-triptans-sumatriptan-or-imitrex-and-other-similar-drugs/ - Categories: Headache medications "Daily triptan use for intractable migraine" is the title of a report by Dr. Egilius Spierings published in the latest issue of the journal Headache. This is a controversial topic, which I addressed in a previous post. Dr. Spierings, who is affiliated with both Tufts Medical Center and Harvard Medical School presents a case of a 50-year-old woman who failed trials of multiple preventive medications. This woman responded well to sumatriptan, 100 mg, which she took daily and occasionally twice a day with excellent relief and no side effects. Dr. Spierings discusses the evidence for Medication Overuse Headaches (MOH), which is common with caffeine-containing drugs, butalbital (a barbiturate), and opioid drugs (narcotics). It is less clear whether triptans cause MOH and he mentions that most patients who end up taking a daily triptan do so only after they failed many preventive (prophylactic) drugs and after they discover that they can have a normal life if they take a triptan daily. This applies not only to sumatriptan, but any other similar drug, such as Amerge (naratriptan), Zomig (zolmitriptan), Maxalt (rizatriptan), Relpax (eletriptan), and other. After 20 years of being on the market, we have no evidence that these drugs have any long-term side effects. In Europe several of these drugs are sold without a prescription. The major obstacle to their daily use has been the cost. However, several of these medications are now available in a generic form and a 100 mg sumatriptan tablet costs as little as $1. 50. --- ### Prilosec, Nexium and other heartburn drugs cause vitamin B12 deficiency. - Published: 2014-01-21 - Modified: 2014-01-21 - URL: https://www.nyheadache.com/blog/prilosec-nexium-and-other-heartburn-drugs-cause-vitamin-b12-deficiency/ - Categories: Alternative Therapies Many headache sufferers take over-the-counter medications which can cause upset stomach and heartburn due to reflux. Many will then resort to taking acid lowering drugs. These drugs reduce acidity which also impairs absorption of various vitamins and minerals, including vitamin B12, D, magnesium, and other. Magnesium deficiency is known to worsen migraine and cluster headaches. The most popular drugs for indigestion, reflux, and stomach ulcers are so called proton-pump inhibitors, or PPIs (Prilosec, Protonix, Nexium, and other), and histamine 2 receptor antagonists (Zantac, Tagamet), and they are available by prescription and over the counter. Over 150 million prescriptions were written for PPIs alone last year. A new study, published in The Journal of the American Medical Association by Dr. D. Corley and his colleagues shows that people who are taking these medications are more likely than the average person to be vitamin B12 deficient. The study was performed at Kaiser Permanente. It involved 25,956 adults who were found to have vitamin B12 deficiency between 1997 and 2011, and who were compared with 184,199 patients without B12 deficiency during that period. Patients who took acid lowering drugs for more than two years were 65 percent more likely to have a vitamin B12 deficiency. Higher doses of PPIs were more strongly associated with the vitamin deficiency, as well. Twelve percent of patients deficient in vitamin B12 had used PPIs for two years or more, compared with 7. 2 percent of control patients. The risk of deficiency was less pronounced among patients using... --- ### Placebo is underrated. - Published: 2014-01-12 - Modified: 2014-01-12 - URL: https://www.nyheadache.com/blog/placebo-is-underrated/ - Categories: Headache medications Placebo effect is a curse for medical researchers. Every new treatment has to be shown to be better than placebo and placebo is often very effective. In clinical practice, unlike in research, placebo effect is a good thing, but many doctors fail to maximize its effect. If the doctor emphasizes all of the potential side effects and does not stress positive attributes of a drug, the patient is not likely to respond well. However, if the doctor is enthusiastic about the efficacy of a drug, the results can be dramatically different. Obviously, side effects need to be mentioned as well, but if the drug is really dangerous, it should not be prescribed in the first place. The importance of placebo effect specifically with migraine drugs was described in a study published in Science Translational Medicine. The findings confirm that patients who receive positive messages about the potential efficacy of their treatment may have better treatment outcomes than patients who receive negative messages. The study involved 66 migraine sufferers with intermittent attacks. Patients first recorded their baseline pain intensity on a scale from zero (no pain) to ten (maximal pain) for an untreated migraine attack. Then each study participant received a series of six envelopes containing treatment for six subsequent migraine attacks: two of the envelopes were labeled as “placebo”, two as “Maxalt” (rizatriptan, one of the the anti-migraine drugs called triptans) and two as “placebo or Maxalt. ” However, for each pair of envelopes with identical labels, one envelope actually... --- ### Rest your brain after a head injury. - Published: 2014-01-07 - Modified: 2014-01-07 - URL: https://www.nyheadache.com/blog/rest-your-brain-after-a-head-injury/ - Categories: Head trauma - Tags: Botox, concussion, dizziness, head trauma, magnesium Strenuous mental activity seems to delay recovery after a head injury, according to a new study published in Pediatrics . Doctors have always recommended rest after a head injury, but it has never been clear how much to limit activities, what kind to limit (physical, mental, or both), and for how long. Dr. William P. Meehan III, director of the Micheli Center for Sports Injury Prevention in Waltham, Massachusetts and his colleagues studied 335 patients (62% were males), aged 8 to 23 who came to a sports concussion clinic within three weeks of their injury between 2009 and 2011. Most of the concussions were sustained while playing ice hockey, football, basketball or soccer. The researchers asked them about their symptoms and how often they were reading, doing homework or playing games at each of their appointments. Those with minimal cognitive activity were not reading or doing homework, and spent less than 20 minutes on the Internet or playing video games each day. They could have watched TV or movies or listened to music. Those with moderate or significant cognitive activity did some reading and some homework, but less than usual. Others had not limited their cognitive activities at all since their last clinic visit. On average, patients took 43 days to fully recover from their concussions. Those with more minor concussions tended to get over their symptoms faster. So did those who did less with their brains while recovering. Results showed that only those engaging in the highest levels of... --- ### What if you do have a brain aneurysm? - Published: 2014-01-06 - Modified: 2014-01-06 - URL: https://www.nyheadache.com/blog/what-if-you-do-have-a-brain-aneurysm/ - Categories: Brain disorders Many people who experience severe headaches are often concerned about having a brain aneurysm. What prompted this post is a patient I just saw who was found to have a small (3 mm) aneurysm on a routine MRI scan as well as a new article just published in The Lancet Neurology. Considering that over 36 million Americans suffer from migraine headaches, this is by far the most common cause of severe headaches. However, aneurysms are not rare - more than 7 million Americans have them. The vast majority of these people do not know that they have an aneurysm and in 50 to 80 percent they never cause headaches or any other problems. Every year, more than 30,000 people do suffer a rupture of the aneurysm. The rupture of an aneurysm is what causes a very severe headache and about one in seven people with a rupture die before reaching the hospital. In addition to a severe headache, the hemorrhage from a ruptured aneurysm can cause a stiff neck, drowsiness, weakness or numbness on one side, difficulty speaking and other symptoms of a stroke. Dutch researchers analyzed the available data, trying to find predictors of aneurysm rupture. They discovered that the risk goes up with age, high blood pressure (hypertension), history of a previous brain hemorrhage, aneurysm size, its location and the geographic region. There is nothing one can do about age and other factors, but blood pressure is one factor that can be controlled. If the aneurysm is less... --- ### Ordering drugs from online pharmacies. - Published: 2014-01-01 - Modified: 2014-01-01 - URL: https://www.nyheadache.com/blog/ordering-drugs-from-online-pharmacies/ - Categories: Headache medications Branded triptan medications are extremely expensive with one pill of Relpax or Frova costing $30 - $40. Fortunately, Imitrex, Maxalt, Amerge, and Zomig tablets are available in a generic form. However, even the generic version of Amerge is $3 to $4 a pill, although generic Imitrex and Maxalt can be found for $2. Unfortunately, some patients respond only to Relpax, Frova or Zomig nasal spray, which insurance companies tend not to pay for. Other people need medications that are not available in the US, such as domperidone, an excellent drug for nausea or flunarizine, a calcium channel blocker for the preventive treatment of migraine (not such an excellent drug because of its side effects). Some patients who need a branded product or one not available in the US buy drugs from online Canadian pharmacies. But how do you know if the pharmacy is legitimate? Some sites that claim being a Canadian pharmacy in fact are not Canadian and the drugs they sell are fakes. One way to find a legitimate Canadian pharmacy is to check if it is certified by the Canadian International Pharmacy Association. You can also check if the pharmacy is certified by the PharmacyChecker. com and is listed on their free website. When buying locally, you can find a pharmacy with the cheapest price for a specific drug by going to GoodRx. com. But do not assume that if a pharmacy offers the lowest price on one drug, its prices on other drugs will also be the... --- ### Cognitive Behavioral Therapy Relieves Chronic Migraine in Children and Adolescents - Published: 2013-12-25 - Modified: 2013-12-25 - URL: https://www.nyheadache.com/blog/cognitive-behavioral-therapy-relieves-chronic-migraine-in-children-and-adolescents/ - Categories: Alternative Therapies Another large scientific article on the benefits of cognitive behavioral therapy (CBT) was just published in the Journal of the American Medical Association. In this study by doctors at the Cincinnati Children's Hospital led by Dr. Andrew Hershey, CBT was combined with amitriptyline (an antidepressant used for the treatment of pain and headaches) and compared to headache education plus amitriptyline. They enrolled 135 children (79% girls) aged 10 to 17 years who were diagnosed with chronic migraine (15 days with headaches per month or more) and who had migraine-related disability. The study was conducted between October 2006 and September 2012. An unusually large number of kids completed the trial - 129 completed 20-week follow-up and 124 completed 12-month follow-up. The treatment consisted of ten CBT or 10 headache education sessions involving equivalent time and therapists' attention. Each group received the same dose of amitriptyline per pound of weight. The main end point was days with headache and the secondary end point was the disability score determined at 20 weeks. Durability was examined over the 12-month follow-up period. The results at the 20-week end point showed that days with headache were reduced by 11. 5 for the CBT plus amitriptyline group vs 6. 8 for the headache education plus amitriptyline group.  The disability score decreased by 53 points for the CBT group vs 39 points for the headache education group.  At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education... --- ### Mindfulness may reduce pain not only in adults but also in adolescents. - Published: 2013-12-25 - Modified: 2013-12-25 - URL: https://www.nyheadache.com/blog/mindfulness-may-reduce-pain-not-only-in-adults-but-also-in-adolescents/ - Categories: Alternative Therapies Mindfulness appears to reduce the effect of pain on day-to-day functioning in adolescents, according to a new study published in The Journal of Pain by Canadian researchers. This was a scientifically rigorous study of 198 boys and girls aged 13 to 18 years. The researchers made an effort to recruit some children who meditated and some who did not. They were all subjected to the Child and Adolescent Mindfulness Measure questionnaire and to the Pain Catastrophizing Scale (questions such as "When I have pain I feel I can't stand it anymore). They were asked about their daily pains, such as headache, stomachache, tooth pain, muscle pain, back pain. They were also subjected to experimental pain, which was produced by submerging their hand into ice cold water. The results showed that mindfulness had a direct effect on pain interference with daily activity and an indirect effect on the experimental pain intensity and tolerance by producing less catastrophizing. The good news is that mindfulness is something that can be learned by meditation and can be taught as part of a course of cognitive-behavioral therapy. Kids with migraines, headaches, and other pains should be always advised to start with meditation, biofeedback, or cognitive-behavioral therapy. --- ### Chewing gum may cause headaches. - Published: 2013-12-20 - Modified: 2013-12-20 - URL: https://www.nyheadache.com/blog/chewing-gum-may-cause-headaches/ - Categories: Alternative Therapies, Science of Migraine Research by Israeli pediatric neurologists confirms the clinical observation that chewing gum can make headaches worse. By chewing gum teenagers and younger children appear to be giving themselves headaches, according to a study published in the journal Pediatric Neurology. Dr. Watemberg, the lead author said that "Out of our 30 patients, 26 reported significant improvement, and 19 had complete headache resolution. Twenty of the improved patients later agreed to go back to chewing gum, and all of them reported an immediate relapse of symptoms. " Headaches occur in about 6% of children before puberty and become three times as frequent in girls after puberty. Typical triggers are stress, lack of sleep, dehydration, skipping meals, noise, and menstruation. Teenage girl patients are more likely to chew gum - a finding supported by previous dental studies. Two previous studies linked gum chewing to headaches. One study suggested that gum chewing causes stress to the temporomandibular joint, or TMJ. The other study blamed aspartame, the artificial sweetener used in most popular chewing gums. Dr. Watemberg favors the TMJ explanation because gum does not contain much aspartame. I suspect that it is not the TMJ joint itself that is responsible for headaches, but tension in masticatory muscles - those we chew with. The main ones are temporalis muscles - the ones over the temples, and masseter - those at the corner of the jaw. I can sometimes tell that those muscles are at least in part responsible for headaches as soon as the patient... --- ### A new device is approved to treat migraine with aura. - Published: 2013-12-15 - Modified: 2013-12-15 - URL: https://www.nyheadache.com/blog/a-new-device-is-approved-to-treat-migraine-with-aura/ - Categories: Alternative Therapies, New treatments Transcranial magnetic stimulation (stimulation of the brain with a magnetic field) has been researched for over 30 years. It has been used to study the brain and to treat a variety of conditions, such as depression, Parkinson's, strokes, pain, and other. The U. S. Food and Drug Administration has "allowed marketing of the Cerena Transcranial Magnetic Stimulator (TMS), the first device to relieve pain caused by migraine headaches that are preceded by an aura: a visual, sensory or motor disturbance immediately preceding the onset of a migraine attack. " Here is an excerpt from the FDA News Release: "The Cerena TMS is a prescription device used after the onset of pain associated with migraine headaches preceded by an aura. Using both hands to hold the device against the back of the head, the user presses a button to release a pulse of magnetic energy to stimulate the occipital cortex in the brain, which may stop or lessen the pain associated with migraine headaches preceded by an aura. The FDA reviewed a randomized control clinical trial of 201 patients who had mostly moderate to strong migraine headaches and who had auras preceding at least 30 percent of their migraines. Of the study subjects, 113 recorded treating a migraine at least once when pain was present. Analysis of these 113 subjects was used to support marketing authorization of the Cerena TMS for the acute treatment of pain associated with migraine headache with aura. The study showed that nearly 38 percent of subjects... --- ### Video of Botox injections for chronic migraine. - Published: 2013-12-13 - Modified: 2013-12-13 - URL: https://www.nyheadache.com/blog/video-of-botox-injections-for-chronic-migraine/ - Categories: Uncategorized Botox is the most effective preventive treatment for chronic migraine headaches. It is also the only treatment approved by the FDA for this condition, which affects 3 to 4 million Americans. Despite the wide use of Botox for cosmetic indications, many people still have unfounded fears of this procedure. Some are afraid of the fact that it is a toxin and indeed, in large amounts it is deadly. However, acetaminophen (Tylenol) kills over 500 people every year, which is significantly more than all the deaths from Botox given to millions of people in over the 25 years that Botox has been on the market. There has been no deaths reported when Botox was used for headaches or cosmetic reasons. Botox is not free of side effects, but they tend to be mild and transient. Another fear is that the procedure is painful and very unpleasant. I recorded this video of me injecting one of my patients (with her permission) so that you can see what the procedure looks like. It took me 3 minutes and 41 seconds from start to finish and, as you can see, with little discomfort. --- ### FDA approves lower dose Sumavel (sumatriptan) needless injection. - Published: 2013-12-12 - Modified: 2013-12-12 - URL: https://www.nyheadache.com/blog/fda-approves-lower-dose-sumavel-sumatriptan-needless-injection/ - Categories: Headache medications The approval of the lower dose Sumavel device is a good opportunity to again remind migraine sufferers about the benefits of injectable sumatriptan. Many doctors do not even mention to their patients that sumatriptan is available in an injection that is easy to self-administer. Obviously, if a tablet of sumatriptan (Imitrex) or another triptan works quickly and prevents the headache from becoming disabling, there is no need for an injection. However, when the tablet does not work fast or well enough or if nausea makes it difficult to swallow tablets, injection can be a life saver. Injections of sumatriptan are available in a variety of devices. One of them is Sumavel, an injection without a needle. This device propels the medicine through the skin as a very thin jet of fluid. It is perfect for those with needle phobia. It also has the advantage of not having to worry about the proper disposal of needles. Having a choice of a 4 mg or a 6 mg dose allows patients with frequent cluster headaches to take 3 4 mg doses in 24 hours (maximum recommended dose is 12 mg). The 4 mg dose is also useful for people who get side effects from 6 mg, since 4 mg may be sufficiently effective without causing side effects. --- ### Exercise is as good as drugs. - Published: 2013-12-11 - Modified: 2013-12-11 - URL: https://www.nyheadache.com/blog/exercise-is-as-good-as-drugs/ - Categories: Alternative Therapies The risk of dying from a variety of causes can be reduced by exercise, according to a new study published in the British Medical Journal. The effect of exercise was as strong as the effect of drugs for the prevention of diabetes, coronary heart disease, rehabilitation of stroke, and treatment of heart failure. The authors reviewed 305 previous trials that involved almost 340,000 people, making their findings very reliable. Exercise has been also proven to prevent migraine headaches (see my previous post). This finding was based on a review of over 46,000 patient records, also a very large number that suggests a true effect. Most people don't need these studies to convince them of the benefits - they know that exercise improves their headaches and makes them feel better. The most common problem is lack of time and motivation. However, headaches also cost time and reduce productivity, so exercising 30 minutes four days a week will save time. Doctor recommendations often do influence their patients' behavior and doctors need to remember to emphasize to their patients the importance of exercise, both for headaches and other conditions. --- ### Cold hands and nose in migraine sufferers - Published: 2013-12-10 - Modified: 2013-12-10 - URL: https://www.nyheadache.com/blog/cold-hands-and-nose-in-migraine-sufferers/ - Categories: Alternative Therapies, Science of Migraine Many migraine sufferers appear to have cold hands and nose, according to a new study by Finnish researchers described in the Wall Street Journal. The study compared 12 women with migraines with 29 healthy controls without migraines. Family history of migraine was present in 85% of those with migraines and 31% of controls. Five migraine sufferers had auras. The average temperature of the nose and hands was 3. 6 degrees lower in migraine sufferers and two out of three had temperatures lower than 86 degrees, which is considered the lower end of normal. Only one out of three of those without migraines had temperatures below 85 degrees. The authors speculate that the disturbance of the autonomic nervous system in migraine sufferers might be responsible for the constriction of blood vessels, which leads to lower temperatures. However, the authors do not mention a much more important cause of coldness of extremities, which is magnesium deficiency. Our research has shown that up to half of migraine patients are deficient in magnesium. One of the main symptoms of magnesium deficiency is coldness of hands and feet or just feeling colder in general than other people in the same environment. Other symptoms of magnesium deficiency are muscle cramps in legs and other places, mental fog, palpitations, PMS in women, difficulty breathing (intravenous magnesium is also given for asthma), and other. Blood test for magnesium is not reliable because the routine test measures so called serum level, while over 98% of magnesium sits inside the... --- ### Features of 1,000 episodes of migraine aura over 18 years in one patient. - Published: 2013-12-09 - Modified: 2013-12-24 - URL: https://www.nyheadache.com/blog/features-of-1000-epidodes-of-migraine-aura-over-18-years-in-one-patient/ - Categories: Science of Migraine Dr. Andrew Charles and his associates at UCLA just published a fascinating report on migraine aura in the journal Brain. We still do not understand the brain mechanisms that lead to the phenomenon of migraine aura. The published report characterizes a large number of visual auras recorded by a single individual over nearly two decades. This person made detailed drawings of his visual aura in real time during more than 1000 attacks of migraine aura. His auras were never followed by a headache. The drawings showed the shape and location of the aura wavefront or blackout areas in the visual field with one minute intervals. These drawings were digitized by the researchers to make it easier to analyze them. Consistent patterns of aura initiation, propagation and termination were observed in both right and left visual fields. Most aura attacks started centrally, but some also started in the periphery, which in most people is more common. The auras that started centrally moved down and in first and then up and to the side. The speed of progression of the auras was always the same. The speed was about 2-3 millimeters per minute, which is what has been reported by most other people in the past. Some auras started and then quickly stopped without progressing. In some episodes the visual aura disappeared for several minutes before reappearing in a distant location, suggesting that the aura can be clinically 'silent'. The authors concluded that these results indicate that there can be multiple distinct... --- ### Vitamin D - new benefits discovered - Published: 2013-12-05 - Modified: 2013-12-05 - URL: https://www.nyheadache.com/blog/vitamin-d-new-benefits-discovered/ - Categories: Alternative Therapies Vitamin D seems to prevent relapses of multiple sclerosis, according to a large study by Dr. Ascherio and his colleagues at the Harvard School of Public Health. My previous posts mentioned that a high proportion of migraine sufferers have low vitamin D levels and that low vitamin D levels have been associated with Alzheimer's disease, other dementias, and strokes. This latest study of patients with MS indicates that those with higher levels of vitamin D did better than those with lower, even if the lower level was still within normal range. Studies of vitamin D in other conditions also reported similar findings of progressive benefits with increasing levels. Many laboratories consider a level between 30 and 100 to be normal. However, even in the absence of definitive proof of benefit, it is probably prudent to aim for a level of at least 50. Just taking vitamin D, even at doses of 2,000 to 5,000 units a day does not guarantee a good level because many people do not absorb it well. Ideally, you should have your vitamin D level rechecked after taking vitamin D for a few months. --- ### Sugary drinks not only cause headaches but can give women cancer - Published: 2013-12-04 - Modified: 2013-12-04 - URL: https://www.nyheadache.com/blog/sugary-drinks-not-only-cause-headaches-but-can-give-women-cancer/ - Categories: Alternative Therapies, Headaches Three out of four migraine sufferers may have reactive hypoglycemia, which may be contributing to their headaches. Reactive hypoglycemia is the so called sugar crash - a drop in blood glucose level after eating or drinking a large amount of sugar. The body's reaction to the consumption of sugar is to produce insulin, but in those with reactive hypoglycemia too much insulin is produced and the blood sugar level drops below normal. A recent study published in Cancer Epidemiology, Biomarkers & Prevention and reported in the NY Times showed that high consumption of sugary drinks significantly raises the risk of endometrial cancer. The researchers at the National Institutes of Health who conducted this large study speculated that the wide fluctuations in sugar levels from very high to very low could play a role in the development of cancer. Obviously, there are other reasons to avoid sugary drinks, such as to avoid weight gain which leads to more frequent migraine and other health problems, such as diabetes, heart disease, strokes, and other. For that matter it is not just sugary drinks, but sugar in any form. Many of my patients are often surprised that I would even advise against drinking orange juice, eating grapes, melons, or other very sweet fruit. These fruit have some redeeming properties, such as having vitamins and fiber, but they also contain too much sugar and can cause the same problems as refined sugar. Photo credit: JulieMauskop. com --- ### Migraines and pain in patients with multiple sclerosis - Published: 2013-12-03 - Modified: 2013-12-03 - URL: https://www.nyheadache.com/blog/migraines-and-pain-in-patients-with-multiple-sclerosis/ - Categories: Science of Migraine Thirty-two percent of patients with multiple sclerosis experience both migraine and pain with neuropathic (related to nerve damage) characteristics, according to a report by French researchers led by Xavier Moisse. These two symptoms appear to be caused by different mechanisms. The authors conducted a postal survey to assess the prevalence and characteristics of neuropathic pain and migraine in multiple sclerosis (MS) patients. Of the 1300 questionnaires sent, 673 were complete enough be used for statistical analysis. Among the respondents, the overall pain prevalence in the previous month was 79%, with 51% experiencing pain with neuropathic characteristics and 46% migraine. MS patients with both migraine and neuropathic pain (32% of the respondents) reported more severe pain and had lower health-related quality of life than MS patients with either migraine or just pain. Migraine was mostly episodic, but in 15% they were chronic, meaning that they occurred on 15 or more days per month. Neuropathic pain was most often located in the extremities, back and head, and was frequently described as tingling and pins-and-needles. The intensity of pain was low to moderate. Nonetheless, patients with pain were more disabled than patients with migraine. Migraine, but not pain, was more common with older age, disease duration, relapsing-remitting course, and interferon-beta treatment. We do see patients without a history of headaches who develop headaches, including migraines, as a side effect of interferon treatment, both when it is given for MS as well as hepatitis C. These headaches can be managed just like any other... --- ### Headache experts: five things to avoid - Published: 2013-11-28 - Modified: 2013-11-28 - URL: https://www.nyheadache.com/blog/headache-experts-five-things-to-avoid/ - Categories: Headaches Many medical specialty groups of doctors have been coming out with "Choosing Wisely" campaign where they recommend avoiding five things in their field. Headache specialists just came out with their own list of items that offer low-value and can be even harmful. The American Headache Society surveyed its members to develop a candidate list of items of low-value care in headache medicine. Then, a committee reviewed the literature and the available scientific evidence about the candidate items on the list and by consensus came up with a final list of five items. The five recommendations are: (1) don't perform a brain scan (MRI or CAT) in patients with stable headaches that are typical migraines; (2) don't perform CAT scan for headache when MRI scan is available, except in emergency settings (MRI is much more informative and does not subject the patient to radiation); (3) don't recommend surgical procedures for migraine, unless it is a part of a clinical trial (several types of surgery are being promoted with little scientific evidence that they are safe and effective); (4) don't prescribe opioids (narcotic drugs, such as codeine, Vicodin, Percocet) or butalbital-containing medications (Fioricet, Fiorinal, Esgic) as a first-line treatment for recurrent headache disorders because these drugs are often ineffective, can worsen headaches and can cause addiction; and (5) don't recommend prolonged or frequent use of over-the-counter pain medications for headache. I would stress that the last item is particularly important in regard to caffeine-containing drugs, such as Excedrin and Anacin, while ibuprofen,... --- ### Fibromyalgia may be caused by nerve damage - Published: 2013-11-19 - Modified: 2013-11-19 - URL: https://www.nyheadache.com/blog/fibromyalgia-may-be-caused-by-nerve-damage/ - Categories: Pain, Pain Research, Science of Migraine More patients with fibromyalgia suffer from migraine headaches than those without this fibromyalgia. Those with fibromyalgia are also more likely to have irritable bowel syndrome, depression, and panic attacks. Fibromyalgia has been a mysterious and an ill-defined condition. However, after years of research specific criteria for the diagnosis were developed and several drugs for fibromyalgia were approved by the FDA (Lyrica, Cymbalta, Savella). A new study by researchers at the Massachusetts General Hospital suggests that half of the patients with symptoms of fibromyalgia have damaged peripheral nerves, a condition called small-fiber neuropathy. They compared skin biopsies (a test to diagnose the neuropathy) in 25 patients with fibromyalgia and 29 healthy controls. In healthy controls only 17% had neuropathy. This type of neuropathy can also occur in diabetics, but none of the 25 patients in the study had diabetes. Other conditions that can cause small-fiber neuropathy are cancer, autoimmune conditions, various toxins, vitamin B12 deficiency, and genetic disorders, but none of these were present either, except for possibly genetic cause since three patients were related (a mother and two daughters). The practical importance of this finding is that sometimes neuropathy responds to immune therapies, such as intravenous gamma globulin. --- ### BPA (the toxin in plastics) and migraine. - Published: 2013-11-15 - Modified: 2013-11-15 - URL: https://www.nyheadache.com/blog/bpa-the-toxin-in-plastics-and-migraine/ - Categories: Science of Migraine Migraine headaches can be triggered by exposure to a variety of chemicals, including fumes, MSG, artificial sweeteners and many other. Now, scientists at the university of Kansas Medical Center published a study suggesting that BPA, a ubiquitous toxic chemical found in plastics, canned food, and ATM receipts, may be also involved in triggering migraine attacks. The New York Times columnist, Nicholas Kristof has been publicizing the dangers of BPA (bisphenol A) in many of his articles. BPA was recently banned from baby bottles and cups, but it is still widely used everywhere else and can be found in significant amounts in the bodies of 90% of the US population. It is not surprising that BPA could impact migraines because it can produce hormonal estrogen-like effects. Women are three times more likely to have migraines than men, with estrogen being the likely culprit. The Kansas researchers hypothesized that BPA exposure exacerbates migraine symptoms through estrogen mechanisms. They studied the effect of BPA on female rats, in which a migraine-like state of increased sensitivity was induced. They studied changes in movement of these rats, light and sound sensitivity, grooming, and startle response. They also measured changes in genes related to estrogen and pain perception. After BPA exposure these rats had significantly increased migraine-like behaviors. They moved less, had an increase in light and sound sensitivity, altered grooming habits, and increased startle responses. BPA exposure also increased expression of estrogen and pain-modulating receptors. These results suggest that BPA may be also a contributing... --- ### More about the white spots seen on MRI scans - Published: 2013-11-10 - Modified: 2013-11-10 - URL: https://www.nyheadache.com/blog/more-about-the-white-spots-seen-on-mri-scans/ - Categories: Science of Migraine White matter lesions (WML) are more common in people who suffer from migraine headaches with or without aura and my recent post mentioned yet another study confirming this finding. Researchers from Johns Hopkins School of Medicine just published a study in the journal Neurology which provides further reassurance about the benign nature of these mysterious lesions. They examined over 1,000 migraine sufferers with two MRI scans separated by 8 to 12 years. While those with migraines had a significantly greater risk of having these WML or as these researchers called them white matter hyperintensities (WMH) the number of these lesions did not increase with the passage of time. This study contradicts a larger, so called CAMERA study which showed progression of the number of WMLs in women. That study was done in younger people and the authors speculate that whatever might be causing these WML may be occurring at a younger age when the disease of migraine is most active. It is a well established fact that migraines are most common in 20s, 30s, and 40s but then tend to subside. Art credit: JulieMauskop. com --- ### A new way to adminster Botox for cluster and migraine headaches - Published: 2013-11-04 - Modified: 2013-11-04 - URL: https://www.nyheadache.com/blog/a-new-way-to-adminster-botox-for-cluster-and-migraine-headaches/ - Categories: Cluster headaches, New treatments Botox injections are currently approved for the treatment of chronic migraines but not cluster headaches. However, my experience at the New York Headache Center suggests that Botox injections may also help relieve cluster headaches, which some call suicide headaches. We inject Botox for cluster headaches in a similar way we do for chronic migraines, that is the injections are given in the forehead, temple and back of the head and neck. One difference is that since cluster headaches are strictly one-sided we inject only one side with the exception of the forehead because injecting only one side of the forehead will result in a lopsided appearance. Researchers at the Norwegian University of Science and Technology in Oslo came up with an idea of injecting Botox into the sphenopalatine ganglion. This ganglion is a bundle of nerve cells that sits behind the back of the throat and has been a target for all kinds of procedures to relieve various pain problems. Doctors have attempted numbing those cells with cocaine and lidocaine, destroying it with heat, and stimulating it with electric current in an attempt to relieve not only cluster and migraine headaches but a range of painful conditions, including low back pain. Unfortunately, we do not have any good scientific studies proving that any of these procedures on the sphenopalatine ganglion work for any condition it's been tried for. We have many so called anecdotal reports describing successful cases, but no large controlled trials have ever been performed. It is not... --- ### Caffeine worsens headaches in adolescents. - Published: 2013-11-03 - Modified: 2013-11-03 - URL: https://www.nyheadache.com/blog/caffeine-worsens-headaches-in-adolescents/ - Categories: Headaches in children, Science of Migraine The previous post mentioned a study confirming that caffeine makes headaches worse in adults 20 years or older. A study by pediatric neurologists from the Cleveland Clinic, Chad Whyte and David Rothner showed that this is also true in adolescents. They looked at 50 children, who were between 12 and 17 years of age who presented to their headache clinic. The average age was 15 and 64% were girls. The mean consumption of caffeine was 109 mg per day. In kids with chronic migraines the intake was 166 mg, while in the rest it was 65 mg. The most popular form of caffeine was soda drinks. This study further confirms the role of caffeine in causing worsening of headaches and leading to chronic migraines. Photo credit: JulieMauskop. com --- ### Nutritional factors in migraine and other headaches. - Published: 2013-10-29 - Modified: 2013-10-29 - URL: https://www.nyheadache.com/blog/nutritional-factors-in-migraine-and-other-headaches/ - Categories: Alternative Therapies A study of 13,573 people by a Harvard physician Catherine Beuttner examined the role of nutrition in patients with migraines and severe headaches. Among these participants of the National Health and Nutrition Examination Survey who were 20 years old or older, 22% or 2,880 suffered from migraines or severe headaches. A large variety of factors that could influence headaches were examined, including age, sex, race/ethnicity, education, smoking, alcohol intake, physical activity, health status, body mass index, diabetes, and number of prescription medications used. Sophisticated statistical analysis established that carbohydrate intake as a percentage of energy consumption and caffeine use were associated with higher prevalence of migraine and severe headaches. On the other hand, fiber intake appeared to reduce the prevalence of migraines and severe headaches. Dr. Beuttner also discovered that intake of foods rich in folate (folic acid, or vitamin B9), thiamine (vitamin B1), and vitamin C was also associated with lower prevalence of migraines and severe headaches. This large study confirms some of the previous reports about the role of carbohydrates and caffeine in the development of headaches. According to one small study, three out of four migraine sufferers have reactive hypoglycemia. Reactive hypoglycemia is a condition that causes blood sugar to drop too low after eating a carbohydrate-rich meal. This drop of sugar seems to trigger headaches. Many migraine sufferers figure this out on their own and reduce their carbohydrate intake, but some fail to make this connection. So, if you suffer from severe headaches try eating small... --- ### Chronic migraine relieved by increasing omega-3 and reducing omega-6 fatty acids - Published: 2013-10-27 - Modified: 2014-04-13 - URL: https://www.nyheadache.com/blog/chronic-migraine-relieved-by-increasing-omega-3-and-reducing-omega-6-fatty-acids/ - Categories: Alternative Therapies Omega-3 and omega-6 fatty acids are needed for our body to produce pain-relieving and pain-enhancing substances. Researchers at the University of North Carolina at Chapel Hill conducted a randomized, single-blinded, parallel-group clinical trial, which was published in the journal Pain, to assess clinical and biochemical effects of changing the dietary intake of omega-3 and omega-6 fatty acids on chronic headaches. After a 4-week baseline, patients with chronic daily headaches undergoing usual care were randomized to 1 of 2 intensive, food-based 12-week dietary interventions: a high omega-3 plus low omega-6 intervention, or a low omega-6 intervention. Clinical outcomes included the Headache Impact Test, which measures headache-related disability, headache days per month, and headache hours per day. They also measured omega-3 and omega-6 levels in red blood cells. Fifty-six of 67 patients completed the intervention. The first intervention (increasing omega-3 and lowering omega-6) produced significantly greater improvement in the Headache Impact Test score and the number of headache days per month compared to the second group (lowering omega-6). The first intervention also produced significantly greater reductions in headache hours per day. The authors concluded that dietary intervention increasing omega-3 and reducing omega-6 fatty acids reduced headache pain and improved quality-of-life in chronic headache sufferers. The omega-3 fatty acids are generally considered good and the omega-6 are considered bad, but it appears that what is more important is the balance between the two types. The known beneficial effects of fish oil include their effect on the heart, brain, peripheral nerves, mood, inflammation, as... --- ### Migraine-related vertigo in perimenopause. - Published: 2013-10-23 - Modified: 2013-10-23 - URL: https://www.nyheadache.com/blog/migraine-related-vertigo-in-perimenopause/ - Categories: Science of Migraine Vertigo presenting during the peri-menopause can be related to migraine, according to a report by Nashville neurologists led by Dr. Jan Brandes. They collected information on 12 women who presented with a new onset of vertigo during their peri-menopause and who fulfilled the criteria for migrainous vertigo. Only 4 of the 12 were previously diagnosed to have migraine headaches and all of them were treated for at least a year for non-migraine causes of vertigo. Once the diagnosis of migrainous vertigo was made a combination of hormonal and conventional migraine preventive therapy produced a significant improvement in these women. The authors concluded that the appearance of vertigo during the peri-menopause should prompt an evaluation for possible migraine connection and if such connection is found the treatment should include a combination of hormonal and traditional migraine therapies. Other non-migraine causes of vertigo include inner ear problems, brain disorders, such as strokes and tumors, and neck muscle spasm. The latter usually causes dizziness rather than true vertigo, which is defined as a spinning sensation. Dizziness can also be caused by drop in blood pressure, especially on standing up, peripheral nerve damage (such as in diabetes or vitamin B12 deficiency), eye, and other conditions. Art credit: JulieMauskop. com --- ### Dihydroergotamine (DHE-45, Levadex) constricts blood vessels less than sumatriptan (Imitrex) - Published: 2013-10-14 - Modified: 2013-10-14 - URL: https://www.nyheadache.com/blog/dihydroergotamine-dhe-45-levadex-constricts-blood-vessels-less-than-sumatriptan-imitrex/ - Categories: Headache medications, Science of Migraine Dihydroergotamine (DHE-45) is considered to be the most effective injectable migraine drug. In addition to injections, it is been available in a nasal spray form (Migranal), but the nasal spray is much less effective than the injection. Early next year we expect to have an inhaled version of dihydroergotamine, Levadex. Clinical trials indicate that it could work as fast and as well as the injection and may have fewer side effects. Dihydroergotamine constricts blood vessels and just like triptans (Imitrex or sumatriptan and other) is contraindicated in people with cardiovascular disease, such coronary artery disease, heart attacks, and strokes. The perception has always been that dihydroergotamine, because it is a less pure drug than triptans, is a stronger vasoconstricter than triptans. However, a recent study by Dutch researchers suggests that this may not be the case. This study compared the contractile effects of sumatriptan and DHE in human coronary arteries. The study looked at both large (proximal) and small (distal) coronary arteries. The arteries (removed from the body) were exposed to sumatriptan (Imitrex) and DHE. In larger (proximal) coronary artery segments sumatriptan was a stronger constricter than DHE but the difference was not significantly different. In contrast, in smaller (distal) coronary arteries, the contractile responses to sumatriptan were significantly larger than those to DHE. At clinically relevant concentrations contractions to both sumatriptan and DHE in proximal as well as distal coronary arteries were below 6%. The researchers concluded that coronary artery contractions to DHE in distal coronary artery are smaller... --- ### Syncope (fainting) and migraine - Published: 2013-10-11 - Modified: 2013-10-11 - URL: https://www.nyheadache.com/blog/syncope-fainting-and-migraine/ - Categories: Science of Migraine Fainting spells (syncope) are more common in people who suffer from migraine headaches. Compared with control subjects, migraineurs have a higher lifetime prevalence of syncope (46 vs 31%), frequent syncope (five or more attacks) (13 vs 5%), and being lightheaded on standing up or on prolonged standing (32 vs 12%). It appears that syncope is also a more common symptom of migraine than previously suspected, according to a study by Case Western Reserve neurologists. The study involved 248 patients who had at least 3 episodes of syncope. Of these patients, 127 had a headache at the time of syncope and 121 did not. Syncopal headaches were classified as either syncopal migraine or a non-migraine headache. The syncope groups were then compared to 199 patients with migraine headaches. Nearly one-third of recurrent syncope patients met criteria for syncopal migraine. This group resembled the migraine headache population more than the syncope population in age, gender, autonomic nervous system testing, and associated medical conditions. The syncopal migraine group also reported a longer duration of syncope and a longer recovery time to normal. Finally, anti-migrainous medications reduced syncope in half in the syncopal migraine patients. The authors concluded that syncope may have a migrainous basis more commonly than previously suspected. To reduce your propensity to fainting, try to avoid dehydration, hunger, sleep deprivation, alcohol, and other triggers that you can identify. Cardiovascular conditioning is also likely to help. Photo credit: JulieMauskop. com --- ### Topiramate (Topamax) may cause inability to sweat and hyperthermia - Published: 2013-10-08 - Modified: 2013-10-08 - URL: https://www.nyheadache.com/blog/topiramate-topamax-may-cause-inability-to-sweat-and-hyperthermia/ - Categories: Headache medications Topamax (topiramate) has been reported to cause inability to sweat which can lead to hyperthermia or overheating. At first, this condition was reported as a rare complication, but a study of 173 children showed that 22 of them or more than 10% developed this side effect. The ability to sweat returns when the drug is stopped. Sweating allows the body to coll off and loss of this mechanism can be dangerous in hot weather or during vigorous exercise. Those who take Topamax should speak to their doctor if they notice reduced sweating. Topiramate is an effective drug which the FDA approved for the prevention of migraine headaches as well as epilepsy and mood disorders. However, in large clinical trials only half of the patients put on this drug for the treatment of migraines stayed on it. The other half either did not obtain relief of their migraines or developed side effects. One of the most common side effects is impairment of cognitive functions - people can't remember names, can't come up with the right words, or as some have told me they feel stupid. Other people become very tired from Topamax because they develop metabolic acidosis - their bodies become too acidic. Long-term side effect of kidney stones was also thought to be rare when the drug was introduced, but subsequent studies showed that up to 20% of patients develop kidney stones. The full extent of side effects of any new drug does not become apparent until years after its... --- ### Cost of Botox injections for migraine headaches - Published: 2013-10-02 - Modified: 2013-10-02 - URL: https://www.nyheadache.com/blog/cost-of-botox-injections-for-migraine-headaches/ - Categories: Headache medications, New treatments Botox injections is the only FDA-approved treatment for chronic migraine headaches. This is a very effective (works in 70% of chronic migraine patients) and very safe treatment. The only major drawback is its cost. However, there is a great variation in the cost from doctor to doctor and hospital to hospital. This post was prompted by an email I received from a former patient. Here are some excerpts from our exchange (with her permission): "You've been my doctor now for many years, and I was just in your office over the summer for Botox treatment, but I live now in Charlottesville, VA and UVA's hospital down here charges around $6000 for the same procedure that your office can do for $2250. With my insurance, I'm still responsible for 20% of the bill, and I can't afford to have the procedure done here in Charlottesville. They tell me it's because they're paying for facilities and staff, but even the drug is more than twice as much... THAT doesn't make sense at all! This treatment has changed my life quite dramatically for the better. I'm so much healthier, more productive, creative, and all around a better citizen and human being as a result of not having constant headaches. " Part of my response to her: "I am not surprised about the $6,000 price tag - I recently gave a lecture at Harvard and they also charge $6,000 and so do Mayo and Cleveland Clinics. They all also charge $2,000 for IV magnesium,... --- ### An educated consumer gets the best results. - Published: 2013-09-29 - Modified: 2013-09-29 - URL: https://www.nyheadache.com/blog/an-educated-consumer-gets-the-best-results/ - Categories: Headache medications, Headaches Cleveland Clinic doctors established that migraine patients who are educated about sumatriptan (Imitrex) and other triptans tend to do better. It is not a surprising discovery, but it highlights the importance of patient education. The study involved 207 patients at the Cleveland CLinic, Mayo Clinic, Brigham and Women's Hospital. Here are some important facts that migraine sufferers need to know. One such fact, taking medicine early, seems obvious, but many patients often wait to take a triptan for a variety of reasons. They often think that it may not be a migraine, but rather a tension headache that will not require a triptan. Others are reluctant to take medication because it might be dangerous, although the most common reason is that patients often don't get enough medicine from their insurer. These are expensive drugs, even in a generic form. However, it is more expensive to lose a day of work and if the medicine is taken early one tablet may be sufficient, but if taken late, the patient may need 2 or 3 tablets to abort an attack. Another fact is that you do not need to take an aspirin (or Migralex) or ibuprofen before resorting to a triptan if the headache is very severe. Many people often keep trying an over-the-counter drug first, even if they always end up taking a triptan. It is OK to combine aspirin or ibuprofen with a triptan if a triptan alone is insufficient. Migraine sufferers should also know that triptans are contraindicated in... --- ### Income and migraines. - Published: 2013-09-23 - Modified: 2013-09-23 - URL: https://www.nyheadache.com/blog/income-and-migraines/ - Categories: Science of Migraine Migraine affects people in all socio-economic categories, however it is more likely to occur in poor, according to a report in the latest issue of Neurology. Researchers examined the data from the American Migraine Prevalence and Prevention Study. This study surveyed 132,674 females and 124,665 males 12 years of age and older. The participants were divided into three income groups, income below $22,500, between $22,500 and $60,000 and above $60,000. They found that those with lower income were more likely to develop migraine headaches. This is not a new finding and a possible explanation for this phenomenon is that poor tend to have more physical and psychological stress. However, a new and very interesting finding of this study is that the remission rate was the same in poor and well to do. The authors speculate that this may be because once migraines start only biological and genetic factors influence the timing of remission. We do know that in many women menopause leads to cessation of migraine headaches. --- ### MRI spots (white matter lesions) in patients with migraines. - Published: 2013-09-16 - Modified: 2013-09-16 - URL: https://www.nyheadache.com/blog/mri-spots-white-matter-lesions-in-patients-with-migraines/ - Categories: Science of Migraine Performing an MRI scan is unnecessary in the vast majority of migraine sufferers. However, many migraineurs end up having this test because they are concerned about having a brain tumor or another serious condition and because many doctors order MRIs to avoid a possible malpractice suit, however remote the possibility. MRI scan does not involve any radiation, so it is not harmful, but it can cause other problems, besides wasting healthcare dollars. The harm often comes from finding an abnormality on the MRI which is benign, but nevertheless can be very anxiety provoking. Lesions seen on MRI scans which are benign but very upsetting to patients are arachnoid cysts and venous malformations. The most common finding though is white matter lesions (WMLs), which doctors sometimes jokingly refer to as UBOs - unidentified bright objects. The origin and the meaning of these spots remains unclear, although the most likely explanation is that these spots are due to ischemia or lack of blood flow. A Dutch study of 295 men and women published in 2004 showed that people who have migraine with aura had a higher risk for silent strokes. As far as WMLs, surprisingly, control subjects, that is people without migraines, had the same high chance of having WMLs as those with migraines - about 38%. However, women with migraine were more likely to have these lesions, regardless whether they had auras or not. A follow-up study published in 2012 reported on 203 of the original 295 patients who underwent another... --- ### Antibiotics for back (and neck?) pain. - Published: 2013-09-11 - Modified: 2013-09-11 - URL: https://www.nyheadache.com/blog/antibiotics-for-back-and-neck-pain/ - Categories: Pain Research It is hard to believe the report of a group of Danish doctors who found 28 out of 61 (46%) patients undergoing surgery for a herniated lumbar disc to have a bacterial infection in those discs. Just like the idea that stomach ulcers are caused by bacteria seemed preposterous, so does the finding of bacterial infection in patients with low back pain. However, after 10 years of skepticism and ridicule Helicobacter bacteria was recognized as the cause of many stomach ulcers and the doctors who made this discovery were awarded a Nobel Prize. Another recent surprise discovery is that babies are not born sterile but are inhabited by a variety of bacteria which they obviously must have acquired from their mothers while in the uterus. This was established by examining the stool of newborns immediately after birth. Of the 23 patients with infections 4 had more than one type of bacteria present. The most common type of infection was with Pseudomonas acnes, which does not require oxygen to grow (so called anaerobic bacterium). Most patients with infections had abnormally looking vertebral bones (bone edema), although these abnormalities were not specific, that is they can be present without an infection as well. About 6% of the general population and 35-40% of those with low back pain have these abnormal findings on an MRI scan. In the second randomized controlled study by Dr. Albert and her colleagues treated 162 patients who had low back pain for more than 6 months, a disc... --- ### Migraine with aura increases the size of a stroke. - Published: 2013-09-06 - Modified: 2013-09-06 - URL: https://www.nyheadache.com/blog/migraine-with-aura-increases-the-size-of-a-stroke/ - Categories: Science of Migraine Migraine aura seems to indicate a different underlying brain condition than that of migraine without aura. We know that the risk of strokes is higher in patients who suffer from migraines with aura. The increase in this risk is very slight, although it is three times higher in women than in men and in women it is magnified by oral contraceptives. The risk is also increased in both men and women by the known risk factors, such as high blood pressure, diabetes, high cholesterol, smoking, and other. A recent study by Stephanie Nahas and other neurologists at Thomas Jefferson University in Philadelphia discovered that aura carries another risk. A study of 139 patients admitted for stroke evaluation showed that those who had a history of migraine aura had a much larger stroke than those without. This is another reason for people who suffer from migraines with aura (or auras without a migraine) to take all possible measures to reduce their risk of strokes. These might include regular exercise, healthy diet, controlling blood pressure, blood glucose, and cholesterol. Some people could also benefit from a daily dose of aspirin (make sure to check with your doctor first), omega-3 fatty acids, and in people with high homocysteine levels, vitamin B12 and other B vitamins. --- ### Depakote (sodium valproate) shrinks the brain in epilepsy patients. - Published: 2013-09-02 - Modified: 2013-09-02 - URL: https://www.nyheadache.com/blog/depakote-sodium-valproate-shrinks-the-brain-in-epilepsy-patients/ - Categories: Headache medications At the New York Headache Center we always try to avoid using medications and use alternative (i. e. non-drug) therapies first. We often succeed, but unfortunately, many of our patients do end up taking some drugs. However, when choosing among many medications, we start with the ones that are least likely to harm. Depakote (sodium valproate) is an effective drug for the treatment of epilepsy, mood disorders, and migraines. While we do prescribe Depakote to our patients, it has never been our first, second, or third choice because we already know that it can cause liver problems and fetal malformations. A recent study published in Neurology adds another reason to avoid this medication. Patients with intractable epilepsy who were taking Depakote were compared with those who were taking other epilepsy medications and with healthy controls. MRI scans showed that those taking Depakote had thinning of the parietal lobes of the brain, had lower total brain volume, and lower white matter volume. This was a small study, but it was conducted because of previous reports of brain atrophy. Fortunately, those previous reports showed that brain atrophy was reversible when the medication was stopped. If you are taking sodium valproate for migraine headaches or a mood disorder, do not stop taking it without consulting your doctor since stopping it suddenly can worsen your condition and in epilepsy patients, cause seizures. But do discuss alternative options with your doctor, although some people may not be able to stop it if no other drugs... --- ### Alternating electric current does not help headaches. - Published: 2013-08-29 - Modified: 2013-08-29 - URL: https://www.nyheadache.com/blog/alternating-electric-current-does-not-help-headaches/ - Categories: Alternative Therapies A variety of electrical devices have been tried for the treatment of headaches and have been mentioned in several of my previous blogs. One study showed that passing direct current through the head may help migraines and depression. Another study recently presented at the joint meeting of the International and American Headache Societies showed that passing alternating current, just like done by any TENS (transcutaneous electric nerve stimulation) machine, but using a proprietary device, Fisher Wallace Stimulator, did not provide relief. This study performed by Dr. Tietjen and her colleagues in Ohio was blinded and involved 50 patients. They applied the stimulator for 20 minutes every day for a month with one half receiving stimulation and the other half not. After a month both groups used real stimulation for another month. While this device did not cause any serious side effects, it also did not help. Hopefully, we will soon see results of large studies using direct current stimulation since this method appears to be more promising than alternating current used in TENS devices. --- ### Fish oil helps cope with stress, possibly headaches. - Published: 2013-08-26 - Modified: 2013-08-26 - URL: https://www.nyheadache.com/blog/fish-oil-helps-cope-with-stress-possibly-headaches/ - Categories: Alternative Therapies Fish oil supplements may protect the heart in stressful situations, according to a study conducted in Michigan with 67 healthy volunteers. The researchers, led by Jason Carter, looked at the effect of fish oil on body's stress response. The volunteers were given either nine grams of fish oil pills or nine grams of olive oil as a placebo, over a two-month period. The heart rate, blood pressure and other parameters were measured before and after the study. After two months, both groups took a math test, which involved adding and subtracting numbers in their head. Their stress response was measured. Those who took fish oil supplements had a milder response to mental stress, including heart rate and sympathetic nervous system activity, which is part of the “fight or flight” response, compared to those who took olive oil instead. The author concluded that “these results show that fish oil could have a protective effect on cardiovascular function during mental stress, a finding that adds a piece to the puzzle on why taking fish oil helps the heart stay healthy,” This study supports the evidence that the omega-3 fatty acids have positive health benefits on the nervous and cardiovascular systems. The author concluded that "In today's fast-paced society, stress is as certain as death and taxes,” he added. “Moreover, our eating habits have deteriorated. This study reinforces that fish oils may be beneficial for cardiovascular health, particularly when we are exposed to stressful conditions. ” He also suggested “If you don’t do... --- ### Trigeminal nerve in trigeminal neuralgia, trigeminal neuropathy and TMJ disorders. - Published: 2013-08-21 - Modified: 2013-08-21 - URL: https://www.nyheadache.com/blog/trigeminal-nerve-in-trigeminal-neuralgia-trigeminal-neuropathy-and-tmj-disorders/ - Categories: Trigeminal and other neuralgias Advances in MRI imaging have allowed visualizing the trigeminal nerve and a group of Australian researchers reported on their findings in three conditions which cause facial pain. Trigeminal nerve supplies sensation to the face and facial pain of any kind is also transmitted to the brain through this nerve. Their report, which appeared in The Journal of Pain, suggests that imaging trigeminal nerve may help in making a more accurate diagnosis, which is turn may lead to more appropriate treatment. Trigeminal neuralgia is an extremely painful condition which is characterized by very brief electric-like pains in the face. The pain is triggered by chewing, talking, brushing teeth, touching a specific spot on the face, and at times occurring without any provocation. This condition usually results from compression of the trigeminal nerve by a blood vessel as it exits the brain stem. Treatment usually involves epilepsy drugs, such as carbamazepine (Tegretol) or oxcarbazepine (Trileptal), Botox injections, nerve destruction (radiofrequency thermocoagulation) or if nothing else works, surgery (microvascular decompression of the trigeminal nerve). Trigeminal neuropathy also causes pain in the face, but it is less intense, usually continuous and is often burning in character. It can result from an injury to the trigeminal nerve in the periphery rather than near the brain stem. Dental procedures and facial injuries can trigger this pain. This pain tends to respond better to antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), protriptyline (Vivactil), and an epilepsy drug, gabapentin (Neurontin). Temporomandibular joint disorders can result from arthritic changes... --- ### An update on butterbur (Petadolex) - we still don't recommend it - Published: 2013-08-17 - Modified: 2013-08-17 - URL: https://www.nyheadache.com/blog/an-update-on-butterbur-petadolex-we-still-dont-recommend-it/ - Categories: Alternative Therapies The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their manufacturing plant in Germany. However, my concerns about butterbur, which I mentioned in a previous blog post, has not been addressed. Here is my email response to the manufacturer: "Thank you for this additional information. It is good to see that the FDA conducted a "comprehensive inspection" of the manufacturing facility in Germany. However, my concerns about the safety of Petadolex are not due to possible deficiencies in manufacturing, but are related to the extraction process. As far as I know, this is why German and UK governments still do not allow the sale of Petadolex and this is why I do not recommend Petadolex to my patients. I am also concerned that because Petadolex is fairly expensive, many patients will decide to buy a cheaper brand of butterbur, which can be truly dangerous. Once Petadolex is cleared for sale in Germany I will be happy to resume recommending it to my migraine patients". --- ### Mental illness, migraine, and doctors' attitudes. - Published: 2013-08-13 - Modified: 2013-08-14 - URL: https://www.nyheadache.com/blog/mental-illness-migraine-and-doctors-attitudes/ - Categories: Science of Migraine Bipolar disorder and other psychiatric problems are 2-3 times more common in those who suffer from migraine headaches and migraines are 2-3 times more common in patients with mental illness. Those who suffer from migraines are very familiar with the attitude of doctors, family members and employers who consider migraine to be just another headache, meaning that it is not something that should stop you from doing any activities. Some doctors still blame migraine sufferers for their condition and think that this is a problem of neurotic women. People with mental illness face even more severe discrimination from doctors and everyone else. A very good article on this topic, "When Doctors Discriminate" has appeared in the New York Times this Sunday. Dr. Robert Shapiro of the University of Vermont recently presented a study which looked at attitudes toward patients with migraine, epilepsy and other conditions. It was an internet-based survey of 705 individuals that examined the levels of stigma by asking following questions: How comfortable would you be with Jane as a colleague at work? How likely do you think it is that this would damage Jane's career? How comfortable would you be with the idea of inviting Jane to a dinner party? How likely to you think it would be for Jane's husband to leave her? How likely do you think it would be for Jane to get in trouble with the law? Scoring ranged from 0 to 100. The mean scores were very similar for migraine, panic disorder,... --- ### Botox relieves hemiplegic migraine. - Published: 2013-08-08 - Modified: 2013-08-08 - URL: https://www.nyheadache.com/blog/botox-relieves-hemiplegic-migraine/ - Categories: New treatments, Science of Migraine Surprisingly, Botox appears to relieve hemiplegic migraines, according to a report by two neurologists from the Mayo Clinic. They describe 5 female patients who suffered from very frequent and severe migraine headaches with four of them having chronic migraines, that is had headaches on 15 or more days each month. The headaches were preceded and/or accompanied by weakness of one side of their body. The weakness lasted only 20 minutes in one patients, but for hours and days in others. All five patients were first treated with prophylactic medications, which either did not help or caused unacceptable side effects. Botox injections were given every 3 months into the usual sites around the scalp, neck and shoulders. A total dose of 150 units was injected. Three of the patients had three sets of injections by the time of this report and they continued to respond well. Migraine with typical visual auras has been reported to respond well to Botox injections, which is also somewhat surprising since Botox appears to work on the sensory nerves. This effect on sensory nerve endings leads to the relief of pain. It is likely that reducing painful episodes in turn leads to a calming effect on the brain in general and the brain stops generating migraines as well as symptoms associated with migraines. I have also seen many patients with visual, sensory and motor aura respond well to Botox injections, often when prophylactic drugs had been ineffective. Art credit: JulieMauskop. com --- ### Auditory hallucinations in migraine. - Published: 2013-08-06 - Modified: 2013-08-06 - URL: https://www.nyheadache.com/blog/auditory-hallucinations-in-migraine/ - Categories: Science of Migraine Auditory hallucinations can be associated with chronic headaches, according to a report by our own Dr. Sara Crystal and three other neurologists from the Bronx. These four doctors reported on 7 of their own patients and also described 8 patients previously reported in the medical literature. Half of the patients had migraine with aura. Regarding hallucination content, the most common sound was distinct human voices in 8 patients, followed by hearing crickets in 2, and ringing bells in another 2, general white noise, also in 2, and repetitive beeping in 1. Regarding timing, 12 experienced hallucinations along with the headache while 3 heard sounds prior to attacks. The duration of the auditory hallucinations was less than one hour but occasionally lasted 4-5 hours or for the duration of the headache. Ten patients had either a current or previous psychiatric disorder, mostly depression. Improvement in both headaches and auditory hallucinations occurred both spontaneously and when prophylactic medications were used, which included propranolol, topiramate, and amitriptyline. In conclusion, auditory hallucinations are uncommon, but do occur before or during migraine attacks. They usually feature the sound of human voices. Because these are unusual manifestations of migraine, doctors should consider other possible causes, such as a brain tumor, epilepsy, or schizophrenia. --- ### Blood vessels may be responsible for migraines after all - Published: 2013-08-04 - Modified: 2013-08-04 - URL: https://www.nyheadache.com/blog/blood-vessels-may-be-responsible-for-migraines-after-all/ - Categories: Science of Migraine The vascular theory of migraine suggested that changes in the blood vessel size and blood flow were responsible for the development of migraine attacks. This theory went out of fashion and for the past 20 years most headache experts thought that the process of migraine begins in the brain and not blood vessels. A new study by researchers at the University of Pennsylvania seems to again implicate blood vessels as the culprit. Brain is supplied by four blood vessels that come up from the neck into the brain - two carotid and two vertebral arteries. At the base of the brain they connect with each other making a circle of Willis. Thomas Willis was a 17th century English physician who first described this circle. This circle ensures good blood flow to the brain even if one or even two of the four blood vessels become occluded. Only a third of the population actually has a complete circle connecting all four arteries, while in the rest the circle is incomplete. This is not a new finding - a group of French physicians reported this discovery in 2009. However, the current study showed that having incomplete circle affected cerebral blood flow and this may be contributing to the process of triggering migraines. This abnormality appears to be particularly common in those who have migraine with aura. The study looked at 170 people from three groups - a control group with no headaches, a group that had migraine with aura, and a group... --- ### Spinal tap may detect increased pressure in the head as a cause of headaches. - Published: 2013-07-30 - Modified: 2013-07-30 - URL: https://www.nyheadache.com/blog/spinal-tap-may-detect-increased-pressure-in-the-head-as-a-cause-of-headaches/ - Categories: Headaches Increased intracranial pressure is an under-diagnosed cause of difficult to treat headaches. Persistent chronic headaches that do not respond to treatment may be due to increased pressure inside the head. These headaches may resemble chronic migraine headaches and many doctors will try treating these patients with preventive medications, such as Neurontin (gabapentin), Topamax (topiramate), amitriptyline (Elavil), or Botox injections. If these approaches do not provide relief, measurement of intracranial pressure should be considered. Most patients who suffer from increased intracranial pressure have swelling of the optic nerves (papilledema), which can be detected by examining the back of the eye, a standard part of a neurological and ophthalmological examination. However, some people with increased pressure do not have papilledema and they are the ones who present a diagnostic challenge. This condition is also called pseudotumor cerebri because tumors also raise intracranial pressure. To measure the pressure a spinal tap (lumbar puncture) is performed. The cerebrospinal fluid circulates around the brain, within its ventricles and around the spinal cord. Putting a needle into the spinal fluid at the lumbar spine level is much safer than anywhere else and gives the reading of the pressure everywhere within this enclosed space, including the brain. Factors that predispose to increased intracranial pressure include delayed effects of a head trauma, certain medications, excessive amounts of vitamin A, obesity, and other. One of the more recent theories suggests that narrowing of the veins that drain blood from the brain is responsible for this condition. This diagnosis is... --- ### Acute care of chronic and episodic migraines is suboptimal. - Published: 2013-07-28 - Modified: 2013-07-28 - URL: https://www.nyheadache.com/blog/acute-care-of-chronic-and-episodic-migraines-is-suboptimal/ - Categories: Headache medications Acute treatment of episodic and chronic migraine headaches in the US leaves a lot to be desired. Results of the American Migraine Prevalence and Prevention Study lead by Dr. Richard Lipton indicates that the acute treatment of migraine headaches in patients with chronic migraines is significantly worse than in patients with episodic migraines. Chronic migraines are defined as those occurring on 15 or more days each month, while patients who have 14 or fewer migraines a month are classified as having episodic migraines. The researchers developed a specific questionnaire to assess acute treatment of migraine headaches. The questionnaire evaluated the effect of treatment on people's functioning, how rapid was the relief, relief consistency, recurrence risk, and tolerability or side effects. They examined responses from 8612 persons who met criteria for migraine (chronic migraine = 539; episodic migraine = 8073). The treatment scores were significantly lower for persons with chronic migraine vs episodic migraine. The conclusion was that the questionnaire was a robust tool for measuring treatment optimization and that acute treatment was suboptimal for both episodic and chronic migraines, particularly for chronic migraines, suggesting that there are opportunities for improving care. Art Credit: JulieMauskop. com --- ### Electrical stimulator for cluster headaches. - Published: 2013-07-23 - Modified: 2013-07-23 - URL: https://www.nyheadache.com/blog/electrical-stimulator-for-cluster-headaches/ - Categories: Cluster headaches, New treatments Stimulation of the sphenopalatine ganglion seems to relieve cluster headaches according to a study by European neurologists. The study examined the efficacy of the on-demand sphenopalatine(SPG) stimulation in chronic cluster headache patients. 43 patients in this randomized controlled study were implanted with the ATI Neurostimulator System. Chronic cluster headache is a disabling neurological disorder that often does not respond to medical therapy. A previous study showed that this stimulator was effective for acute cluster headache pain relief and in some patients made their attacks less frequent. These patients also had clinically and statistically significant improvement in quality of life and reduction in headache disability. The 43 patients in the current study were dissatisfied with their cluster headache treatment and 32 of them completed the one-year study with 23 continuing to use the stimulator beyond one year. At enrollment, 18 (78%) of patients indicated their overall evaluation of the ATI Neurostimulation System for treating their chronic cluster headaches as good or very good. 18 (78%) found SPG stimulation a useful therapy in treating their cluster headaches. 19 (83%) found surgical effects tolerable and the implanted neurostimulator comfortable or did not notice it and 23 (100%) found the stimulation sensation tolerable. 15 (65%) did not have significant side effects after stimulation. 21 (91%) would make the same decision again to treat their CH with the ATI Neurostimulation System, and 22 (96%) would recommend the ATI Neurostimulation System to someone else. 13 (57%) of patients experienced clinically significant improvement in headache disability and... --- ### Blood pressure drugs for the prevention of migraine. - Published: 2013-07-22 - Modified: 2013-07-22 - URL: https://www.nyheadache.com/blog/blood-pressure-drugs-for-the-prevention-of-migraine/ - Categories: Headache medications Candesartan (Atacand) is a relatively new blood pressure medication in the family of ACE receptor blockers (ARBs), which is also effective in the preventive treatment of migraine headaches. Another ARB, Benicar, or olmesartan has also been shown to be effective in preventing migraine headaches. Propranolol (Inderal), a beta blocker, is one of the oldest preventive drugs for migraines and many doctors often use it first. A recent study by Norwegian doctors compared candesartan with propranolol and placebo. They conducted a triple-blind, double crossover study, with 72 adult patients with episodic or chronic migraine, recruited in an outpatient clinic and through advertisements. Participants underwent three 12-weeks’ treatment periods on either candesartan (Atacand) 16 mg, propranolol slow release (Inderal LA) 160 mg, or placebo. The primary outcome measure was days with migraine headache in a 4 week period. They also looked at days with headache, hours with headache, proportion of responders (50% reduction of migraine days from baseline), and side effects. Their analysis showed that candesartan and propranolol were equally effective and both were superior to placebo. Both drugs had more side effects than placebo, but side effects were different. The researchers concluded that candesartan should be included in the arsenal of drugs recommended for migraine prevention. The advantage of ARBs, such as Atacand and Benicar, is that unlike beta blockers they do not slow down the heart rate, which can be a problem during exercise. During exercise heart rate increases to deliver more blood to the muscles and lungs, but propranolol... --- ### In kids,cognitive therapy with medicine is better than medicine alone and is possibly better than Botox and other drugs - Published: 2013-07-07 - Modified: 2013-07-07 - URL: https://www.nyheadache.com/blog/in-kidscognitive-therapy-with-medicine-is-better-than-medicine-alone-and-is-possibly-better-than-botox-and-other-drugs/ - Categories: Headaches in children Half of the kids seen by pediatric headache specialists suffer from chronic migraines. Dr. Hershey and his colleagues at the Cincinnati Children’s Hospital presented results of a study that compared cognitive behavioral treatment combined with amitriptyline (an antidepressant used to treat migraine and other pains) with amitriptyline alone in children aged 10 to 17 who suffered from chronic migraines. This was a first randomized clinical trial in childred with chronic migraines. Combined psychological & pharmacological treatment has been reported to be effective in adults and children with chronic pain other than migraine. Psychological intervention was cognitive behavioral therapy (including biofeedback); pharmacological intervention was amitriptyline (goal dose of 1 mg/kg/day). The control group was taught attention control with equal to psychological intervention in terms of contact frequency and face-to-face time, and involved education and support. They enrolled 135 children with mean age of 14 years; 15% minority; 79% female. Mean baseline headache frequency was 21 days and mean baseline disability score was 68 (severe disability grade). There were no differences between groups at baseline. For the combined group, a greater than 50% headache frequency reduction was seen in 66% at post-treatment (20 weeks later), 86% at 12-month follow-up. And most impressively, 71% no longer had chronic migraines at the end of treatment and 88% were not chronic at 12-month follow-up. The disability score dropped to below 20 (mild to no disability) in 75% at post-treatment and 88% at 12-month follow-up. These results were significantly better than in the control group of... --- ### Surprisingly, naproxen may be better than naproxen with sumatriptan - Published: 2013-07-05 - Modified: 2013-07-05 - URL: https://www.nyheadache.com/blog/surprisingly-naproxen-may-be-better-than-naproxen-with-sumatriptan/ - Categories: Headache medications A non-steroidal anti-inflammatory (NSAID) drug naproxen (Aleve) alone seems to be more effective than naproxen combined with sumatriptan (Treximet), according to a study by Dr. Roger Cady and his colleagues from Missouri, which was presented at the International Headache Congress in Boston. This was a small study involving 39 patients who suffered with moderate to severe attacks of migraine. The researchers looked at possible effect of acute medications on frequency of headaches. As migraine frequency increases, so too can the risk of medication overuse, which leads to more headaches. On the other hand, frequent administration of acute medications may act both as an acute and prophylactic treatment. The patients in the study were 18 to 65 years of age, with frequent episodic migraine with or without aura, in Stage 2 migraine (3 to 8 headache days per month) or Stage 3 migraine (9 to 14 headache days per month). Patients were asked to treat their migraines with sumatriptan/naproxen (Group A) or naproxen alone (Group B) for 3 months. Patients in Group B had a statistically significant reduction in migraine headache days at month 3 compared to baseline. Group A also had a reduction of migraine headache days but this decrease did not reach statistical significance over baseline. In addition, subjects in Group B had a statistically significant reduction of migraine attacks at all three months of the study compared to baseline. A greater than 50% reduction in the number of migraine days at month 3 occurred in 43% (6/14) of... --- ### Sea Bands work for nausea of migraine - Published: 2013-07-03 - Modified: 2013-07-03 - URL: https://www.nyheadache.com/blog/sea-bands-work-for-nausea-of-migraine/ - Categories: Alternative Therapies Nausea of migraines responds to an acupressure device, according to two German doctors who presented their findings last week at the International Headache Congress in Boston. I spoke to one of the authors, Dr. Zoltan Medgyessy about his study. The study included 41 patients, whose average age was 47 years. They had been suffering from migraines for on average 26 years and had experienced an average of 33 migraine days over the previous three months. The average migraine pain intensity was 7 on a scale from 0 to 10; the average intensity of nausea was 6 on a 1-10 scale. Patients were instructed to use the device (Sea Band) instead of taking nausea medication during their next migraine attack and to complete and return a migraine attack diary. After using the acupressure band, 34 (83%) patients noticed a reduction of nausea and 18 (44%) reported a significant improvement in nausea. The average intensity of nausea after therapy was 3. The relief of nausea was reported after an average of 29 minutes. The average duration of the migraine attacks was 22 hours. The Sea Bands were worn on average for 18 hours. Forty patients (98%) reported that they would use Sea Band during migraine attacks again. The authors concluded that the use of an acupressure band can reduce migraine-related nausea. The advantage of this therapy is that it is drug-free and has no risks or side-effects such as dizziness, fatigue, or restlessness seen with drugs. Its effect is rapid, and it... --- ### Oxygen for cluster headaches through a demand valve - Published: 2013-06-25 - Modified: 2013-06-25 - URL: https://www.nyheadache.com/blog/oxygen-for-cluster-headaches-through-a-demand-valve/ - Categories: Cluster headaches Oxygen inhalation is a proven method of treating cluster headaches. The patient usually rents a large oxygen tank and breathes in pure oxygen through a mask whenever he gets an attack (it is usually a he since 5 times as many men suffer from cluster headaches as women). Demand valve oxygen (DVO) is a promising new oxygen delivery system for the acute treatment of cluster headaches, according to a recent report by Dr. Todd Rozen. DVO delivers oxygen to the user as soon as they inhale from an attached mask and the amount of oxygen is controlled by how fast they are breathing. DVO is capable of delivering much more oxygen than by just breathing it through a regular mask. In the study 3 patients tried both DVO and a regular mask. All patients had chronic cluster headaches. On DVO all 3 subjects became pain free; 2 of 3 became pain free on a regular mask, while the third subject needed 30 minutes to get to mild pain. Patients using DVO became pain free faster than when a regular mask was used. This was a very small sample and bigger studies are needed, but DVO appears to be at least as effective for acute treatment for cluster headaches as inhalation of oxygen through a regular mask. --- ### Infantile colic and pediatric migraine - Published: 2013-06-22 - Modified: 2013-06-22 - URL: https://www.nyheadache.com/blog/infantile-colic-and-pediatric-migraine/ - Categories: Headaches in children Infantile colic seems to be a precursor or an early manifestation of migraine headaches in children. A new European study published in the journal JAMA supports an earlier American study mentioned in one of my previous blogs. This European study involved 208 children who were diagnosed with migraine at emergency departments found that 73% of them had a history of colic in infancy, compared with 27% of a control group of children. History of being colicky was as common in children and teens who suffered from both migraine with and without aura. This study suggests that many colicky babies whose colic does not respond to any treatment directed at their digestive system may be suffering from migraine headaches. Some of these children may develop cyclic vomiting as they get older and then go on to have typical migraine headaches. The researchers at two Italian and one French hospital did a second study involving 120 children with tension-type headaches. Only 35% of these children had a history of infantile colic, confirming that it is not any headache, but specifically migraine that is associated with infantile colic. Migraines are very common in children. Before puberty, about 6% of boys and girls suffer from migraines. After puberty, boys remain at 6% and the incidence of migraines goes upt o 18% in girls. One of the authors of the study suggested that migraine medications might be effective for colicky babies, although this would require a controlled study. Such studies in infants are difficult to... --- ### Frequent migraines are not different from chronic migraines - Published: 2013-06-19 - Modified: 2013-06-19 - URL: https://www.nyheadache.com/blog/frequent-migraines-are-no-different-from-chronic-migraines/ - Categories: New treatments, Science of Migraine Botox is approved by the FDA for the prophylactic treatment of chronic migraine headaches. Chronic migraine was arbitrarily defined by headache researchers as headache occurring on more than 14 days each month. Epidemiological research by Dr. Richard Lipton and his colleagues at the Albert Einstein School of Medicine suggests that there is no biological difference between frequent migraines that occur on 10 or more days each month and chronic migraines. They compared clinical features and the incidence of other chronic medical conditions in three groups of patients with migraine: low frequency (0-9 days/month), high frequency (10-14 d/mo) and chronic migraine (15-30 d/mo). The American Migraine Prevalence and Prevention Study is a US-population-based study with 16,573 people with migraine who responded to a 2005 survey. Of these, 10,609 had low frequency, 640 had high frequency and 655 had chronic migraines. Rates of pulmonary and respiratory conditions including asthma, bronchitis, chronic bronchitis, emphysema/COPD, allergies/hay fever, and sinusitis increased across headache frequency groups and were significantly different for chronic migraine vs. low frequency, but not for chronic migraine vs. high frequency. A similar finding was seen for cardiac conditions and strokes. Depression, nervousness or anxiety, bipolar disorder/mania, and chronic pain were also much more common and similar in those with frequent or chronic migraine compared to those with low frequency migraines (around 30% vs 15%-18%). These findings suggest that patients with frequent migraines resemble those with chronic migraines much more than they do those with low frequency migraines. One practical implication of this... --- ### Calcium promotes chronic pain - Published: 2013-06-16 - Modified: 2013-06-19 - URL: https://www.nyheadache.com/blog/calcium-promotes-chronic-pain/ - Categories: Pain Research Calcium inside the nerve cells (neurons) seems to be crucial in making pain chronic, according to a publication in the journal Neuron by researchers in Heidelberg, Germany. They discovered that in patients with persistent pain, calcium in the spinal cord neurons helps contact other pain-conducting neurons resulting in increased sensitivity to painful stimuli. This may explain how the pain memory is formed. Chronic pain caused by inflammation, nerve injury, herniated disks, and other causes often leads to a persistent structural change in the nervous system. This pain often persists even after the original cause, such as a herniated disc, is removed. Many chronic pain patients including those with chronic migraine develop allodynia, an increased sensitivity which results in pain from touch and minor pressure. Migraine patients often cannot brush their hair or wear glasses because of such sensitivity. In people with chronic pain, too much calcium inside the neurons that transmit pain makes them react to activation of neurons that normally transmit sensation of touch, heat, and other non-painful sensations. This excess calcium enters the nucleus of the cell where the genetic material is located and it activates certain genes that promote pain. One of the researchers, Prof. Kuner said that “These genes regulated by calcium in the spinal cord are the key to the chronicity of pain, since they can trigger permanent changes. ” Blocking calcium in the cell seems to prevent such increased sensitivity. Mice in which the effect of the calcium in the cell nucleus is blocked... --- ### Chronic headaches and sexual pain - Published: 2013-06-10 - Modified: 2013-06-10 - URL: https://www.nyheadache.com/blog/chronic-headaches-and-sexual-pain/ - Categories: Pain, Science of Migraine Female pelvic/genital pain is more common in women with chronic Headache, according to a study presented by Canadian neurologists. The study was carried out by researchers and clinicians at the Wasser Pain Management Centre, Mount Sinai Hospital and the Centre for Headache at Womens College Hospital in Toronto, Canada. During the study period, every adult English speaking female patient at the Centre for Headache at WCH was asked if they would consent to complete a specifically devised questionnaire. Of the 72 completed questionnaires, 32 (44%) of patients reported that they had pelvic region or genital pain brought on by sexual activity. Thirteen (18%) admitted to having pelvic pain that prevents them from engaging in sexual activity. 46% of these women had not had treatment, 39% were currently being treated, and 15% said they had received treatment in the past. All but one said that she would be interested in receiving treatment if available. The researchers concluded that it is important to ask women with chronic headache about sexual pain and, if present, be able to offer a management option. Art credit: JulieMauskop. com --- ### Leeches are definitely revolting, but can they help migraines? - Published: 2013-06-03 - Modified: 2013-06-03 - URL: https://www.nyheadache.com/blog/leeches-are-definitely-revolting-but-can-they-help-migraines/ - Categories: Alternative Therapies Leeches are not pleasant to look at, but they have been used for medicinal purposes for hundreds of years. Growing up in the Ukraine in the 1960s I remember (this is hard to forget) seeing big jars with leeches in a corner pharmacy. Patients would bring in a prescription from the doctor for 4 leeches to be applied daily. The leeches would be placed into a small jar and taken home by the patient to treat swelling, high blood pressure and I don't know what else. Leeches went out of fashion because of the advances in medicine and just because they are just disgusting. They are being used again in the US for removing extra blood around the scars after cosmetic surgery, arthritic pains, shingles, and other conditions. British writer Emma Parker Bowles was recently in the news writing about how leeches cured her migraines. She decided on this unusual treatment because her headaches were so severe. She says, "the word headache doesn't even begin to describe them". She goes on with a vivid description, "Migraines are miserable with bells on – actually, the idea of listening to the sound of a bell with a migraine brings me out in a sweat. When I am suffering with one, I can’t even stand the sound of my sheets rustling. Apart from the intense throbbing, all-encompassing pain in my head, I also feel extremely nauseous and sensitive to light. I feel as if I am a vampire – a small sliver of... --- ### Getting medicine straight from the nose to the brain - Published: 2013-06-01 - Modified: 2013-06-01 - URL: https://www.nyheadache.com/blog/getting-medicine-straight-from-the-nose-to-the-brain/ - Categories: New treatments Many migraine sufferers suffer from nausea and vomiting and cannot swallow pills or even if they can swallow them, it takes too long for them to work. Injections is one way to overcome this problem, but nasal spray is a much more pleasant alternative. There are several migraine medications available in a nasal spray form, including Zomig (zolmitriptan), Imitrex (sumatriptan), Migranal (dihydroergotamine), Sprix (ketorolac), and Stadol (butorphanol). Unfortunately, they don't always work or work inconsistently. Having nasal congestion due to allergies, a cold, or migraine itself often makes these medicines ineffective. Stadol is a narcotic, which can be addictive, while Imitrex and Migranal require delivery into the nose a large volume of fluid, which tends to leak out or gets swallowed, thus reducing their efficacy. Seattle-based Impel Neuropharma has been working for five years to show it can quickly deliver drugs through the nose, directly to the brain, rather than what happens with the currently available sprays - absorption into the blood stream first and then carried to the brain. Impel, a University of Washington spinoff, recently presented a study of seven patients who used the company’s nose-to-brain drug delivery device, which was able to propel a test protein deep into the upper nasal passages and to the brain stem at an “order of magnitude” greater concentration than a conventional nasal spray. Researchers saw it get delivered to the destination within 10 to 20 minutes. Most nasal sprays don’t propel drugs anywhere close to the upper nasal passages, which is... --- ### TENS unit Cefaly is no longer available in the US - Published: 2013-05-28 - Modified: 2013-05-28 - URL: https://www.nyheadache.com/blog/tens-unit-cefaly-is-no-longer-available-in-the-us/ - Categories: Alternative Therapies In my previous post I mentioned a TENS unit spcifically designed for the treatment of migraine headaches. It was available for a short time on Amazon. com, but no longer is. It is sold at COSTCO stores in Canada and in Europe. Howere, regular TENS units can be tried and they are less expensive. --- ### Intravenous medications for trigeminal neuralgia - Published: 2013-05-22 - Modified: 2013-05-22 - URL: https://www.nyheadache.com/blog/intravenous-medications-for-trigeminal-neuralgia/ - Categories: Trigeminal and other neuralgias Trigeminal neuralgia is an extremely painful condition that causes electric-like pain in the face. It is often misdiagnosed as a dental problem, sinus headache or another condition. The pain is very brief, just like an electric shock, but it can occur continuously and is often triggered by brushing teeth, chewing, talking, or even by wind. This is a very treatable condition and it usually responds to anti-epilepsy drugs, Botox injections and, if those fail, surgery. Many patients have periods of sudden worsening of pain and until medications or Botox begin to help they need emergency treatment for pain. Narcotics (opioids) are usually ineffective. Dr. Merritt and Cohen of the Beth Israel Hospital in New York recently described the use of intravenous antiepileptic medications for acute exacerbations of trigeminal neuralgia in the emergency department. They described 21 patients, 15 women and 6 men whose aged ranged from 33-88 and the mean age was 69 (trigeminal neuralgia is more common in the elderly). 19 received intravenous fosphenytoin (Cerebyx, a drug related to an oral drug Dilantin) 2 received levetiracetam (Keppra) with excellent relief. Side effects included double vision, dizziness, sleepiness, and itchiness with fosphenytoin and no side effects were observed in 2 who received levetiracetam. Unfortunately, the most commonly used oral drugs for trigeminal neuralgia, carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are not available in an injectable form. Another epilepsy drug, divalproex sodium (Depakote) can be given intravenously (Depakene) but it does not appear to be very effective for trigeminal neuralgia. Art credit:... --- ### Another triptan is going generic - Published: 2013-05-17 - Modified: 2013-05-17 - URL: https://www.nyheadache.com/blog/another-triptan-is-going-generic/ - Categories: Headache medications Zomig (zolmitriptan) is the fourth triptan (out of seven) to become available in a generic form. This spells big relief for migraine sufferers who rely on this drug. Only tablets and orally disintegrating tablets (ZMT) will become available, not the nasal spray. Nasal spray offers faster relief and for some patients it is as fast as sumatriptan injection (Imitrex, Sumavel, Alsuma). It may take another 6 months for the price to drop significantly from the current $30 to $45 a pill because at this point only four companies are coming out with a generic version. There are about 10 manufacturers making generic Imitrex. Generic sumatriptan (Imitrex) is now available for $3 a pill, while the other two generics, Maxalt (rizatriptan) and Amerge (naratriptan) are still more expensive. One caveat with the generics is that the quality sometimes is not as good as that of the brand. Of approximately 10 generic sumatriptan versions, my patients have found that 2 are very ineffective. One of these two manufacturers which is based in India (Ranbaxy), recently paid $500 million fine to the FDA for improper manufacturing, storing and testing of drugs. Many generic manufacturers are based in India and most of them produce good quality products. One of them is Dr. Reddy's Laboratories. Of the four generic manufacturers of Zomig two are based in India (Glenmark and Zydus), one in Taiwan (Impax) and one is based in the US (Mylan) but also has many manufacturing plants in India. An Israeli company Teva, the... --- ### Triptans are the first line migraine drugs in pregnant women - Published: 2013-05-15 - Modified: 2013-05-15 - URL: https://www.nyheadache.com/blog/triptans-are-the-first-line-migraine-drugs-in-pregnant-women/ - Categories: Headache medications Pregnant women are admonished not to take any medications while pregnant. Fortunately, two out of three women stop having migraines during pregnancy, especially during the second and third trimester. Unfortunately, one third of women continue having migraines and in some they get worse. Tylenol (acetaminophen), which is deemed to be the safest pain medicine in pregnancy is also the weakest pain killer and does nothing to relieve the agony of a migraine attack. Many obstetricians say that they are also "comfortable" giving drugs containing butalbital (a barbiturate) and caffeine along with acetaminophen (Fioricet) because these drugs have been around for many years. However, barbiturates are really not good for the developing brain while regular intake of caffeine can cause worsening of migraine headaches. Narcotic (opioid) analgesics are not exactly healthy either. Not taking any medications is also harmful to the mother and the fetus because severe pain causes serious distress to both and vomiting, which often accompanies migraines, can cause dehydration. Not treating migraine attacks may also lead to chronic migraines with pain present continuously. So, what is a pregnant woman to do? At the recent annual meeting of the American Congress of Obstetricians and Gynecologists several doctors expressed their preference for the use of triptans in pregnant women. Sumatriptan (Imitrex) was first introduced 20 years ago and a registry of women who took sumatriptan during pregnancy suggests that this is a safe drug. Pregnancy registry for rizatriptan (Maxalt), which is the second triptan to come to the market 15... --- ### Botox helps post-traumatic headaches in soldiers - Published: 2013-05-13 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/botox-helps-post-traumatic-headaches-in-soldiers/ - Categories: New treatments Botox appears to be effective for the treatment of chronic post-traumatic headaches in service Members with a history of mild traumatic brain injury according to a recent report by Dr. Juanita Yerry and her colleagues at Ft. Bragg, NC. The researchers assessed the safety of onabotulinum toxin type A (Botox) in the preventive care of post traumatic headache. Headache is a common complication of mild traumatic brain injury in active duty service members. Migraine and chronic migraine type are the most common headache types. The approved use of Botox in chronic migraine made the doctors think that Botox might be safe and possibly effective in post-traumatic headaches with features of chronic migraines. They examined records of all patients treated with Botox for post-traumatic headache in the Concussion Care Clinic at Womack Army Medical Center, Ft. Bragg, NC between 2008 and 2012. They recorded patient demographics, prior history of headache, injury type, current headache type, time from injury to first injection, treatment techniques, number of treatments/treatment interval, side effects, reasons for discontinuation and Patient Global Evaluation of Change (PGEC). Out of 67 patients (66 male) who were treated 10% had prior history of headaches. Most common injuries were blast (46. 3%), parachute jumps (14. 9%) and motor vehicle accidents (11. 9%). About 56% reported more than one headache type. Headache types included: chronic migraine (22. 4%), episodic migraine (7. 5%), chronic tension type (7. 5%), hemicrania continua (7. 5%), nummular (1. 5%); mixed tension/chronic migraine (41. 8%), and tension/migraine (7. 5%).... --- ### Not all narcotics are equally addictive - Published: 2013-05-08 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/not-all-narcotics-are-equally-addictive/ - Categories: Headache medications, Pain Abuse of prescription narcotic (opioid) drugs is growing at an alarming rate and they are responsible for tens of thousands of deaths due to overdose every year. While all such drugs can cause addiction, there appears to be a difference among these drugs. A study recently published in The Journal of Pain suggests that a new opioid pain killer, tapentadol (Nucynta) is less likely to cause addiction than oxycodone (Percocet, Percodan, Endocet). The study was conducted by the manufacturer of Nucynta, a subsidiary of Johnson & Johnson. The researchers looked at the risk of shopping behavior (going to more than one doctor to obtain prescriptions) in over 150,000 patients. People who were prescribed oxycodone were four times more likely to be doctor shoppers than those who were prescribed tapentadol. Also, 28% of those prescribed oxycodone were asking only for oxycodone, while only 0. 6% of those prescribed tapentadole were asking for tapentadol. This means that of those prescribed tapentadol less than one percent were asking only for tapentadole and the rest asked for other narcotics. Tapentadol has another advantage in that it causes less nausea and constipation than other opioid drugs. Abuse potential is also reduced by making the pill temper resistant. About two years ago Oxycontin, which is one of the most popular (and most abused) long-acting narcotic pain killers was reformulated to make it difficult to crush. Because Oxycontin is a long-acting drug and does not give a quick high, addicts usually crush the tablet and inject or... --- ### Fear delays recovery in whiplash injuries - Published: 2013-05-04 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/fear-delays-recovery-in-whiplash-injuries/ - Categories: Pain Fear and avoidance of activity may play a role in fostering disability in whiplash-associated disorders, according to a new study by University of Washington researchers published in the latest issue of journal Pain. This study examined the role of fear after whiplash and assessed the effectiveness of 3 treatments targeting fear. They evaluated 191 people still suffering from whiplash symptoms 3 months after the injury. Patients were assigned to one of the following three treatments: (1) informational booklet describing whiplash disorder and the importance of resuming activities, (2) informational booklet plus a discussions with clinicians reinforcing the booklet, and (3) informational booklet, plus a psychological technique called imaginal and direct exposure desensitization to feared activities. The second and the third group received three 2-hour treatment sessions. Those given psychological intervention reported significantly less post-treatment pain severity compared with those given a brochure or brochure and discussion. Reduction in fear was the most important predictor of improvement, followed by reductions in pain and depression. The authors concluded that the results highlight the importance of fear in individuals with persistent whiplash injury symptoms and suggest the importance of addressing fear through exposure therapy and educational interventions to improve function. Photo credit: JulieMauskop. com --- ### Prophylactic migraine drugs are all equally mediocre - Published: 2013-05-01 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/prophylactic-migraine-drugs-are-all-equally-mediocre/ - Categories: Headache medications Preventive drugs for migraine headaches help less than half of the patients they are given to. There is no significant difference in effectiveness in these drugs. They reduce frequency of attacks by 50 percent, according to a review published in the recent issue of the Journal of General Internal Medicine. Dr. Shamliyan from the University of Minnesota in Minneapolis and her colleagues conducted a literature review to identify high quality clinical trials of preventive drugs versus placebo. Based on 215 published trials, the researchers found that all FDA-approved drugs, including topiramate (Topamax), divalproex (Depakote), timolol (Blocadren), propranolol (Inderal) and off-label medicines metoprolol (Toprol), atenolol (Tenormin), nadolol (Corgard), captopril (Capoten) and lisinopril (Zestril); and candesartan (Atacand) were effective in reducing monthly migraine frequency by 50 percent or more in 20% to 40% of patients. Topiramate, other off-label antiepileptics, and antidepressants had higher levels of side effects and were more likely to be stopped by patients because of side effects. While there were no significant differences in benefits between approved drugs, candesartan and other blood pressure drugs were the most effective and had fewest side effects for the prevention of episodic migraines. The authors also noted that there was no evidence for long-term effects of drug treatments (that is trials lasting more than three months). This review confirms my bias in favor of Botox injections over drugs. Botox helps not only 70% of chronic migraine patients, but in my anecdotal (but involving thousands of patients) experience it is equally effective for the... --- ### Anxiety and depression are associated with various pains and migraines - Published: 2013-04-28 - Modified: 2013-04-28 - URL: https://www.nyheadache.com/blog/anxiety-and-depression-are-associated-with-various-pains-and-migraines/ - Categories: Science of Migraine It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The reverse is also true: if you suffer from anxiety and depression, you are 2-3 times more likely to develop migraine headaches. These associations are called comorbidities. Anxiety and depression are also comorbid with other pain syndromes. A group of Dutch researchers examined records of almost 3,000 patients with anxiety and depression to look for the presence of comorbid migraines and pain in the back, neck, face, abdomen, joints, and chest. All patients were interviewed twice, with a two year interval, and were asked if they had any of those pains in the preceding 6 months. Their results, published in The Journal of Pain, clearly show that having anxiety and depression increases the risk of developing migraines and other pain syndromes equally. So, this association is not specific to migraines, but applies to all pain syndromes. This means that anxiety and depression do not cause headaches and pain and the other way around. Most likely, one condition predisposes the sufferer to develop the other. It is also likely that shared genetic predisposition or the involvement of certain brain chemicals that are involved in both pain and depression, such as serotonin, adrenalin, and other, may be responsible for these associations. --- ### Botox relieves myofascial (muscle) pain - Published: 2013-04-24 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/botox-relieves-myofascial-muscle-pain/ - Categories: Pain Botox seems to help neck and upper back muscle pains, according to a recent study by UCLA doctors. We know that one of the actions of Botox is to relax muscles and it has been effective for the treatment of sciatic pain, according to a previous blinded study. Drs. Nicol and Ferrante at UCLA gave a single injection of Botox to 118 patients with neck and upper back pain. Six weeks later 54% of patients showed improvement. Then, 8 weeks later, half of the 54 responders were given again Botox and the other half placebo (saline injection). Those who received Botox did much better not only on pain scores, but also on quality of life measures. They also had a significant improvement in the number of headaches. This is not that surprising, since many of our patients report that their headaches begin with muscle spasm in the neck or upper back. It is very likely that giving more than one injection will lead to a greater improvement in a larger percentage of patients. In chronic migraine headache patients injecting Botox into 31 sites has been proven to be very effective. Art credit: JulieMauskop. com --- ### A new procedure for pseudotumor cerebri - Published: 2013-04-22 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/a-new-procedure-for-pseudotumor-cerebri/ - Categories: New treatments A new treatment for pseudotumour cerebri was reported by a team of interventional neuroradiologists and neurosurgeons. Pseudotumour cerebri is a rare condition, which manifests itself by increased pressure in the head, leading to severe headaches, vision impairment and even complete loss of vision and brain damage. It affects more women than men and usually occurs without an obvious trigger, although pregnancy, obesity, and certain medications increase the risk of developing this condition. The diagnosis is made by performing a spinal tap (lumbar puncture) and measuring cerebrospinal fluid pressure. Typical MRI scan findings (narrowing of the ventricles - cerebrospinal fluid filled spaces in the brain) and finding of swollen optic nerves (papilledema)on eye exam confirm this diagnosis. The new treatment is based on the theory that narrowing of a vein located at the back of the brain is the underlying cause, although this theory remains controversial. Narrowing of this vein is thought to reduce drainage of the cerebrospinal fluid from inside the brain, leading to build up of this fluid and increased pressure inside the skull. The usual treatments for pseudotumor include weight loss, medications that reduce pressure, such as acetazolamide (Diamox), and the surgical placement of a shunt to continuously drain spinal fluid from the brain, thus reducing the pressure. The study, published in the online edition of the Journal of Neuro-Ophthalmology, shows that lowering pressure inside the vein alleviates the condition and improves vision. The doctors at Johns Hopkins used an advanced ultrasound scanner to thread an expandable metal... --- ### Levadex is delayed again - Published: 2013-04-19 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/levadex-is-delayed-again/ - Categories: New treatments Approval of the inhaled dihydroergotamine or DHE to be sold under the name of Levadex has been delayed again by the FDA. We expected approval last year because the FDA did consider the product to be safe and effective, but they were not happy with the manufacturing process. The application for approval was resubmitted and we all expected the product to become available in the middle of this year, but apparently the FDA still has the some concerns about the manufacturing. If all goes well Levadex may come to the market at the end of 2013. In the past few months the small company that developed Levadex, MAP Pharmacueticals sold itself to the maker of Botox, Allergan. Allergan hopes to find synergy between Botox, which is approved for the prevention of chronic migraines and Levadex, which is indicated for the treatment of an acute migraine attack. It will be much more efficient for Allergan's sales force to sell two complementary drugs to neurologists rather than just one. Both are excellent drugs with high efficacy (70% for Botox and 60% - 70% for Levadex), excellent safety for Botox and relatively good safety for Levadex (comparable to triptans, such as Imitrex). Photo credit: JulieMauskop. com --- ### Elimination diet based on antibodies in the blood helps migraines - Published: 2013-04-17 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/elimination-diet-based-on-antibodies-in-the-blood-helps-migraines/ - Categories: Alternative Therapies Food sensitivities have been always suspected to be a trigger for migraine headaches. A group of Turkish neurologists published a study in the journal Headache in which they gave an elimination diet to 21 migraine sufferers who also had irritable bowel syndrome (IBS). The study was double-blind, randomized, controlled, and cross-over, which is the most reliable type of study. Depending on the results of blood tests against 270 potential food triggers each patient was given a diet that eliminated foods they tested positive for. On average, patients were sensitive to 23 items. Compared with baseline levels, elimination diet was associated with significant reductions in migraine attack count, maximum attack duration, maximum attack severity, and number of attacks requiring medication. There was a significant reduction in pain-bloating severity, pain-bloating within the last 10 days, and was a significant improvement in quality of life by the elimination diet as compared with provocation diet. The authors concluded that food elimination based on IgG antibodies in migraine patients who suffer from concomitant IBS may effectively reduce symptoms of both disorders with a positive impact on the quality of life of patients. A similar, but much larger double-blind study published in 2011 compared true and sham diets in 167 migraine sufferers. 84 patients received a diet that eliminated trigger foods identified by IgG testing and the other 83 a sham diet and neither the doctor nor the patients knew who received a true elimination diet and who was given a sham diet. After 12 weeks... --- ### Pleasant pain??? - Published: 2013-04-12 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/pleasant-pain/ - Categories: Pain The importance of context: When relative relief renders pain pleasant, is the title of an article recently published in the leading international medical journal, Pain. British and Norwegian researchers examined how context can influence the experience of any event. For instance, the thought that “it could be worse” can improve feelings towards a present misfortune. They measured hedonic (pleasant) feelings, brain activation patterns, and skin conductance (which indicates stress, since increased sweating increases electrical skin conductance; this phenomenon is also used in biofeedback). 16 healthy volunteers experienced moderate pain in two different contexts. In the “relative relief context,” moderate pain represented the best outcome, since the alternative outcome was intense pain. However, in the control context, moderate pain represented the worst outcome and elicited negative hedonic feelings. The context manipulation resulted in a “hedonic flip,” such that moderate pain elicited positive hedonics in the relative relief context. Somewhat surprisingly, moderate pain was even rated as pleasant in this context, despite being reported as painful in the control context. This “hedonic flip” was confirmed by skin conductance and brain activation patterns on MRI scans. When moderate pain was perceived as pleasant, skin conductance and activity in certain parts of the brain were significantly reduced, relative to the control moderate stimulus. “Pleasant pain” also increased activity in reward and pain relieving brain centers. The context manipulation also significantly increased connections between reward circuitry and the pain relieving centers. Photo credit: JulieMauskop. com --- ### More about catastrophizing - Published: 2013-04-08 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/more-about-catastrophizing/ - Categories: Pain Research It is not surprising that persistent pain can cause depression, but a study just published in The Journal of Pain suggests a possible mechanism and more importantly a possible treatment. Australian doctors examined 669 patients who were over 60 years old and were seen at a pain clinic. Catastrophizing, measured by a validated scale, was a reliable predictor of depression. They showed a strong correlation between pain intensity, catastrophizing, and depression. That is, if someone tended to think thoughts such as, "I will never get better" or "I cannot go on like this" they were also more likely to be depressed. Fortunately, this kind of thinking can be changed with psychological interventions and such change usually leads to improvement in pain. Art credit: JulieMauskop. com --- ### Melatonin prevents migraine headaches - Published: 2013-04-02 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/melatonin-prevents-migraine-headaches/ - Categories: New treatments Melatonin does seem to help prevent migraine headaches according to a new study by Brazilian researchers just presented at the annual scientific meeting of the American Academy of Neurology. In my previous post over two years ago I wrote about a negative study that showed no benefit from 2 mg of extended release melatonin given to 46 migraine sufferers. This new study was also blinded and it compared 3 mg of immediate release melatonin with placebo and with 25 mg of amitriptyline, which is one of the oldest preventive drugs for migraines. This was a larger study - it involved 196 patients who suffered from 2-8 attacks of migraine with or without aura each month. The number of headache days dropped by 2. 7 days in the melatonin group, 2. 18 for amitriptyline, and 1. 18 for placebo. Melatonin significantly reduced headache frequency compared to placebo, but not to amitriptyline. Not surprisingly, melatonin was better tolerated then amitriptyline. Considering its safety and very low cost, it is worth considering a trial of 3 mg of melatonin for the prevention of migraine headaches. Some studies have suggested that taking a much smaller dose of 0. 3 mg (300 mcg) of melatonin may be more effective for insomnia than taking a much larger dose. It would be interesting to see if this also applies to the treatment of migraine headaches. Art credit: JulieMauskop. com --- ### Vagus nerve stimulator seems to work for acute migraines - Published: 2013-03-31 - Modified: 2013-03-31 - URL: https://www.nyheadache.com/blog/vagus-nerve-stimulator-seems-to-work-for-acute-migraines/ - Categories: New treatments Vagus nerve stimulation (VNS) seems to be effective for the treatment of migraine headaches. In my post over a year ago I mentioned our study of a device that stimulates vagus nerve with an external portable device. The results of this study were just presented at the annual scientific meeting of the American Academy of Neurology. The device was developed by scientists at ElectroCore, a small company following my publication of a study of implantable VNS in 6 patients. In the current study we included patients with migraine with or without aura. Participants acutely treated up to 4 migraine attacks with this portable VNS within 6 weeks. Treatment consisted of two, 90-second doses, at 15-minute intervals. Patients were asked to self-treat once pain became moderate or severe, or after 20 minutes of mild pain. Of 30 enrolled patients, 26 treated 79 migraine headaches. At two hours, 46 of 79 headaches (58%) responded, and in 22 out of 79 (28%) pain was completely gone. At two hours, 76 of 79 (96%) were improved or did not worsen. Of 26 patients 20 (77%) reported mild or nor pain at 2 hours, for at least one treated headache. Side effects were limited to muscle or skin irritation and two reports of lightheadedness, most of which resolved immediately after treatment, and all within two hours of treatment. These are very preliminary results, but they suggest that VNS may be an effective and well-tolerated acute treatment for migraine. Additional large clinical trials are needed to... --- ### Generic rizatriptan (Maxalt) and sumatriptan (Imitrex) - Published: 2013-03-27 - Modified: 2013-03-27 - URL: https://www.nyheadache.com/blog/generic-rizatriptan-maxalt-and-sumatriptan-imitrex/ - Categories: Headache medications The release of a generic substitute of the branded drug Imitrex (sumatriptan) has dramatically reduced the cost and improved the access to this uniquely effective migraine drug. The generic sumatriptan was released four years ago and now the price of one tablet is down to about $3 from over $20. The cost of two other generic triptans, Amerge (naratriptan) and Maxalt (rizatriptan) has remained very high, but it is expected to drop as more companies begin making generic copies. However, generics are not always the exact copies of the original branded drug that we expect them to be. In my previous post in 2009 I mentioned a study that showed that the generic Topamax (topiramate) does not work as well as the brand for some patients. I have also seen this with sumatriptan - my patients tell me that some generics do not work very well or at all. Out of about 10 generics of sumatriptan, I would guess that two are of poor quality. Once you find a generic that works for you, try to stick with the same generic manufacturer. The name of the manufacturer is printed on the bottle the pharmacy gives you. If one pharmacy does not have your generic, try another one. Here is a part of an email I just received from a patient (she gave me permission to share it with you): "Just wanted to share with you that my pharmacy filled my maxalt melt prescription with yet another generic brand yesterday, which... --- ### Changing the meaning of pain from negative to positive reduces pain - Published: 2013-03-22 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/changing-the-meaning-of-pain-from-negative-to-positive-reduces-pain/ - Categories: Pain Research Pain is defined as a negative emotional experience that is affected by a variety of psychological factors. Some of the pain brain mechanisms involve endorphins (endogenous opioids) and cannabinoids (substances related to marijuana - yes, we have those in our brains) and they have been found to be involved in stress-related and placebo pain relief. A study by Italian researchers just published in journal Pain showed that when the meaning of the pain experience is changed from negative to positive through verbal suggestions, the opioid and cannabinoid systems are co-activated and these, in turn, increase pain tolerance. Healthy volunteers had a blood pressure cuff inflated over the upper arm to the point of pain and were asked to tolerate the pain as long as possible. One group was told about the negative effects of pain. The second group was told that the the pain would be beneficial to the muscles. The second group was able to tolerate pain much longer than the first one. When the researchers gave the group with the positive message opioid antidote or the antidote to marijuana, their pain tolerance worsened. Interestingly, the combined administration of these two antidotes completely eliminated their advantage over the negative message group. This study showed that a positive approach to pain reduces the global pain experience. The authors concluded that their findings may have a profound impact on clinical practice. For example, postoperative pain, which means healing, can be perceived as less unpleasant than cancer pain, which means death. Therefore,... --- ### Migraine and tension-type headache sufferers are more likely to have low back pain - Published: 2013-03-20 - Modified: 2013-03-20 - URL: https://www.nyheadache.com/blog/migraine-and-tension-type-headache-sufferers-are-more-likely-to-have-low-back-pain/ - Categories: Pain, Pain Research, Science of Migraine German researchers examined the possible connection between headaches and low back pain in a study published in the recent issue of journal Pain. They questioned 5605 headache sufferers about the frequency and type of their headaches and about the frequency of their low back pain. Of these 5605 people 255 (4. 5%) had chronic headache and the rest had episodic (less than 15 headache days each month). Migraine was diagnosed in 2933 subjects, of whom 182 (6. 2%) had chronic migraines. Tension-type headache was diagnosed in 1253 respondents, of whom 50 (4. 0%) had chronic tension-type headaches. They also found that 6030 out of 9944 people suffered from back pains, of whom 1267 (21. 0%) reported frequent low back pain. The odds of having frequent low back pain were between 2. 5 times higher in all episodic headache subtypes (migraine and tension) when compared to those without any headaches. The odds of having frequent low back pain were 15 times higher in all chronic headache subtypes when compared to those without headaches. One possible explanation for this association is that having pain in any part of your body makes you more likely to develop other types of pain. We know that persistent pain makes the nervous system more excitable and this in turn may predispose to other pain syndromes. We also know that people with fibromyalgia are more likely to suffer from headaches, and those with migraines are more likely to develop painful irritable bowel syndrome. --- ### Expect relief and you will get it - Published: 2013-03-19 - Modified: 2013-03-19 - URL: https://www.nyheadache.com/blog/expect-relief-and-you-will-get-it/ - Categories: Pain Research Expectation of relief can enhance pain relief, according to a new study published in The Journal of Pain by Canadian researchers. This is not a new discovery, but provides additional confirmation of this important clinical observation. The current study was performed in 60 healthy volunteers, 15 of whom expected relief of experimental pain, 15 expected worsening of pain from the procedure, 15 had no expectations, and 15 were in a control group. Pain was induced by electrical stimulation of right leg, while applying an ice pack to the left arm (counterstimulation) was tested as a treatment to reduce pain in the leg. Those who were told that the pain will worsen from the ice pack in fact felt more pain, while those who were expecting relief, experienced less pain. A study published in 2009 by Harvard researchers showed that expectation of relief from acupuncture also translated into stronger relief experienced by volunteers subjected to experimental pain. Their clinical observation was confirmed by functional MRI scans showing stronger activation of pain relieving structures in the brain. The researchers concluded that while acupuncture provides pain relief by sending blocking messages up to the central nervous system, messages regulating pain perception from the brain down can affect pain perception depending on person's expectations. This suggests that having a positive expectation when seeing doctors and undergoing various treatments may improve the outcome of these treatments. --- ### Sex can relieve migraine and cluster headaches - Published: 2013-03-16 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/sex-can-relieve-migraine-and-cluster-headaches/ - Categories: Alternative Therapies, Science of Migraine Many people report that sex relieve their migraine and tension-type headaches. We also know that sexual activity can trigger severe headaches. A group of German researchers conducted an observational study among patients of a headache clinic. They sent out a questionnaire to 800 unselected migraine patients and 200 unselected cluster headache patients. They asked about their experience with sexual activity during a headache attack and its impact on headache intensity. 38% of the migraine patients and 48% of the patients with cluster headaches responded. In migraine, 34% of the patients had experience with sexual activity during an attack; out of these patients, 60% reported an improvement of their migraine attack (70% of them reported moderate to complete relief) and 33% reported worsening. In those with cluster headaches, 31% of the patients had experience with sexual activity during an attack; out of these patients, 37% reported an improvement of their cluster headache attack (91% of them reported moderate to complete relief) and 50% reported worsening. Some patients, in particular male migraine patients, even used sexual activity to treat their headaches. Obviously, the majority of patients with migraine or cluster headache do not have sexual activity during headache attacks. However, the doctors concluded that sexual activity can lead to partial or complete relief of headache in some migraine and a few cluster headache patients. Some of my patients report that masturbation is as good as having sex in relieving their migraine attacks. Art Credit: JulieMauskop. com --- ### Optimists have lower pain sensitivity - Published: 2013-03-10 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/optimists-have-lower-pain-sensitivity/ - Categories: Pain Research Optimists appear to tolerate pain better than pessimists, an old discovery that is supported by a new study published in The Journal of Pain. The study by researchers at the Universities of Florida and Alabama involved 140 older individuals with osteoarthritis. They were subjected to experimental pain (heat was repeatedly applied to the forearm) and also had a variety of psychological tests. Those elderly who were judged to be optimists (based on an established and validated test) had lower pain perception. The study also showed that optimism was associated with lower levels of catastrophizing. Catastrophizing was also measured by validated scale, which includes questions such as "I feel it is never going to get better" and "I can't stand it anymore". The good news is that studies have shown that cognitive-behavioral therapy can reduce catastrophizing and improve pain. So, if you are a pessimist, do not give up - see a psychologist and your pain may be easier to control. Photo credit: JulieMauskop. com --- ### Migraine drug, Cambia (dicolfenac) can cause heart attacks - Published: 2013-03-07 - Modified: 2013-03-07 - URL: https://www.nyheadache.com/blog/migraine-drug-cambia-dicolfenac-can-cause-heart-attacks/ - Categories: Headache medications Cambia (diclofenac) is a prescription anti-inflammatory drug (NSAID) which is approved by the FDA for the treatment of migraine headaches. It is sold as a licorice-tasting powder that has to be dissolved in water before being ingested. This drug belongs to the same family as Advil or Motrin (ibuprofen), Aleve (naproxen), and prescription drugs, such as Relafen (nabumetone), Celebrex (celecoxib), and other. One of the drugs in this category, Viox (rofecoxib) was taken off the market because it increased the risk of heart attacks and strokes. A recent study published in an online medical journal, PLOS Medicine and translated into lay language in an NPR article indicates that diclofenac is as dangerous as Vioxx in causing heart attacks and strokes. The study also indicates that diclofenac unfortunately is one of the most popular NSAIDs in the world. It is probably safe to take Cambia a few times a month to treat migraine headaches, however, it should be avoided by people with other risk factors for heart disease and strokes. These risk factors include migraine with aura, high blood pressure, high cholesterol, diabetes, smoking, oral contraceptives, family history of heart disease, and other. Aspirin (in Migralex and other products), on the other hand, is the only NSAID that has been shown to prevent strokes, heart attacks, and several forms of cancer. Photo credit: CambiaRx. com --- ### Stopping high doses of triptans suddenly can cause depression - Published: 2013-03-04 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/stopping-high-doses-of-triptans-suddenly-can-cause-depression/ - Categories: Headache medications Daily and prolonged intake of high doses of triptan medications (sumatriptan, or Imitrex, rizatriptan, or Maxalt, eletriptan, or Relpax and 4 others) has been shown to be safe in at least three clinical reports. I also have a few patients who have good control of their headaches and no side effects after many years of taking high doses of triptans daily. (I am not suggesting that it is healthy to take any medicine daily for years, but some people have no other choice because without this treatment they are disabled). A report just published in The Journal of Clinical Pharmacy and Therapeutics describes a patient who also was taking high doses of triptans daily (zolmitriptan or Zomig and frovatriptan or Frova tablets and sumatriptan injections), but who developed severe depression on two occasions when the triptans were stopped suddenly. The first bout of depression was very difficult to treat despite trials of several antidepressant drugs (amitriptyline, or Elavil, mirtazapine, or Remeron, and duloxetine, or Cymbalta, with addition of quetiapine, or Seroquel). All these antidepressants work through the serotonin system. His second bout of depression responded very well to bupropion (Wellbutrin), an antidepressant that works on norepinephrine and dopamine, rather than serotonin. This report suggests that while it may be safe to take triptans daily for a long time, they can affect the serotonin mechanisms in the brain and that they should never be stopped suddenly. Another important lesson is that if depression does develop after stopping daily triptans, the preferred... --- ### Predicting response to Botox (or rather, a similar product, Myobloc) - Published: 2013-03-01 - Modified: 2013-03-01 - URL: https://www.nyheadache.com/blog/predicting-response-to-botox-or-rather-a-similar-product-myobloc/ - Categories: New treatments A recently published study by neurologists at the Military Medical Center in San Antonio led by Dr. Grogan tried to find predictors of response to botulinum toxin injections in chronic migraine sufferers. They looked at the records of 128 patients who received injections of botulinum toxin, although they did not receive Botox (onabotulinumtoxinA), but a similar product, Myobloc (rimabotulinumtoxinB). It has been previously reported (and mentioned in this blog) that patients with headaches who experience constricting pain or pain in the eye are more likely to respond than those who have an "exploding" headache or pain with pressure felt going from inside out. This new study confirmed this observation, originally made by Dr. Rami Burstein and his colleagues at Harvard Medical School. Dr. Grogan and his colleagues' patients received an average of 7 and a half treatments over a period of 22 months. Treatment results showed that 80% of their patients who received injections of Myobloc had at least a 50% improvement and 57% had a greater than 75% reduction in their headache frequency. This is similar to the 70% response rate we see with Botox injections. Patients who had migraine with aura were more likely to respond to Myobloc injections. Just like with Botox side effects were few and mild and only 4% of patients decided to stop this treatment due to side effects. More patients who received Myobloc (82%) complained of pain during injections. I have also observed this and the reason is that Myobloc is very acidic,... --- ### Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world - Published: 2013-02-26 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/tension-and-migraine-headaches-are-the-2nd-and-3rd-most-common-medical-problem-in-the-world/ - Categories: Science of Migraine Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world after dental caries (cavities), according to a new study conducted by the World Health Organization (The Global Burden of Disease Survey 2010) and reported in the journal Headache. Tension-type headaches affects 20. 1% of the world's population and migraine, 14. 7%. Migraine is the 7th most disabling of all medical conditions. Migraine sufferers spend more than 5% of all of their time having pain and other symptoms of this condition. Migraine is by far the most disabling of all neurological condition. Hundreds of millions of people in the world suffer unnecessarily from headaches. This is in part due to lack of awareness of the extent, the severity, and the impact of headaches, but also due to limited resources. The National Institutes of Health in the US allocates very little money to researching headache disorders and a disproportionally large amounts on neurological conditions such as epilepsy, MS, Parkinsons, and other. I am not suggesting that these other condition do not deserve to be studied, but suffering by many more people would be relieved by investing more money in headache research. Art credit: JulieMauskop. com --- ### A potential treatment for prolonged auras - Published: 2013-02-18 - Modified: 2013-02-18 - URL: https://www.nyheadache.com/blog/a-potential-treatment-for-prolonged-auras/ - Categories: New treatments A typical visual aura which precedes the headache in about 20% of migraine sufferers usually lasts 20 to 60 minutes. A small number of patients suffer prolonged auras, which can last for hours. While we have many medications to treat the pain of migraine, we have no effective way to stop a prolonged aura. The only possible exception is intravenous magnesium, which I have found to help some patients for prolonged visual and other types of aura. Researchers at UCSF led by Dr. Peter Goadsby conducted a rigorous blinded study of intranasal ketamine for prolonged auras. They compared ketamine to a strong tranquilizer, midazolam. The results of the study published in Neurology showed that ketamine but not midazolam can make aura milder, but it did not shorten it. Ketamine is a drug given intravenously for anesthesia, but it has been also widely tested for the treatment of pain, albeit with mixed results. --- ### TENS vs tDCS - Published: 2013-02-13 - Modified: 2013-02-13 - URL: https://www.nyheadache.com/blog/tens-vs-tdcs/ - Categories: New treatments I failed to mention in my two previous posts that there is a difference in the type of electrical current used in transcutaneous electrical nerve stimulation (TENS) and transcranial direct current stimulation. The former uses alternating current, while the latter is a direct current (AC vs DC). Cefaly device uses AC, while tDCS devices use DC. It is possible that both types of stimulation are equally effective for chronic migraine headaches and other conditions. We would need to have a blinded trial comparing these two types of stimulation to see if one is superior to the other. --- ### More on electrical stimulation - Published: 2013-02-12 - Modified: 2013-02-13 - URL: https://www.nyheadache.com/blog/more-on-electrical-stimulation/ - Categories: New treatments An article in today's New York Times reported on the efficacy of electrical brain stimulation for the treatment of depression. It described a study published last week in the journal JAMA Psychiatry, in which a commonly used antidepressant, sertraline (Zoloft) was compared with transcranial direct current stimulation, or tDCS. This blinded study showed that Zoloft and the electrical stimulation of the brain were equally effective, but the electrical stimulation lacked the side effects of the drug. Combining electrical stimulation with Zoloft produced even better results. This type of electrical stimulation is very safe and is somewhat similar to the transcutaneous electrical stimulation mentioned in my previous post. tDCS was also tried in patients with chronic migraines. A study published in Headache last year showed that pain intensity and migraine duration was reduced after 10 sessions of tDCS given over a period of 4 weeks. Even though the study involved only 13 patients, the active treatment was compared to sham stimulation, which makes the findings more likely to be true, rather than due to the placebo effect. It is too early to recommend tDCS for the treatment of chronic migraines. However, this is a very safe and inexpensive treatment that may be worth trying before other unproven, more expensive, and more invasive treatments, such as occipital or supraorbital nerve stimulation or migraine surgery. Photo credit: neuroconn. de --- ### Transcutaneous electrical nerve stimulation (TENS) for headaches - Published: 2013-02-12 - Modified: 2013-02-12 - URL: https://www.nyheadache.com/blog/transcutaneous-electrical-nerve-stimulation-tens-for-headaches/ - Categories: New treatments Electrical stimulation of the nervous system is widely used for a variety of conditions and in a variety of ways. The nervous system can be electrically stimulated at the level of the brain, by implanting electrodes into the brain, at the level of spinal cord, also with implanted electrodes or at the level of peripheral nerves in the skin by attaching an adhesive electrode or with an implanted wires. The conditions that can be helped by electrical stimulation range from Parkinsons disease and depression to chronic low back pain and post-herpetic neuralgia (shingles). Stimulation of the nerves through adhesive electrodes temporarily attached to the skin is called transcutaneous electrical stimulation, or TENS. TENS has been proven to help a variety of musculo-skeletal conditions, such as back pain and arthritis pain. There have been some studies of the use of TENS for headaches, but none of them have been as rigorous and scientific as the one just published in Neurology. The lead author, a Belgian neurologist and a headache specialist Dr. Jean Schoenen and his colleagues conducted a study on 67 patients with a proprietary TENS device called Cefaly. The device is put on the forehead like eyeglasses and it contains electrodes which stimulate the nerves above the eyes. The study showed that by using this stimulator for 20 minutes daily for 3 months patients reduced the number of their migraine headaches from an average of 7 to 5 a month. Those patients who put on the device but were not... --- ### Migraine is a risk factor for sudden hearing loss - Published: 2013-02-11 - Modified: 2013-02-11 - URL: https://www.nyheadache.com/blog/migraine-is-a-risk-factor-for-sudden-hearing-loss/ - Categories: Science of Migraine Sudden hearing loss is a rare condition, but it is more common in people who suffer from migraine headaches, according to just published study by Taiwanese researchers. Taiwan, just like many Scandinavian countries has national health insurance and the large computerized data base allows doctors to perform reliable studies of many medical conditions. This study, which was published in Cephalalgia, an international headache journal, involved 10,280 migraine sufferers who were compared to 41,120 healthy control subjects. Doctors examined ten years worth of records of these people and discovered that having migraines almost doubled the risk of sudden hearing loss (the medical term is sudden sensorineural hearing loss). The incidence was about 82 per 100,000 person-years in migraine sufferers and 46 in those without migraines. They also discovered that having hypertension (high blood pressure) increased the risk of sudden hearing loss. This suggests that the hearing loss may be due to sudden drop in blood supply to the hearing nerves. Surprisingly the increased risk was not more pronounced in patients with migraine with aura since vascular problems are more common in those with auras. Treatment of sudden hearing loss requires immediate visit to a doctor, who takes a detailed history, examines the patient, does hearing tests, and obtains an MRI scan of the brain. Sudden loss of hearing can be caused by impacted wax in the ear, brain tumor and other brain disorders, but usually no such causes are found. If no obvious cause is found, treatment typically involves taking a... --- ### Do flickering lights and exercise really trigger migraines? - Published: 2013-02-08 - Modified: 2013-02-08 - URL: https://www.nyheadache.com/blog/do-flickering-lights-and-exercise-really-trigger-migraines/ - Categories: Science of Migraine Many migraine sufferers report that flickering lights and vigorous exercise trigger their migraine attacks. Danish researchers published a study in the journal Neurology , in which they recruited 27 patients who suffered from migraines with aura. Of these 27, 12 reported that flickering lights triggered their attacks, 10 reported that vigorous exercise did and 4 felt that both of these were triggers, while only one felt that these were not triggers for her migraine headaches. These patients were then subjected to bright flickering lights for 30-40 minutes, exhausting exercise for 1 hour, or both. None of the 11 patients who were exposed to bright flickering lights developed a migraine, exercise alone triggered a migraine in 4 out of 12 patients (one migraine with aura and three had migraine without aura), while both types of stimulation together triggered a migraine with aura in 2 out of 7. This is a surprising finding, but it does not mean that patients are wrong about flickering light and strenuous exercise triggering migraines. A more likely explanation is that any particular trigger may require certain additional conditions, such as location which is associated with the expected headache, prior conditioning, such as stress that accompanies exposure to bright light in a certain room, added triggers, such as lack of sleep, alcohol, blood caffeine level, and many other. It is also possible that migraine with aura, unlike migraine without aura, is less likely to be triggered by exercise and flickering lights. If you are exposed to one... --- ### Botox converts chronic migraines into episodic in 70% of patients - Published: 2013-02-06 - Modified: 2013-02-06 - URL: https://www.nyheadache.com/blog/botox-converts-chronic-migraines-into-episodic-in-70-of-patients/ - Categories: New treatments Botox (anabotulinumtoxinA) is the only treatment approved by the FDA for the treatment of chronic migraine headaches. The FDA based its approval on the results of two clinical trials with 700 patients in each (I participated in one of them). In these studies half of the patients were given placebo injections and the other half, Botox for the first six months and then everyone was getting Botox. Even after 4 weeks following the first treatment those who received Botox were doing better than those who received placebo. After the first Botox treatment 49% of participants had a 50% reduction in the number of headache days, after the second treatment this number was 60% and after the thurs, 70%. After 56 weeks, 70% of patients treated with Botox continued to have at least a 50% improvement in headache days per month. This means that by that time 70% of patients were no longer were having chronic migraine, which is defined as having a headache on more than half of the days. So, even in those chronic migraine sufferers who were having daily headaches, a 51% improvement meant that they no longer had headaches on more than half of the days. This also means that Botox converts chronic migraine into episodic. My observation over 18 years of injecting Botox for headaches also indicates that with continued treatment some people stop having migraines altogether. Of course, this observation does not mean that Botox was definitely the reason why headaches stopped since migraines often... --- ### If you had migraine surgery - what was your experience? - Published: 2013-02-04 - Modified: 2013-02-04 - URL: https://www.nyheadache.com/blog/if-you-had-migraine-surgery-what-was-your-experience/ - Categories: New treatments Migraine surgery continues to be promoted by an ever increasing number of plastic surgeons. In my previous post in 2007 I mentioned the reasons to avoid such surgery and five years later all those reasons remain. Some of the leading objections are lack of proof, existence of a safer alternative (Botox injections), and most importantly, the risk of potentially serious side effects. Several of my colleagues have seen patients who suffered complications of surgery and we decided to ask other patients who underwent migraine surgery to come forward and share their experience. We understand that this will not be a highly scientific study and it will not tell us what percent of people suffer negative outcomes since those who suffered complications and side effects are more likely to come forward than those who had none. However, we think that because doctors who perform surgery are unlikely to report side effects and complications, it is important for people to know what can go wrong. So, please post your experience in response to this blog or if you prefer to remain anonymous, email me at DrMauskop@nyheadache. com. --- ### Botox relieves SUNCT - a rare headache syndrome - Published: 2013-02-02 - Modified: 2013-02-02 - URL: https://www.nyheadache.com/blog/botox-relieves-sunct-a-rare-headache-syndrome/ - Categories: New treatments Botox relieved severe pain of SUNCT, a rare and very painful condition, according to a report recently published in journal Cephalalgia. SUNCT stands for short-lasting, neuralgiform headache attacks with conjuctival injection and tearing. The pain of SUNCT is very sudden and brief, lasting 5 to 240 seconds and occurring 20-30 or more times a day. The pain usually occurs around the eye and is accompanied by tearing and redness of the eye. It can be a very debilitating condition because it is difficult to treat. Medications, such as lamotrigine (Lamictal), gabapentin (Neurontin), carbamazepine (Tegretol), and other have been reported to help. The report in Cephalalgia by a Spanish neurologist describes a patient with SUNCT who did not respond to a variety of medication and nerve destruction (thermocoagulation of the trigeminal ganglion), but had an excellent response to Botox injections given every three months. He has received 10 Botox injections over a period of 2 and 1/2 years with sustained relief. He was still having 6-8 attacks per week, but before Botox he was having 20-30 a day. His functioning has also significantly improved. Botox is approved by the FDA only for chronic migraines, although it also seems to work for cluster headaches, which cause pain similar to SUNCT, although it lasts for 1-3 hours and occurs once or twice a day. SUNCT is a very rare condition and it is very unlikely that a blinded clinical trial of Botox for SUNCT will ever be conducted, but this report suggests that... --- ### Zecuity - transdermal sumatriptan - Published: 2013-01-17 - Modified: 2013-01-17 - URL: https://www.nyheadache.com/blog/zecuity-transdermal-sumatriptan/ - Categories: New treatments Zecuity was just approved by the FDA for the treatment of acute migraines. Zecuity is a skin patch containing sumatriptan. Delivering sumatriptan through the skin is an appealing option for patients who have severe nausea or vomiting and have difficulty swallowing tablets. NuPath is a company that has been working on such a delivery system for several years and I mentioned their research in one of the posts on this blog over three years ago. Recently, they completed another clinical trial which confirmed that the idea is valid and their product (it was first named Zelrix, but now is to be called Zecuity) is effective in treating migraine attacks. The patch containing sumatriptan delivers medicine through the skin with the help of an electrical current derived from a miniature battery embedded within the patch. The patch is used once and then is discarded. The results of this trial were published in the journal Headache. This study involved 469 patients half of whom treated their migraine with an active patch and the other half with an inactive (placebo) patch. A significantly higher proportion of patients given sumatriptan were completely pain-free compared to those who were given placebo - 18% vs 9%. Pain relief after two hours was observed in 53% patients receiving sumatriptan compared to 29% of those receiving placebo and this difference persisted. Side effects were mostly local due to the patch - 23% had pain at the site of patch, 20% had either burning of tingling, and 7% had... --- ### New oral contraceptives increase the risk of strokes and other types of blood clots in patients with migrianes with aura - Published: 2013-01-16 - Modified: 2013-01-16 - URL: https://www.nyheadache.com/blog/new-oral-contraceptives-increase-the-risk-of-strokes-and-other-types-of-blood-clots-in-patients-with-migrianes-with-aura/ - Categories: Science of Migraine Newer oral contraceptives increase the risk of strokes and other types of blood clots in patients with migraines with aura, according to a study to be presented at the next meeting of the American Academy of Neurology in San Diego in March. We have known for many years that estrogen-based oral contraceptives increase the risk of strokes in women who suffer from migraines with aura. However, most of the studies were done looking at the old contraceptives which contain a relatively high amount of estrogen (such as Ortho-Novum 1/50, Ovral, Ogestrel, and other). It was logical to assume that the newer contraceptives (such as Yaz, Yasmin, Loestrin, and other) with lower amounts of estrogen would be safer. Most headache specialists, myself included, were not as adamant about avoiding the newer low-dose estrogen contraceptives in our patients who had migraine auras. I would always discuss the risk of strokes and other blood clots with my patients and would always suggest using other modes of contraception, but if other methods were not acceptable to the woman or if the contraceptive had other benefits (helped PMS, acne, regulated periods, reduced bleeding, etc) I would not make a big fuss. This new study will make me more insistent on stopping the pill because the risk appears to be even higher with the newer contraceptives than with the old ones. Even the vaginal ring (NuvaRing), which I mentioned in a recent post as a good option to reduce menstrual migraines, carries a higher risk than... --- ### Risk factors for migraine aura - Published: 2013-01-11 - Modified: 2013-10-14 - URL: https://www.nyheadache.com/blog/risk-factors-for-migraine-aura/ - Categories: Science of Migraine Some features of migraine with aura clearly set it apart from migraines without aura. Aura is present in 15% to 20% of migraine sufferers. Most often it is a visual disturbance, which consists of either gradual loss of vision, starting from the periphery of visual field and moving to the midline. Many people see shimmering and sparkling lights with or without loss of vision and some see things smaller than they are. Sensory aura consists of pins-and-needles, tingling and numbness on one side of the body, often starting with the hand, moving up the arm and then involving the face. Typical aura lasts 20-60 minutes, but it can be shorter or longer. Auras are usually followed by a headache, but sometimes it occurs without any pain. People who have auras are at a slightly higher risk of having a stroke. This risk is magnified by other factors, such as smoking, high-dose estrogen contraceptives, hypertension, diabetes, and high cholesterol. A recent study by Austrian neurologists published in Headache examined 54 patients who kept a detailed diary and recorded a total of 354 migraine auras. Using a statistical tool called multivariate analysis they discovered that smoking, menstruation, and hunger were likely to increase the risk of having an aura. Holidays and days off reduced the possibility of experiencing an aura. They also found that non-migraine headaches and migraine without aura were more likely to occur during menstruation, psychological stress, tiredness, odors, and were decreased by smoking. The surprising finding in this study... --- ### Magnetic brain stimulation may relieve migraines with aura - Published: 2013-01-05 - Modified: 2013-01-05 - URL: https://www.nyheadache.com/blog/magnetic-brain-stimulation-may-relieve-migraines-with-aura/ - Categories: New treatments - Tags: aura, magnetic, migraine, stimulation, transcranial Transcranial magnetic stimulation (TMS) seems to be effective for the treatment of migraines with aura. "Spring TMS" device which delivers a jolt of such stimulation has been on the market in Europe since 2011. The American company that manufactures this device, eNeura Therapeutics hopes to obtain approval to sell it in the US in the near future. The approval of this device in Europe was based on a multi-center study results of which were published in Lancet Neurology. Unfortunately, the device is fairly bulky and needs to be carried around constantly because it seems to work only if used during the aura phase of the migraine. Auras usually begin unpredictably and last 20-60 minutes. Migraine with aura affects only 15-20% of all migraine sufferers, further limiting the potential market for this device. --- ### Frovatriptan (Frova) helps menstrual migraines - Published: 2013-01-02 - Modified: 2013-01-02 - URL: https://www.nyheadache.com/blog/frovatriptan-frova-helps-menstrual-migraines/ - Categories: Headache medications Migraine headaches that occur at around the time of menstrual period tend to be more severe and more difficult to treat. Analysis of studies that involved 187 women with menstrual migraines who treated at least one of their attacks with frovatriptan (Frova) and one with another triptan showed that frovatriptan was more effective. While all triptans were equally effective in providing pain relief at 2 and 4 hours, rate of headache recurrence was significantly lower for frovatriptan. After 24 hours, 11% of women who took frovatriptan had a recurrence of their headache, but with other triptans 24% had their migraine come back. After 48 hours, the numbers were 15% for frovatriptan and 26% for other triptans. One caveat is that all of these studies were funded by the maker of frovatriptan. --- ### Aspirin is best to prevent migraine with aura - Published: 2012-12-25 - Modified: 2017-01-30 - URL: https://www.nyheadache.com/blog/aspirin-is-best-to-prevent-migriane-with-aura/ - Categories: New treatments, Science of Migraine - Tags: aspirin, aura, migraine Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from Turin. They reported on 194 consecutive patients who had migraine with aura and who were placed on a prophylactic medication. Ninety of these patients were on 300 mg of aspirin daily and the rest were given propranolol (Inderal), topiramate (Topamax), and other daily medications. At the end of 32 weeks of observation 86% of those on aspirin had at least a 50% reduction in the frequency of attacks of migraine with aura compared with their baseline frequency, while 41% had even better results - at least a 75% reduction. In contrast, only 46% of patients on other drugs had a 50% improvement in frequency. The probability of success with aspirin was six times greater than with any other prophylactic medication, according to the lead author, Dr. Lidia Savi. Aspirin is not only effective for the prevention of migraines with aura but also for acute therapy of migraine attacks. In previous posts I mentioned that a rigorous analysis of large numbers of patients showed that 1,000 mg of aspirin is better than 500 mg of naproxen (2 tablets of Aleve) and that 1,000 mg of aspirin was as good as 100 mg of sumatriptan (Imitrex) with fewer side effects. Many health benefits of aspirin, which was originally derived from the willow bark, are becoming widely known. In addition to helping prevent heart attacks and strokes, aspirin has cancer-fighting properties. You may... --- ### Taking medication to stop an attack prevents migraines from becoming chronic - Published: 2012-12-20 - Modified: 2012-12-20 - URL: https://www.nyheadache.com/blog/taking-medication-to-stop-an-attack-prevents-migraines-from-becoming-chronic/ - Categories: Science of Migraine The use of acute anti-migraine medications in patients with episodic migraine (migraine occurring on less than 14 days a month) prevents progression of episodic migraine into its chronic form, according to Dr. Zaza Katsarava and his colleagues in Essen, Germany. They followed 1,601 patients with episodic migraine headaches for two years. None of these patients were taking prophylactic medications and 151 patients took no acute anti-migraine medications. Overall, during the two years of observation, 6. 2% of 1,601 patients developed chronic migraines (defined as headaches occurring on 15 or more days each month). However, those who took triptans (sumatriptan and other) had a 66% reduction of risk of headaches becoming chronic, those who took a single pain medicine had a 61% lower risk of chronification, and those who took a combination pain killer, like Excedrin, had a 40% reduction of this risk. This analysis took into account patients' age, sex, body mass, education level and baseline migraine frequency. A possible explanation for why combination drugs were less protective is that most of them contain caffeine, which is known to make headaches worse. Another very important lesson that can be drawn from this study is that it is important to treat migraine attacks with effective medications because if left untreated these intermittent attacks may become more frequent and even daily. At least two million Americans suffer from chronic migraines and it is likely that in many this debilitating condition could have been prevented by more aggressive and effective treatment of acute... --- ### New treatment offers hope to sufferers with chronic cluster headaches - Published: 2012-12-19 - Modified: 2012-12-19 - URL: https://www.nyheadache.com/blog/new-treatment-offers-hope-to-sufferers-with-chronic-cluster-headaches/ - Categories: Cluster headaches A new treatment developed by Belgian neurologists was reported to help patients with chronic refractory cluster headaches. The name cluster headaches originates from the fact that headaches occur in clusters, typically once a year for a period of a month or two, during which headaches occur daily. Unfortunately, in some patients cluster headaches are chronic and occur continuously. Some of these chronic cluster patients respond to medications, such as verapamil, topiramate, lithium or Botox injections. A small number of patients fails to respond to any of the usual therapies and are considered refractory to treatment. Because the pain of cluster headaches is extremely severe and because headaches occur daily and often more than once a day these patients often become despondent. Out of desperation, doctors have tried different unproven and at times risky treatments, such as deep brain stimulators with electric probes implanted deep into the brain. This is obviously a very invasive procedure that has resulted in strokes and deaths. I have treated two patients with a much less invasive Vagus Nerve Stimulator and these two responded well. Dr. Jean Schoenen and his colleagues implanted 28 patients with chronic refractory cluster headaches with a miniature neurostimulator implanted in the back of the nasal cavity, near the sphenopalatine ganglion. This ganglion has been injected and anesthetized (with lidocaine and cocaine) in an attempt to relieve various pains for many years. The stimulator was implanted by a neurosurgeon in an out-patient visit and the procedure leaves no visible scar. Once implanted,... --- ### Exercise-related headaches among cyclists - Published: 2012-12-11 - Modified: 2013-01-11 - URL: https://www.nyheadache.com/blog/exercise-related-headaches-among-cyclists/ - Categories: Science of Migraine - Tags: exercise-induced headache, migraine Exercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is to exercise regularly, starting with low intensity and short duration exercise sessions. If headache occurs with minimal exertion, I suggest taking Advil (ibuprofen), Aleve (naproxen), Migralex (aspirin/magnesium) an hour before exercise for several weeks. However, it appears that even experienced athletes suffer from what is officially known as a primary exertional headache. Dutch researchers are reporting on the incidence of exercise-related headaches among cyclists in the latest issue of journal Headache. They performed an online survey of 4,000 participants of a very challenging cycling race. Thirty seven percent of them suffered from such headaches at least once a month and 10% had them at least once a week. Women were more likely to have these headaches - 54% vs 44% in men. Older cyclists were significantly less likely to have these headaches. Tension-type and migraine headaches were most common. Headache medications were used by 37% of participants. Extreme exertion was the most commonly reported contributing factor (50%), while some reported that low fluid intake (39%) and warm weather (39%) contributed to their headaches; 26% could not identify their trigger. Another possible trigger not reported in the article is neck strain. Riding sports bikes with low handlebars makes riders strain their neck and trigger a cervicogenic headache. The authors concluded that these headaches are widely underestimated and may cause many people quit their sports. They also called for research into causes... --- ### Erythromelalgia and migraine - Published: 2012-12-07 - Modified: 2012-12-07 - URL: https://www.nyheadache.com/blog/erythromelalgia-and-migraine/ - Categories: Science of Migraine, Uncategorized - Tags: calcium channel, erythromelalgia, genetics, intravenous, magnesium, migraine, sodium channel Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw another woman who had both erythromelalgia and migraines. My observation of several patients who had both diseases does not mean that these conditions are connected since migraines are very common in the general population. However, magnesium is known to help both conditions, so it is possible that there are common underlying causes. In fact, a sodium channel mutation which is responsible for erythromelalgia was also found in a family with familial hemiplegic migraine. Magnesium is involved in the regulation of sodium channels (as well as calcium and potassium channels) in all cells of the body. Most people who are deficient in magnesium and suffer from erythromelalgia and/or migraines respond well to oral magnesium supplementation, but a small percentage requires monthly intravenous infusions. We give intravenous infusions to those patients who do not tolerate oral magnesium (get diarrhea or stomach pains), those who do not absorb it (as evidenced by persistently low RBC magnesium levels) and those who prefer a monthly infusion to taking a daily supplement. --- ### Vaginal ring and migraines - Published: 2012-11-25 - Modified: 2012-11-29 - URL: https://www.nyheadache.com/blog/vaginal-ring-and-migraines/ - Categories: Science of Migraine Many women are denied therapy with combined (estrogen with progesterone) hormonal contraceptives because published guidelines by doctor organizations recommend against their use in migraine with aura. The concern is that these products might further increase the risk of a stroke that accompanies aura. Stroke risk has been reported to vary directly with aura frequency, and aura frequency in turn has been shown to have a direct relationship to estrogen concentration. With the introduction of increasingly lower dosed hormonal contraceptives it is not clear if these risks are as high as with high-dose contraceptives. These formulations are expected to result in a lower frequency of migraine aura. In addition, continuous therapy eliminates monthly estrogen drops which can be expected to prevent menstrual migraines. Dr. Anne Calhoun and her colleagues in North Carolina examined a database of 830 women seen in a menstrual migraine clinic and identified 23 women who had current history of migraine with aura, had a confirmed diagnosis of menstrually-related migraines, and were receiving extended-cycle (continuous) dosing of a vaginal ring contraceptive. At baseline, subjects averaged 3. 23 migraine auras per month. With extended dosing of the vaginal ring contraceptive, median frequency was reduced to 0. 23 auras per month after a mean observation of 7. 8 months. No at a single woman reported an increase in aura frequency. On this regimen, menstrual migraine was eliminated in 91. 3% of women. The authors concluded that continuous use of vaginal ring contraceptive was associated with a reduced frequency of migraine... --- ### More on celiac, bowels, and headaches - Published: 2012-11-20 - Modified: 2012-11-20 - URL: https://www.nyheadache.com/blog/more-on-celiac-bowels-and-headaches/ - Categories: Alternative Therapies, Science of Migraine Celiac disease and gluten sensitivity is known to cause or at least increase the frequency of migraine headaches. The recently published study in journal Headache by doctors from Columbia University and Mt. Sinai School of Medicine in New York City examined records of 502 individuals in an attempt to find out the frequency of headaches in these conditions. They looked at records of 188 patients with celiac disease, 111 with inflammatory bowel disease (such as Crohn's and ulcerative colitis, 25 with gluten sensitivity and compared these to 178 healthy controls. Chronic headaches were reported by 30% of celiac disease, 56% of gluten sensitivity, 23% of inflammatory bowel disease, and 14% of control subjects. Migraine headaches were more common in women and those with anxiety and depression. The severity of the impact of migraine headaches was worst in celiac patients - 72% reported it to be severe, while this number was 60% in those with gluten sensitivity and 30 % with inflammatory bowel disease. This study confirms previous observations that celiac disease and gluten sensitivity are associated with increased frequency of migraine headaches. The difference between celiac disease and gluten sensitivity was well described in this WSJ aritcle. --- ### Migraine impairs school performance - Published: 2012-11-13 - Modified: 2012-11-13 - URL: https://www.nyheadache.com/blog/migraine-impairs-school-performance/ - Categories: Headaches in children, Uncategorized Children suffering from migraine headaches are more likely to have difficulty performing well in school, according to a new report published in Neurology. The doctors studied 5,671 children between ages 5 and 12 from 87 Brazilian cities and found that episodic migraine was present in 9% of children (9. 6% of girls and 8. 4% of boys), probable migraine, in 17. 6% (17. 3% of girls and 17. 8% of boys) while chronic migraine in 0. 6% (equally in boys and girls). Headaches were more common between ages 9 and 12 than 5 to 9. Chronic migraine was more common in poor children. Poor performance at school was significantly more likely in children with migraine and chronic migraine, compared to probable migraine and tension-type headaches. These are not very surprising results, although they cannot be generalized to all children with migraines. It is very common for me to see children who do exceptionally well in school despite having many migraine attacks and missing many days of school. It is possible that those hard-working and driven kids get headaches because of stress, but despite their severe headaches are able to perform well. Because they are high achievers and like doing everything well, they often excel at biofeedback, which helps them learn how to control their stress and reduce their headaches. Regular meals, exercise, and sleep are also very important. We try magnesium, COQ10 and other supplements next, and if headaches are very frequent, Botox injections followed by preventive medications. --- ### Blood pressure drugs for the prevention of migraines - Published: 2012-11-07 - Modified: 2012-11-07 - URL: https://www.nyheadache.com/blog/blood-pressure-drugs-for-the-prevention-of-migraines/ - Categories: Headache medications I see many patients who tell me that "I've tried every migraine drug" and seek me out to explore non-drug approaches, such as herbs, supplements, Botox, acupuncture and other. I always try to avoid using medications (and have written books on non-drug approaches), but some patients do best with a combination of medications and non-drug approaches. So, when someone tells me that they've tried "every drug", I tell them that I've never seen such a person because there are so many drugs that we use to treat headaches. For example, they might've tried a blood pressure medication, but we have many different anti-hypertensive drugs and they work in different ways. One type of blood pressure medication may work when another does not. Also, if one drug caused side effects, another in the same or different category may not. Here is a brief description of blood pressure medications that are used for the prophylactic treatment of headaches. The first medication approved by the FDA for the prevention of migraine headaches was propranolol (inderal) (methysergide or Sansert was approved earlier, but it is no longer available in the US). Propranolol was originally developed for the treatment of hypertension and then accidentally was found to help migraine headaches as well. A second beta blocker, timolol (Blocadren) was also tested, was found to work well and it also received FDA approval. Other beta blockers, such as atenolol (Tenormin), labetalol (Normodyne), and nebivolol (Bystolic) were also shown to be effective. Nebivolol tends to have fewer... --- ### Why does pituitary adenoma cause headaches? - Published: 2012-10-19 - Modified: 2012-10-19 - URL: https://www.nyheadache.com/blog/why-does-pituitary-adenoma-cause-headaches/ - Categories: Headaches, Uncategorized Pituitary adenoma is a benign tumor of an endocrine gland that is situated underneath the brain. Pituitary gland is connected to the brain and it produces several hormones. The most common type of pituitary tumor is one that secretes prolactin, hormone responsible for breast milk production. Women with this tumor usually have irregular periods and breast discharge. Pituitary adenoma usually does not cause headaches, unless it becomes large and compresses the brain. Most of the tumors are small and are called microadenomas and only rarely become large macroadenomas. A group of German researchers just published a study in Cephalalgia that looked at possible causes of headaches induced by pituitary adenoma. Fifty-eight patients with pituitary adenoma were analyzed. Twenty-four patients (41%) had tumor-attributed headache with seven having migraine-like headaches, 11 tension-type headaches, and three having both. Cluster headache-like headache was found once, and two headaches remained unclassified. Tumor-attributed headache was associated with a positive prior history of headaches, nicotine abuse, and a faster tumor growth. Whenever a woman with headaches has irregular periods or a milky discharge from her breast an MRI scan of her brain and a blood test for prolactin level must be obtained. If the tumor is allowed to grow large it can cause impairment and even loss of vision because of the compression of optic nerves. The treatment is usually with medication that shrinks the tumor and only rarely surgery is needed. This surgery can often be performed transnasally - through the nose with faster recovery than... --- ### Occipital nerve stimulation is ineffective - Published: 2012-10-17 - Modified: 2012-10-19 - URL: https://www.nyheadache.com/blog/occipital-nerve-stimulation-is-ineffective/ - Categories: New treatments Occipital nerve stimulation (ONS) has been reported to relieve refractory (difficult to treat) migraine headaches. Results of a clinical trial of ONS for patients with refractory migraine was just published in the journal Cephalalgia. This study was sponsored by St. Jude Medical, company that manufactures occipital nerve stimulators. This was a large (157 patients) and very scientific (randomized, controlled) study. ? Patients were considered refractory if they failed two prophylactic migraine medications, such as blood pressure medications, anti-epilepsy drugs, or anti-depressants. Of the 157 patients, 105 patients had real stimulation and 52 had sham stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ? 50% reduction in pain scores after 12 weeks). The researchers found no significant difference in the percentage of responders in the Active compared with the Control group. The authors of the report suggest that had they used different measures of efficacy, the results would have been positive and they are calling for more studies. The most common adverse event was persistent implant site pain, which occurred in 15% of patients. The editorial by Hans-Christoph Diener, one of the leading headache experts suggested that the efficacy of this treatment appears to be very low, while side effects and costs are quite significant. The cost of the stimulator and of the surgery to implant it ranges from $20,000 to $40,000. Another problem with the study is that it did not require that patients fail Botox injections before they were... --- ### Steroid injections and meningitis - Published: 2012-10-13 - Modified: 2012-10-19 - URL: https://www.nyheadache.com/blog/steroid-injections-and-meningitis/ - Categories: Headache medications Steroid injections are routinely used at our Center for the treatment of cluster headaches and occipital neuralgia. I just received a call from a concerned patient with cluster headaches who recently received an occipital nerve block with methylprednisolone acetate (Depo-Medrol), the same drug that caused fungal meningitis in almost 200 patients, of whom 14 died. His cluster headaches stopped after the injection and he had no symptoms of meningitis, but understandably he was still concerned. All of the patients who contracted meningitis were given epidural injections which are given for low back or neck pain with medicine deposited near the meninges or soft covering that envelopes the spinal cord. All of them received a tainted product manufactured by a compounding pharmacy, which was not licensed to mass produce such medications. Their product was significantly cheaper than the same medicine produced by the largest pharmaceutical company in the world, Pfizer. We have never used any other products except for the one made by Pfizer. I an addition to methylprednisolone (Depo-Medrol) some doctors use a different steroid, triamcinolone, which is manufactured by Brystol Myers Squibb under the name Kenalog. Whenever you receive a steroid injection for back pain, joint inflammation, cluster headaches, or any other indication, ask the doctor if the steroid you are going to receive was manufactured by a major pharmaceutical company. In case of epidural steroid injections, you should also question if these injections are really necessary because they have never been proven to be effective in the first... --- ### Long-term outcome of vestibular migraine with vertigo - Published: 2012-10-11 - Modified: 2012-10-11 - URL: https://www.nyheadache.com/blog/long-term-outcome-of-vestibular-migraine-with-vertigo/ - Categories: Science of Migraine Vertigo is a common symptom in patients suffering from migraine headaches. Vestibular migraine is a new category of migraine proposed by German researchers led by Dr. Andrea Radtke.   In the current issue of Neurology Dr. Radtke and her colleagues report on the long-term outcomes of 61 patients with this condition. The average follow-up period was 9 years. Unfortunately, 87% of sufferers still had vertigo and in 56% it improved, 29% it worsened and in 16% it remained unchanged. In 21% the impact of vertigo on their lives was severe, in 43% moderate and in 36% mild. Mild hearing loss occurred in 11 or 18% of patients. This report does not mention what kind of treatments were attempted in these patients. It is possible that aggressive therapy with vestibular rehabilitation, possibly acupuncture, magnesium, other supplements and medication can make a difference. --- ### Prodrome to migraine headaches - Published: 2012-10-04 - Modified: 2012-10-04 - URL: https://www.nyheadache.com/blog/prodrome-to-migraine-headaches/ - Categories: Science of Migraine Prodrome refers to symptoms that precede an actual attack of migraine. Migraine aura also precedes an attack, but it occurs 20 to 60 minutes before the headache and typically consists of visual disturbances or partial visual loss. Prodrome typically is a period of 24 to 48 hours before a migraine attack and it can consist of a wide variety of symptoms. Many people are aware that these symptoms indicate an impending migraine attack, but some are not. Some people tell me that when they feel unusually full of energy, very happy, and creative they realize that they will get a headache the next day. And some realize that what was happening to them was a prodrome only in retrospect, even after having all of the same symptoms repeat themselves many times. Not many people experience prodrome and its features are varied. Here are some of the symptoms reported in the prodrome period: Depression Euphoria Irritability Restlessness Hyperactivity Fatigue Drowsiness Difficulty concentrating Neck or other muscle stiffness Feeling hot or cold Increased thirst Increased urination Food cravings Loss of appetite Yawning Tearing Constipation Diarrhea Fluid retention Sensitivity to light and/or sound If you do experience a prodrome and are aware of it while it is happening, taking an anti-inflammatory medication (Advil, Aleve, Migralex) or, if that does not work, a triptan may prevent an attack or at least make it milder. --- ### When does migraine aura occur? - Published: 2012-10-01 - Modified: 2012-10-02 - URL: https://www.nyheadache.com/blog/when-does-migraine-aura-occur/ - Categories: Science of Migraine Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. The aura can sometimes occur without a headache and some people, myself included, always have migraines and auras independently of each other. A typical aura usually lasts 20-30 minutes and consists of partial loss of vision on one side of both eyes, or flashing lights, colored zigzags, or tunnel vision. Most headache specialists and neurologists have always believed that most people have an aura first and when it resolves, the headache begins. A study by Dr. Jakob Hansen suggests that this may not be the case. He examined diaries of 201 adults who experienced 861 migraine attacks and discovered that in 61% of attacks the headache was present within 15 minutes of the onset of aura. Nausea was present in 40%, sensitivity to light (photophobia) in 84% and to noise (phonophobia) in 67% within 15 minutes of the onset of visual aura. I have heard from some of my patients similar reports of a headache and aura starting at the same time, but it seemed that those were a small minority. I will have to be more thorough in questioning my patients. One practical application of this finding is that we usually tell patients who use injectable sumatriptan (Imitrex) to treat their migraine attacks to wait for the aura to resolve and then take the injection. The reason for this delay is a perception that the injection will not help if taken during... --- ### Infant colic and migraine - Published: 2012-09-27 - Modified: 2012-09-27 - URL: https://www.nyheadache.com/blog/infant-colic-and-migraine/ - Categories: Headaches in children Infant colic appears to be more common in babies whose mothers suffers from migraines, according to a just published study by researchers at UCSF. This study looked at 154 infant-mother pairs and discovered that the risk of colic increases 2. 6 times if mother suffers from migraines. Dr. Amy Gelfand, the pediatric neurologist who was the lead author concluded that infant colic could be the earliest manifestation of migraine headaches. We also know that some people who suffer from migraines report being told by their parents that as infants they had brief attacks of vomiting associated with paleness which seemingly were not related to food intake. This study confirms the old suspicion that migraines can begin from infancy. While we have many effective therapies, the true cure of migraines will come from genetic therapies, which unfortunately are decades away. --- ### Triptans for pediatric patients - Published: 2012-09-24 - Modified: 2012-10-07 - URL: https://www.nyheadache.com/blog/triptans-for-pediatric-patients/ - Categories: Headaches in children Rizatriptan (Maxalt) is the only migraine drug approved by the FDA for children as young as 6. Almotriptan (Axert), another drug in the same family of triptans, is approved for children from age 12 and up. Rizatriptan also has an advantage over almotriptan in that it is available in a "melt" formulation (Maxalt MLT), which is a wafer that melts in the mouth. This is especially important for younger children who may have difficulty swallowing solid tablets, but is also useful for migraine sufferers of any age who have severe nausea that makes swallowing tablets difficult. The study that led to the FDA approval of rizatriptan included over 900 children. Obviously, it was a positive study, however, it showed what many previous studies have also shown - children respond to placebo at a much higher rate than adults. That is after two hours many children will have good relief from taking a sugar pill. This is partly due to the fact that pediatric migraines tend to be much shorter in duration, often only one or two hours. So, regardless of what a child takes, the headache will be gone in two hours. Nasal sprays work a little faster, so they may be a little more effective in children and sumatriptan nasal spray (Imirex NS) is approved for children in Europe. Nasal spray also avoids the need to swallow tablets. Another triptan in a nasal spray form is zolmitriptan (Zomig NS) and anecdotally it is more consistently effective than sumatriptan. Zolmitriptan... --- ### More about marijuana - Published: 2012-09-23 - Modified: 2012-09-23 - URL: https://www.nyheadache.com/blog/more-about-marijuana/ - Categories: Alternative Therapies Marijuana seems to help some patients with migraine and cluster headaches. However a new study suggests that it has more negative effects than previously thought. We know that smoking pot causes lung problems and risks serious damage to various organs due to possible impurities. A recent report in the Proceedings of the National Academy of Sciences shows that regular cannabis use is harmful to health. Adolescents are beginning to use marijuana at younger ages, and more adolescents are using it on a daily basis. This study showed that persistent use of marijuana leads to neuropsychological decline. Researchers from Duke University, England and New Zealand examined records of 1,037 individuals who were followed from birth to age 38. Marijuana use was determined in interviews at ages 18, 21, 26, 32, and 38. Neuropsychological testing was conducted at age 13, before initiation of marijuana use, and again at age 38. Persistent use was associated with neuropsychological decline, including IQ, even after taking into account years of education. Persistent marijuana users reported noticing more cognitive problems. Impairment was strongest among those who started using marijuana in adolescence and the more persistent was the use the greater was the cognitive decline. Stopping marijuana use did not fully restore neuropsychological functioning and IQ among those who started its use in adolescence. This study suggests that cannabis has a toxic an persistent effect on the adolescent brain. --- ### Online cognitive-behavioral therapy - Published: 2012-09-19 - Modified: 2012-09-19 - URL: https://www.nyheadache.com/blog/online-cognitive-behavioral-therapy-2/ - Categories: Alternative Therapies Cognitive-behavioral therapy (CBT) has been convincingly proven to help pain and headache sufferers. Many people are very skeptical about the value of psychological treatments and tell me, just get rid of my migraines and I will be fine. Unfortunately, sometimes it takes time to relieve chronic headaches and pain. So, while we are trying to find relief, it helps to learn how to function better despite pain, how not to panic and become completely paralyzed by headaches, how to inform and interact better with family, friends, and employers. Research indicates, that people who take charge of their care, get involved in working with the doctor to find relief, learn relaxation techniques, rather than just sit back and wait for doctors to "fix" the problem, do much better. CBT, which usually involves relaxation training, is one way to improve your care and it usually involves 8 to 12 structured sessions. Here is an example of what might take place during these sessions: 1. Three-component CBT model (thoughts, feelings, behaviors), pain monitoring 2. Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery) 3. Migraine trigger avoidance 4. Pain-fatigue cycle, activity pacing, and pleasant event scheduling 5. Identifying and challenging negative thoughts (Activity, Belief, Consequences, Dispute model) 6. Problem-solving skills training and assertive communication 7. Review and practice 8. Review and practice 9. Relapse prevention Another form of CBT is Acceptance Commitment Therapy (ACT) and this is what a typical schedule of sessions of ACT looks like: 1. The limits of control (short... --- ### Spinal tap (lumbar puncture) headache - Published: 2012-09-17 - Modified: 2012-09-17 - URL: https://www.nyheadache.com/blog/spinal-tap-lumbar-puncture-headache/ - Categories: Headaches Spinal tap, or lumbar puncture headache occurs in one out of four people undergoing this procedure. Spinal tap is usually done to examine spinal fluid for infections, bleeding, multiple sclerosis, and other conditions. A small percentage of people undergoing epidural anesthesia, which involves placement of the same kind of needle into the same space between vertebrae, also develop a spinal tap headache. This happens because the needle is accidentally placed too far and it causes a leak of spinal fluid. Spinal tap headache is very easy to diagnose - it stops as soon as the person lies down and begins within minutes of sitting up. Normally, the brain floats in cerebrospinal fluid, but if this fluid is drained away by a spinal tap, the brain sags, pulls on the brain coverings, called meninges, and causes a severe headache. The majority of people do not develop this headache after a spinal tap because as soon as the needle is withdrawn, the hole in the dural sac that covers the spinal cord and the brain closes. In some people, especially if it takes a few sticks to get the fluid flowing and with a larger needle, the hole may not close right away and the fluid keeps leaking inside the spine. In most people the headache stops on its own within a day or two. If it doesn't, the problem can be fixed by a "blood patch" procedure. It involves taking the patient's own blood from the vein and injecting it into... --- ### An autoimmune reaction may cause pain - Published: 2012-09-10 - Modified: 2012-09-24 - URL: https://www.nyheadache.com/blog/autoimmune-reaction-may-cause-pain/ - Categories: Pain Research Autoimmune dysfunction can cause pain according to a study just published in Neurology by a group of Mayo Clinic researchers. Dr. CJ Klein and his colleagues examined 316 patients who had antibodies to a structure involved in various nerve functions (voltage-gated potassium channel, or VGKC) and discovered that 159 of them had pain as the initial symptoms and 45 of those had pain as the only symptom of this autoimmune reaction. In 19 of these patients pain was localized to face and head, suggesting that some of the headache patients may also suffer from this condition. The antibodies to VGKC are known to cause excessive excitability of the nervous system. Some of the patients in the study were previously thought to have fibromyalgia (a condition known to be associated with excessive excitation of the nervous system) or psychogenic (not real) pain. This is an exciting discovery since treatment with immune therapies (such as drugs and intravenous immune globulin, or IVIG) relieved chronic pain in 81% of the Mayo Clinic patients. Epilepsy drugs can also help some of these patients. The difficulty at this point is in identifying patients who should be tested for VGKC antibodies. Probably, we should test patients with chronic persistent pain that does not easily respond to standard treatments. Another difficulty is that the immunosuppressive drugs can have serious side effects, while IVIG is very expensive and can also cause side effects. So these therapies should be reserved for patients in whom pain causes significant disability and... --- ### Ointments for headaches and neck pain - Published: 2012-09-03 - Modified: 2012-09-03 - URL: https://www.nyheadache.com/blog/ointments-for-headaches-and-neck-pain/ - Categories: Alternative Therapies There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and other topical products can provide relief of milder headaches. There are no scientific studies proving that these treatments work beyond the placebo effect, although we do have some evidence established by Hartmut Gobel and his colleagues in Germany suggesting that the smell of peppermint can provide some pain relief. So it is possible, that the smell of herbs in Tiger Balm and possibly the cooling effect of these ointments combined with placebo effect is what accounts for the popularity of these products. I have been using a prescription ointment for some of my patients with headaches and neck pain. This ointment has to be prepared by a compounding pharmacy and typically is not available from big chains, such as CVS or Walmart, although Walgreens does offer compounding services at some of its pharmacies. We do not have any information about the best combination of ingredients to use for the relief of headaches and pain. However, some studies indicate that topical skin application of some products does provide relief. Ketamine, which blocks the so called NMDA pain receptor can relieve pain of complex regional pain syndrome, a very serious and painful condition. Application of clonidine, a blood pressure medication has been shown to relieve pain of diabetic neuropathy - painful nerve damage due to diabetes. We also know that lidocaine is very effective when applied to the skin and it is... --- ### Children with epilepsy have more migraines - Published: 2012-08-27 - Modified: 2012-08-27 - URL: https://www.nyheadache.com/blog/children-with-epilepsy-have-more-migraines/ - Categories: Science of Migraine Children with epilepsy are more likely to suffer from migraine headaches than children without epilepsy, according to a study just published in Neurology by researchers from Johns Hopkins University. Dr. Sarah Kelley and her colleagues studied 400 children who were seen at an epilepsy clinic. They discovered that 25% of children with epilepsy also suffered from migraine headaches. Children aged 10 and older, as well as those with JME (juvenile myoclonic epilepsy) and BECTS (benign epilepsy with centrotemporal spikes) were more likely to have migraines than younger children or those with other types of epilepsy. Unfortunately, pediatric neurologists who were seeing children who had both epilepsy and migraines (with migraines occurring once a week or more) did not discuss their migraines in half of such cases. Primary care doctors treating adults have also been shown to ignore complaints of migraine headaches in many patients, but in this study doctors were pediatric neurologists and they should know better. The education of all doctors, including adult and pediatric neurologists in the treatment of headaches leaves a lot to be desired. Many prominent neurology programs, including those at Cornell, Yale, NYU, and other medical schools lack a dedicated headache specialist. This is probably due to a combination of factors, including low prominence of headaches as compared to conditions such as epilepsy, Alzheimer's, strokes, and MS, as well as lack of funding for research and lack of faculty trained in headache medicine. Parents of children with migraines also sometimes minimize the seriousness of migraine... --- ### Omega-3 fatty acids (from fish oil) and nerve damage - Published: 2012-08-26 - Modified: 2012-08-26 - URL: https://www.nyheadache.com/blog/omega-3-fatty-acids-from-fish-oil-and-nerve-damage/ - Categories: Alternative Therapies Omega-3 fatty acids (most abundantly found in fish oil) may relieve migraine headaches but only one small study found this to be the case. However, there is mounting evidence for beneficial effects of omega-3 fatty acids for various conditions, such as strokes, heart disease, dementia, and other. A just published study in the journal BMC Cancer shows that omega-3 fatty acids prevent nerve damage caused by a chemotherapy drug used to treat breast cancer. Paclitaxel (Taxol) caused peripheral neuropathy in 60% of women who received placebo and in only 30% of those who were given omega-3 fatty acids (640 mg three times a day). Using this safe and natural supplement may allow many more women receive this life-saving chemotherapy without causing crippling side effects. Considering all of the positive studies of fish oil for a variety of neurological and other conditions and, considering its safety and low cost, it is reasonable to try this supplement for the prevention of migraine headaches despite the lack of definitive studies. --- ### Slow breathing reduces pain - Published: 2012-08-24 - Modified: 2012-08-24 - URL: https://www.nyheadache.com/blog/slow-breathing-reduces-pain/ - Categories: Alternative Therapies Slow breathing can reduce pain, according to a recently published study in The Journal of Pain. Researchers at the University of Tulsa led by Satin Martin evaluated the effect on pain of slow breathing, normal and fast breathing in 30 healthy volunteers. Pain was induced by an electric shock to the leg. Slow breathing (50% of normal rate) significantly reduced pain perception when compared to normal or fast (at 125% of normal rate) breathing. Slow breathing has been long utilized for the reduction of pain and is usually included in biofeedback, meditation, and other relaxation methods. This study provides solid scientific support for this simple and ancient technique, which should be utilized more widely in the management of pain, including migraine and other headaches. --- ### Meditation - Published: 2012-08-16 - Modified: 2012-08-16 - URL: https://www.nyheadache.com/blog/meditation/ - Categories: Alternative Therapies Extraordinary benefits of meditation are described in the current issue of Neurology Now - The American Academy of Neurology's Magazine for Patients & Caregivers". Dr. Mauskop is extensively quoted in this article. --- ### What type of magnesium is the best? - Published: 2012-08-12 - Modified: 2012-08-12 - URL: https://www.nyheadache.com/blog/what-type-of-magnesium-is-the-best/ - Categories: Alternative Therapies Many patients ask about the best type of magnesium supplement to take for the prevention of migraines and other symptoms. Research studies have compared magnesium oxide with chelated magnesium and a slow release form of magnesium chloride and showed that all three types are absorbed equally well. I usually recommend starting with 400 mg of magnesium oxide but chelated magnesium is also very inexpensive and either one can be effective. However, if one type of magnesium causes upset stomach or diarrhea, another one should be tried. Chelated magnesium is a form of magnesium which is attached to an amino acid and depending on the amino acid it is called magnesium aspartate, glycinate, gluconate, orotate, malate, and other. Besides chelated and magnesium oxide, magnesium citrate or carbonate can be tried. When these magnesium salts are not tolerated or not absorbed, slow release forms should be considered, although they are much more expensive. There are two slow release forms, Mag Tab SR (containing magnesium lactate) and Slow Mag (magnesium chloride with calcium). Each tablet of these two products contains only a small amount of magnesium and the daily dose is at least 4 tables. Presence of calcium in Slow Mag may impair absorption of magnesium, making Mag Tab SR the preferred product. People who need to take calcium as well as magnesium should be taking these two separately because calcium interferes with the absorption of magnesium. The reason calcium and magnesium are often combined in one pill (Cal-Mag, Slow Mag, and other)... --- ### Boswellia - an herbal remedy for headaches - Published: 2012-08-08 - Modified: 2013-02-27 - URL: https://www.nyheadache.com/blog/boswellia-an-herbal-remedy-for-headaches/ - Categories: Alternative Therapies Boswellia extract may relieve migraine, cluster and indomethacin-responsive headaches. Boswellia serrata (Indian frankincense) has been long reported to relieve migraines, although I could not find any scientific articles. A study recently published in journal Cephalalgia by Christian Lampl and his colleagues describes four patients with chronic cluster headaches whose headaches improved after taking Boswellia extract. The dose of Boswellia was 350 to 700 mg three times a day. All four patients failed at least three standard preventive medications for cluster headaches, such as verapamil (Calan), topiramate (Topamax), and lithium. It is very surprising that an herbal remedy helps what many consider to be the most painful type of headaches. Dr. Eric Eross reported that Boswellia extract was also reported to help another very severe headache type - indomethacin responsive headache syndrome. Of the 27 patients with this type of headaches who were given Boswellia, 21 responded. The starting dose was 250 mg three times a day and then the dose was increased as needed, although it is not clear what the highest dose was. Indomethacin is a very strong non-steroidal anti-inflammatory medication, but it also tends to have strong gastro-intestinal side effects. Finding a safe natural alternative is a very important discovery. Unlike butterbur, Boswellia has no toxic ingredients and is safe to consume in any form. The mechanism of action of Boswellia is not entirely clear, but it seems to have anti-inflammatory properties similar to aspirin. Obviously, it does more than that since aspirin is usually ineffective for cluster... --- ### Butterbur - we no longer recommend it - Published: 2012-07-24 - Modified: 2012-07-24 - URL: https://www.nyheadache.com/blog/butterbur-we-no-longer-recommend-it/ - Categories: Alternative Therapies We no longer recommend butterbur to our patients. We participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in the leading neurological journal - Neurology and the American Academy of Neurology recently endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex and other brands), where it had to pass strict safety studies. However, Germany is no longer allowing butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur made in Germany and in the US is still sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany. This is why we no longer recommend butterbur for our patients. --- ### Migraine and restless leg syndrome - Published: 2012-07-22 - Modified: 2012-07-22 - URL: https://www.nyheadache.com/blog/migraine-and-restless-leg-syndrome/ - Categories: Science of Migraine, Uncategorized Restless leg syndrome (RLS) is more common in women who also suffer from migraines, according to a new study published in the journal Cephalalgia. Women with migraines are 20% more likely to also have RLS. This study involved 31,370 US health professionals making its findings highly reliable. In my previous post 5 years ago I mentioned that RLS, by disrupting normal sleep, may increase the frequency and severity of migraines, but at that time we did not know that these two conditions are connected. Possible causes of this association include the fact that disturbance of metabolism of iron and dopamine in the brain is thought to play a role in both conditions. People who have symptoms of RLS should be tested for iron and vitamin B12 deficiency which can cause similar symptoms. A sleep study is sometimes necessary to confirm the diagnosis of RLS. This study involves sleeping in a sleep lab with wires attached to the scalp, monitors measuring breathing and video camera recording movements of legs and body. Most major hospitals have a sleep lab and it is usually covered by insurance. Fortunately, we have many effective drugs to treat RLS - Requip (ropinirole), Mirapex (pramipexole), Horizant (gabapentin), Neupro patch (rotigotine), as well as opioid drugs, such as Vicodin (hydrocodone), Percocet (oxycodone), and other. Horizant is a long-acting form of gabapentin, which is available in a short-acting form as a generic, much cheaper form. The advantage of gabapentin (also known as Neurontin and Gralise) is that it has... --- ### Migraine and erectile dysfunction - Published: 2012-07-20 - Modified: 2012-07-20 - URL: https://www.nyheadache.com/blog/migraine-and-erectile-dysfunction/ - Categories: Science of Migraine Until now, migraine headaches have not been associated with erectile dysfunction (ED). A study by Taiwanese doctors published in journal Cephalalgia makes a strong case that such a connection exists. The researchers analyzed electronic records of one million patients randomly selected out of almost 24 million who are covered by the Taiwan National Health Insurance. They eliminated from this analysis patients with mental illness and they also controlled for hypertension, diabetes, obesity and other condition known to cause ED. Men who suffer from migraines were 1. 6 times more likely to have ED. Surprisingly, younger men with migraines, aged 30 to 39 had the highest risk of having erectile dysfunction - they were twice more likely to have ED than men of that age without migraines. The causes for this association are not clear. We do know that patients with chronic pain are more likely to have sexual dysfunction. We also know that migraine patients have impaired regulation of their brain blood vessels, so it is possible that penile blood vessels are also affected. Men are less likely to see doctors for all medical conditions compared to women and this includes migraines - I see about ten times as many women as men, while we know that women outnumber men only by 3 to 1 ratio. This may apply even more to such an embarrassing condition as sexual dysfunction, making these young men suffer unnecessarily from both migraines and ED. Encourage men with migraines to see a doctor, while in... --- ### Burning mouth syndrome - Published: 2012-07-11 - Modified: 2012-07-11 - URL: https://www.nyheadache.com/blog/burning-mouth-syndrome/ - Categories: Pain Burning mouth syndrome (BMS) affects over a million Americans. It has no known cause or otherwise it would not be called a syndrome. For example, burning pain in the mouth due to chemotherapy damage to the mouth lining is called oral mucositis. This condition is not related to migraines, but just like with migraines, three times as many women suffer from BMS than men. Some people with BMS have a sensation of having sand in their mouth and itching, in addition to the burning pain. The pain can be very intense and can persist for many months. A recent study by Italian researchers published in the journal Headache examined 53 patients with with BMS and compared them to 51 healthy volunteers. They discovered that patients with BMS were much more likely to have anxiety and depression than the healthy controls. This is not surprising since patients with chronic headaches or pain of any kind are also more likely to be anxious and depressed. This does not mean that the pain is a manifestation of depression, as suggested by the authors. A more interesting study of BMS in the same issue of Headache was published by Brazilian doctors. They treated 26 patients with mechanical stimulation of their mouth in order to increase the flow of saliva. This was achieved by having patients chew on a rubbery stick for ten minutes three times a day for 90 days. This resulted in a significant reduction of pain, even though the amount of saliva... --- ### Let-down headaches - Published: 2012-07-10 - Modified: 2012-07-10 - URL: https://www.nyheadache.com/blog/let-down-headaches/ - Categories: Science of Migraine Many migraine sufferers complain of headaches on weekends, vacations, or after a period of stress. Researchers at the Montefiore Medical Center in the Bronx confirmed this observation by observing 17 migraine patients. The patients completed over 2,000 twice daily diary entries about their headaches and the amount of stress they had. The doctors found that patients had 20% higher chance of developing a migraine 12 to 24 hours after their mood changed from "sad" or "nervous" to "happy" or "relaxed". There are several possible explanations for this phenomenon. One, is that some people have a certain amount of control over their headaches and do not allow themselves to have a headache when they know that they have to perform important functions, but as soon as this demand ends, they pay for the stress by getting a headache. Another possibility is that sleeping longer on weekends, vacations, or after the stress is over, triggers a migraine. Migraine sufferers can be very sensitive to changes in their sleep schedule with both too much and not enough sleep being a trigger. Weekend headaches can be also triggered by caffeine withdrawal - drinking your first cup of coffee at 10 instead of 8 in the morning. --- ### Underutilization of behavioral and other alternative therapies by headache specialists - Published: 2012-06-24 - Modified: 2012-06-24 - URL: https://www.nyheadache.com/blog/underutilization-of-behavioral-and-other-alternative-therapies-by-headache-specialists/ - Categories: Alternative Therapies Behavioral therapies, such as biofeedback, progressive relaxation, cognitive therapy, and other alternative therapies are routinely recommended only by a quarter of headache specialists, according to research presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles by Robert Nichols of St. Louis. This despite the fact that these therapies are considered proven (so called, Grade A evidence) to relieve migraine and other headaches. Physicians are more likely to prescribe medications, even if they are less proven to work and carry a risk of serious side effects, which are absent with behavioral therapies. Cost of biofeedback and cognitive therapy can be one of the obstacle for some patients, but many techniques such as relaxation training or meditation are inexpensive and are easily learned without the help of a mental health professional. Other studies have shown that combining a behavioral technique with a preventive migraine medication results in better outcomes than with either therapy alone. So, if you take a medication it does not mean that you could not find additional relief from behavioral approaches, as well as aerobic exercise, magnesium, and other alternative therapies. --- ### Headaches after a head injury - Published: 2012-06-24 - Modified: 2012-06-24 - URL: https://www.nyheadache.com/blog/headaches-after-a-head-injury/ - Categories: Headaches Many patients visiting the New York Headache Center with persistent post-traumatic headaches report having had a relatively mild head injury. The perception by neurologists has always been that milder injuries without loss of consciousness are more likely to cause headaches that severe ones. A research study just presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles confirms this old observation. Dr. Sylvia Lucas and her colleagues at the University of Washington in Seattle evaluated 220 patients with a mild traumatic brain injury (TBI) and a group of 378 individuals with moderate or severe brain injury. Both groups were evaluated within a week of the head injury and then again, by phone, 3, 6 and 12 months later. Both groups had similar demographics (age, sex, etc) and similar causes of injury (motor vehicle accidents was the most common cause). In the mild TBI group headaches were present in 63% after 3 months, 69% after 6, and 58% after 12 months. In the moderate and severe TBI group these numbers were 37%, 33%, and 34%. In both groups about 17% also had headaches prior to the injury. As far as the kind of headaches these individuals experienced, migraine was the most common type in both groups. It remains unclear why a milder injury should cause so many more headaches than a severe one. Treatment of post-traumatic headaches includes the usual approaches to the treatment of migraines - aerobic exercise, biofeedback and relaxation training, magnesium, butterbur, CoQ10,... --- ### Migraine and sinus headaches - Published: 2012-06-24 - Modified: 2012-06-24 - URL: https://www.nyheadache.com/blog/migraine-and-sinus-headaches/ - Categories: Science of Migraine Sinus inflammation can seriously worsen migraine attacks according to a recent presentation by Dr. V. Martin and his colleagues made at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles. Migraines are often mistaken for sinus headaches because pain of migraine is often felt in the area of sinuses and many migraine attacks are accompanied by a clear nasal discharge. These patients will naturally first see an ENT specialist and often undergo treatment with antibiotics and even surgery before the diagnosis of migraine is considered. However, sinus inflammation, both allergic and non-allergic in nature, can coexist and worsen migraines and increase disability caused by migraine according to these new findings. Many neurologists will often dismiss the diagnosis of sinus headaches and proceed with treating only migraine symptoms. On the other hand, many patients and ENT doctors will focus solely on treating sinus disease and ignore the possibility of migraines. As a neurologist, I also tend to be biased in the direction of migraine headaches, however, but now will try to always consider the possible contribution of sinus disease as an aggravating factor. This study may explain why some of my patients with definite migraines will often report at least some improvement from sinus or allergy medications. --- ### Steroids for migraines - Published: 2012-06-10 - Modified: 2012-06-10 - URL: https://www.nyheadache.com/blog/steroids-for-migraines/ - Categories: Headache medications Steroid medications can be very effective for migraine headaches that fail to respond to other medications. Steroids, such as prednisone, dexamethasone, methylprednisolone have many potential serious side effects if taken for a long time. We know about these long-term side effects from patients with asthma, arthritis, lupus and other conditions who have take steroids daily for months and even years. However, these medications are relatively safe if taken for only a few days. If a severe headache does not respond to Migralex, sumatriptan, (Imitrex), or other medications, I prescribe a two-day course of dexamethasone. The usual dose is 8 mg daily for two days. Other doctors prescribe a six-day course of methylprednisolone (Medrol Dosepak). However, if a headache completely resolves after two days, it seems unnecessary to continue this medication for the full six days. In the office, we also give intravenous dexamethasone which provides faster relief than tablets. Another indication for steroids is for cluster headaches. A ten-day course of prednisone (starting with 100 mg and reducing by 10 mg every day) can sometimes stop the entire cluster period. Unfortunately, for some cluster headache sufferers headaches return as soon as the dose of prednisone is lowered. If no other preventive medication, such as verapamil, lithium, topiramate (Topamax) or divalproex (Depakote) work, some patients with severe attacks are willing to accept the risk of long-term side effects of steroids. Some of these side effects are weight gain, diabetes, stomach ulcers, glaucoma, high blood pressure, and osteoporosis. --- ### Injectable sumatriptan: Imitrex, Sumavel, Alsuma - Published: 2012-06-09 - Modified: 2012-06-09 - URL: https://www.nyheadache.com/blog/injectable-sumatriptan-imitrex-sumavel-alsuma/ - Categories: Headache medications Injections of sumatriptan (Imitrex) are very underutilized. Many doctors fail to offer this option to their migraine and cluster headache sufferers because they are not aware of this option or more often because they are not aware how debilitating migraines can be or because they consider it to be dangerous. Patients who wake up with a severe headache (migraines commonly occur in the morning) and have to go to work or take care of their children often become disabled for the day because oral medications are not effective. Another group of patients who benefit from injections are those with nausea and vomiting. But you do not have to have a severe attack or have vomiting to take an injection. I have occasional migraines, usually triggered by wine or lack of sleep and if I take an oral medication it will usually help, but it may take an hour or even two before it works. So, if I have a headache late in the evening, I take an injection which stops my migraine within 10 minutes and I can fall asleep right away instead of waiting for an hour before the tablet takes effect. Sumatriptan injection is the only drug approved for the treatment of cluster headaches and it is a true life saver for cluster sufferers. It is very easy to give yourself an injection of sumatriptan. There are three different devices on the market. The oldest one is a little more cumbersome to use, which can be a factor... --- ### Namenda, an Alzheimer's drug for migraines - Published: 2012-05-31 - Modified: 2012-05-31 - URL: https://www.nyheadache.com/blog/namenda-an-alzheimers-drug-for-migraines/ - Categories: Headache medications Migraine patients can sometimes benefit from an Alzheimer's drug, Namenda (memantine). All drugs for the preventive treatment of migraines, including Botox, had been first approved for a completely different indication. Beta blockers and other high blood pressure drugs, epilepsy drugs, and antidepressants are the most commonly used medications for migraine. It is surprising that such a wide variety of medications with very different mechanisms of action would all provide relief for migraines. We have only a basic understanding of how these drugs might work because they were discovered to help migraines by accident. Namenda is a very old medicine that has been available in Europe for over 30 years. It was used for a variety of neurological conditions, but in the US it was introduced and approved only for Alzheimer's disease in 2003. It works by blocking an NMDA receptor, which is found in brain cells and which is responsible for letting calcium into the cells. Excessive inflow of calcium leads to many negative effects, including propagation of pain messages along the nervous system. Magnesium is a natural NMDA receptor blocker and we often add Namenda to magnesium for stronger effect. Namenda is not a very strong medication, meaning that it probably works for less than half of the patients, but it also causes fewer side effects than many other drugs. It is well tolerated even by the elderly Alzheimer patients, although like any other drug it can cause side effects, including nausea, drowsiness, and dizziness. Another problem with the... --- ### Indomethacin-responsive headaches - Published: 2012-05-30 - Modified: 2012-05-30 - URL: https://www.nyheadache.com/blog/indomethacin-responsive-headaches/ - Categories: Headache medications Chronic and episodic paroxysmal hemicrania and hemicrania continua are rare types of headaches that have one common feature - they respond very well to indomethacin (Indocin). The diagnosis is actually based not only on clinical features but also on the response to indomethacin. Indomethacin belongs to the category of NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, naproxen, and other. Indomethacin is somewhat unique in the way it works and it is often stronger, however it also causes more gastrointestinal side effects than other NSAIDs. Symptoms of paroxysmal hemicrania are similar to those of cluster headaches: the pain is very severe, very brief (lasting a few minutes) and occurs anywhere from a few times to a few hundred times a day. The pain is always one-sided, localized to the eye and it is often accompanied by tearing, nasal congestion, and redness of the eye. Hemicrania continua is very different in that it is present constantly and it is not very severe, but it also involves only one side of the head. Hemicrania continua is often mistaken for chronic migraine or chronic tension-type headache, which leads to ineffective treatments. The dose of indomethacin varies from 25 to 75 mg, taken three times a day. Some patients with these headache types do not tolerate indomethacin, which can cause heartburn, stomach ulcers, bleeding ulcers and other side effects. In those patients we try epilepsy drugs, other NSAIDs (which may or may not be better tolerated), as well as Botox injections and sometimes these... --- ### Biofeedback - Published: 2012-05-14 - Modified: 2012-05-14 - URL: https://www.nyheadache.com/blog/biofeedback/ - Categories: Alternative Therapies Biofeedback is an excellent preventive headache treatment with its efficacy proven in many rigorous studies. What prompted me to write this blog post is seeing yet another child (I see kids with headaches aged 10 and older) who had seen his pediatrician and a pediatric neurologist and neither physician mentioned biofeedback. Instead, they just prescribed drugs. Biofeedback is very effective for adults as well, but seeing a 10-year-old child with headaches who is prescribed medications as the only option was somehow more upsetting than when I see and adult under the same circumstances. Children tend to learn biofeedback with greater ease than adults - sometimes they need only 4 - 5 sessions instead of the usual 10 or more. Biofeedback is a way to learn to relax and stay relaxed under pressure, at least relaxed as far as your body goes, if not the mind. The person learning biofeedback is usually connected to a computer by a probe which measures body's temperature or muscle tension (or brain wave activity in case of neurofeedback). The computer displays this information on the screen, which helps you learn how to relax your body. Biofeedback is taught by a psychologist, a nurse or another trained professional. Some insurers will cover this treatment, but many do not. Fortunately, studies show that self-taught relaxation training can be as effective as biofeedback. There are many free sources and some that you can buy. Many people are skeptical about biofeedback, but there is a simple explanation why it... --- ### Botox for trigeminal neuralgia - Published: 2012-04-24 - Modified: 2012-04-24 - URL: https://www.nyheadache.com/blog/botox-for-trigeminal-neuralgia/ - Categories: Trigeminal and other neuralgias Botox injections relieve pain of trigeminal neuralgia, according to a new study just published in Cephalalgia, a leading headache journal. Trigeminal neuralgia is an extremely painful condition which manifests itself by intense electric shock-like pain on one side of the face. The pain is triggered by speaking, chewing and often without any provocation. Persistent pain can lead to malnutrition from the inability to chew and to severe depression and despondency. Epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and other types of drugs often relieve the pain, but not always and at times the drugs can cause intolerable side effects. Research on the mechanism of action of Botox has shown that it may be blocking sensory nerves and this led me to try Botox for a few of my patients with conditions other than chronic migraines and other headaches. Several patients with post-herpetic neuralgia (shingles) and a few with trigeminal neuralgia responded very well. This rigorous double-blind, placebo-controlled study in Cephalalgia by Chinese researchers involved 42 patents with trigeminal neuralgia, of whom 40 completed the study. Among the patients who received Botox injections, 68% had significant improvement compared to only 15% of responders in the group tht received placebo. This study strongly suggests that Botox is an effective treatment for some patients with trigeminal neuralgia. The advantage of Botox is that it has significantly fewer side effects than oral drugs. --- ### Pollution and headaches - Published: 2012-04-22 - Modified: 2012-04-22 - URL: https://www.nyheadache.com/blog/pollution-and-headaches/ - Categories: Science of Migraine Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been established. A recent study showed that even low levels of particulate matter can increase the risk of a stroke. Doctors looked at 1,705 patients who were admitted to the hospital with an acute stroke and checked pollution records on the days these strokes occurred. They found that strokes were more common within 12 hours of the rise in the level of pollution. The correlation was linear - the higher the pollution, the higher the risk of stroke. The risk of stroke was elevated even at pollution levels considered "satisfactory". --- ### Mal de Debarquement syndrome - Published: 2012-04-16 - Modified: 2013-03-09 - URL: https://www.nyheadache.com/blog/mal-de-debarquement-syndrome/ - Categories: Science of Migraine, Uncategorized Mal de debarquement syndrome (MdDS) or disembarkment syndrome is a rare condition which often, but not always, occurs after getting off a ship. Many people have "sea legs" after getting off a boat, but in most this sensation of still being on a rocking boat quickly subsides. Very few unfortunate people continue to have this sensation for months and even years. Last week I happened to see two patients with this condition. It was not entirely a coincidence since both read online report by a patient whom I helped. One woman I saw today said that she feels that her life was taken away from her. Despite her symptoms, she was able to hold a full-time job and care for her 3 children. However, the second patient with the worst case of MdDS I've seen, demonstrated how debilitating this seemingly minor disorder can be. She had to quit her job, became very anxious and depressed, which never happened to her before this illness. She also reported feeling very tired, could not think clearly, complained of difficulty breathing, diarrhea, constipation, and had many other debilitating symptoms. When I examined her, she was unable to stand with her feet together and eyes closed and could not walk a straight line, heel-to-toe. Almost all patients I've seen with MdDS had extensive testing, which was normal. Vestibular rehabilitation seems to help a few, as does acupuncture, or medications such as Klonopin or clonazepam (which seems to be the most commonly prescribed drug). Most of... --- ### Traditional Chinese Medicine - Published: 2012-04-13 - Modified: 2013-09-27 - URL: https://www.nyheadache.com/blog/traditional-chinese-medicine/ - Categories: Alternative Therapies Risks involved in using Chinese herbs are highlighted in the just released AFP report, which you can read on Yahoo News. Here is an edited quote from this story: The samples analyzed for this study included herbal teas, capsules, powders and flakes were tested by scientists at Australia's Murdoch University. 68 different plant families that were detected in the 15 samples can be toxic if taken in the wrong doses, but the packaging did not list the concentrations of the elements inside. I am a big proponent of alternative and complementary medicine, recommend herbs, and am a certified acupuncturist. I think acupuncture and many herbal products have a place in the modern medicine because they've been shown to be effective. However, many people who go to acupuncturists are often given Chinese herbs along with acupuncture. Unfortunately, there is very little or no quality control in the production of the Chinese herbs. The most dramatic example of this problem was described in the New England Journal of Medicine in 2000 - an herb people were taking for weight loss was contaminated by a toxic plant which caused kidney failure and urinary cancer in 18 of 105 patients. China (just like India, Russia, etc) still has extreme levels of corruption, which means that we cannot rely on their herbal products unless they are first tested in an American laboratory for purity. For now, stick with herbal products made in the US or Western Europe. Feverfew, boswellia, ginger, valerian root, and other are... --- ### Health care in Holland - Published: 2012-04-12 - Modified: 2012-04-12 - URL: https://www.nyheadache.com/blog/health-care-in-holland/ - Categories: Headache medications We should not complain about our health care system. People in such advanced European countries as Netherlands have it much worse. I just saw a 27-year-old Dutch woman with chronic migraines who has been coming to see me for Botox injections every three months for the past 3 years. Three years ago she was told by her neurologist to quit law school because even if she was able to graduate, her migraines will prevent her from being able to hold a job. She is graduating from law school this June. Her doctors also told her not to take sumatriptan (called Imigran in Europe and Imitrex in the US) more than once or twice a week and take only aspirin on other days. This approach made her unable to function on the five days when she did not take sumatriptan, but even with sumatriptan her headaches were still disabling. Botox injections produced a significant improvement in the severity of her attacks, although not in the frequency. However, now sumatriptan provides complete relief and she can function normally. She tried to find a way to get Botox injections in Holland and offered to pay the doctor. He was not able to do it because medicine is socialized in Holland and he could not accept payment for procedures not covered by the health service. She turned to the government and offered to reimburse the health service for Botox, but they also refused. She is fortunate in that she is able to afford to... --- ### Muscle relaxants for migraines - Published: 2012-04-11 - Modified: 2012-04-11 - URL: https://www.nyheadache.com/blog/muscle-relaxants-for-migraines/ - Categories: Headache medications Muscle relaxants can be surprisingly effective for the prophylactic treatment of migraine headaches. It is surprising because migraine is a brain disorder and not a disorder of muscles. However, studies have shown that during a migraine attack muscles are in fact very contracted and that is probably why people find some relief by rubbing their temples and the back of the head. We also thought that Botox works by relaxing these tight muscles, but it turned out that it also works on nerve endings. Muscle relaxants also do more than just relax muscles - they actually work on brain mechanisms of migraines. Not all muscle relaxants help migraines and the most evidence exists for tizanindine (Zanaflex). A double-blind study was done by Dr. Alvin Lake and his colleagues and it showed very good efficacy and few side effects. The target dose was 8 mg three times a day, but the average dose was 18 mg a day. The main side effect of this drug is sedation, but otherwise it is fairly benign. Baclofen (Lioresal) is another muscle relaxant that has been subjected to a double-blind study and was found to be effective for the prevention of migraine headaches. The drug was also given three times a day with a total dose ranging from 15 to 40 mg a day. The main side effect of baclofen is also sedation. Other muscle relaxants, such as metaxalone (Skelaxin), cyclobenzaprine (Flexeril), clonazepam (Klonopin), and other have helped some patients, but there are no scientific... --- ### Throbbing headache starting after 60 - Published: 2012-04-10 - Modified: 2012-04-10 - URL: https://www.nyheadache.com/blog/throbbing-headache-starting-after-60/ - Categories: Headaches A throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a year seemed to indicate a typical chronic migraine headache in a man I saw last week. His headache did not respond to pain medications, short courses of steroids and sinus surgery. The MRI scan of the brain and neurological examination was normal. The only unusual part was that this was a 66-year-old man who never had any headaches before and who had no family history of headaches. Migraines can begin as early as infancy and as late as 50's, but it is extremely unusual to start having migraines for the first time in the 60s. Headaches that occur in later years are more likely to be due to conditions such as brain tumors (primary - glioma or meningioma, or secondary due to metastases from breast, lung and other tumors), subdural hematoma, or inflammation of blood vessels, which was the case in this 66-year-old man. He suffered from temporal arteritis, also called giant cell arteritis. The diagnosis is confirmed by blood tests (elevated ESR and CRP) and biopsy of the artery. Treatment is usually very effective and typically consists of a steroid medication such as prednisone. Unfortunately, many patients with temporal arteritis need to stay on at least a small amount of this medicine for many years if not the rest of their lives and this drug has many potential serious side effects. However, if left untreated temporal arteritis can cause... --- ### Botox for chronic cluster headaches - Published: 2012-04-09 - Modified: 2013-02-08 - URL: https://www.nyheadache.com/blog/botox-for-chronic-cluster-headaches/ - Categories: New treatments I just saw a man with chronic cluster headaches whom I've been treating for the past 5 years. He had tried various treatments and still remains on verapamil which provides partial relief, but he finds excellent relief from monthly intravenous infusions of magnesium and Botox injections given every 2 to 4 months. He sometimes needs a magnesium infusion every three weeks. He occasionally takes sumatriptan (Imitrex) injections as needed for breakthrough headaches, but many of his remaining attacks are mild and are relieved by rizatriptan (Maxalt) tablets or zolmitriptan (Zomig) nasal spray. Botox is not approved by the FDA for the treatment of cluster headaches, only for chronic migraines. However, there are several case reports of successful use of Botox in patients similar to mine. I've treated several other cluster headache patients with Botox with good results, but this is the only one who has been receiving Botox for three years (he has had 15 treatments to date). As far as the use of intravenous magnesium, we've published an article showing that 40% of patients with cluster headaches are deficient in magnesium and respond to intravenous infusions. Photo credit: IHS-Classification. org --- ### Weather and headaches - Published: 2012-04-06 - Modified: 2012-04-06 - URL: https://www.nyheadache.com/blog/weather-and-headaches/ - Categories: Science of Migraine Weather is a common trigger of migraine headaches. Review of studies linking weather to migraines suggests that there are three weather-related triggers. It is high humidity, high temperature, and drop in barometric pressure. Some migraine sufferers, just like many people with arthritis, can predict rainy weather. We can speculate that the drop in barometric pressure causes blood vessels inside the skull to dilate and trigger a migraine. This happens because of faulty regulation of blood vessels in those with migraine. This is also probably the reason why migraines are sometimes caused by exercise or sexual activity - blood vessels dilate excessively and trigger a migraine. High altitude headache or mountain sickness is another example of headaches caused by low barometric pressure. In fact, one study showed that people living at high altitudes, specifically in Denver, are more likely to have mgraines than those living at sea level. Treatment of barometric pressure headaches involves the usual approaches to migraines - regular exercise, biofeedback, magnesium, CoQ10, Botox, and drugs. Diamox (acetazolamide) is a diuretic drug that is particularly effective for mountain sickness and in some patients can also prevent weather-related headaches. It is not clear why high humidity causes headaches, but high temperature may lead to a) dehydration, which is a trigger of migraines for many and b) again, dilatation of blood vessels which the body uses to cool itself by bringing more warm blood to the surface (this is why we look red in the heat). There is an easy way... --- ### Headaches are common in patients with HIV/AIDS - Published: 2012-04-05 - Modified: 2012-04-05 - URL: https://www.nyheadache.com/blog/headaches-are-common-in-patients-with-hivaids/ - Categories: Science of Migraine Headache is one of the most common complaints reported by patients suffering from AIDS, according to a new study by researchers from the University of Alabama. They evaluated 200 patients with HIV/AIDS and discovered that 107 or 54% of them had headaches. Only 4 of these patients had a serious underlying cause, while 88, or 44% had migraines and the rest had tension-type headaches. This is a much higher incidence of migraines than in the general population, where only 12% have migraines. The severity of HIV (CD4 cell count) correlated with the headache severity, frequency, and disability. The findings of this study suggest the importance of diagnosing and treating migraines in this population which already has reduced quality of life and which migraines make even worse. --- ### Smoking during pregnancy causes headaches in offspring - Published: 2012-04-04 - Modified: 2012-04-04 - URL: https://www.nyheadache.com/blog/smoking-during-pegnancy-causes-headaches-in-offspring/ - Categories: Science of Migraine Smoking by the mother during pregnancy increases the risk that the child will suffer from headaches. Brazilian researchers published results of their study in the journal Cephalalgia. They collected information on over 1,600 children aged 10 - 11 years and discovered that children of mothers who smoked 10 or more cigarettes a day were more likely to suffer from tension or migraine headaches. Surprisingly, exposure to second-hand smoke was not associated with an increased risk of headaches in children. --- ### Omega-3 fatty acids (fish oil) - Published: 2012-04-03 - Modified: 2012-04-04 - URL: https://www.nyheadache.com/blog/omega-3-fatty-acids-fish-oil/ - Categories: Alternative Therapies Omega-3 fatty acids, found in fish oil, have been reported to relieve migraine headaches, although the only such study was relatively small. The dose of omega-3 fatty acids was 6 grams taken daily as a preventive treatment for migraines. A recent study published in Neurology shows another reason to take fish oil. Researchers at UCLA measured levels of omega-3 fatty acids, DHA and EPA in red blood cells of 1,575 healthy people with an average age of 67 +/- 9 years. They discovered a strong correlation between low levels of DHA and EPA and shrinking of the brain as well as impaired cognitive function even in people without any signs of dementia. High fish intake has been associated with reduced risk of death from heart disease and strokes and this study shows another highly beneficial effect of omega-3 fatty acids. --- ### Depression and migraine - Published: 2012-04-02 - Modified: 2012-04-02 - URL: https://www.nyheadache.com/blog/depression-and-migraine/ - Categories: Science of Migraine Depression is more likely to occur in people with migraines, but migraines are also more likely to develop in those who suffer from depression first. A new Canadian study reexamined this link in 15,254 people. They confirmed this association, but unlike in previous studies the researchers from Calgary discovered that this bi-directional relationship is symmetrical. That is, if you have migraines you are 80% more likely to develop a major depressive episode, but if suffer from depression first, you are only 40% more likely to develop migraines. They found that childhood trauma and stress may be a contributing factor to both conditions. The authors of the study discuss the fact that common genetic abnormalities may also predispose people to both conditions. --- ### Another study confirming genetic link in migraine. - Published: 2012-04-01 - Modified: 2012-04-01 - URL: https://www.nyheadache.com/blog/another-study-confirming-genetic-link-in-migraine/ - Categories: Science of Migraine Genetic analysis of 594 members of 134 families by Spanish researchers confirmed the results of a previous study that discovered a genetic abnormality on the sixth chromosome that seems to be associated with migraines. This genetic marker is present only in a small proportion of migraine sufferers, but it is very likely that there are several or many other genetic abnormalities that predispose to migraine. In patients with familial hemiplegic migraine very specific genes have been identified, but even in this rare form of migraine different families had different genes that were abnormal. This wide variety of genetic factors will make it difficult to develop genetic therapies for migraine, when such therapies become available (probably 10 or more years from now). However, people who have genetic abnormalities are only predisposed to having migraines, but not necessarily will have them. This predisposition makes it more likely that the person will develop migraines, however, avoiding triggers and improving general health may prevent or at least reduce the frequency and the severity of attacks. --- ### Women with migraine are at a higher risk of widespread chronic pain - Published: 2012-03-23 - Modified: 2012-03-25 - URL: https://www.nyheadache.com/blog/women-with-migraine-are-at-a-higher-risk-of-widespread-chronic-pain-is/ - Categories: Science of Migraine Women who suffer from both episodic and chronic migraines are more likely to have widespread chronic pain, which is often diagnosed as fibromyalgia. Brazilian researchers evaluated 179 women with episodic and chronic migraine. They discovered that the more frequent were their migraine attacks, the more likely they were to have widespread chronic pain. A likely explanation of this association is the phenomenon of allodynia. Allodynia is an increased sensitivity of the skin during and after a migraine attack, which affects many migraine sufferers. Patients often report not being able to brush their hair or wear glasses because the skin becomes very sensitive. This skin sensitivity can spread from the face and scalp to involve the upper body. It is logical to assume that with frequent migraine attacks this sensitivity spreads and can involve the entire body. This sensitivity is is a reflection of increased excitability of brain cells, which has been documented to be present in migraine sufferers. If migraines are frequent and are left untreated, this increased excitability can become persistent and may predispose to other chronic pain conditions. The obvious important lesson of this study is that migraine headaches need to be treated aggressively in order to avoid the development of additional pain syndromes and impaired quality of life. This treatment should utilize all available approaches - abortive drugs such as triptans (as well as Migralex and NSAIDs), and prophylactic therapies, including aerobic exercise, biofeedback, magnesium, CoQ10, Botox injections and prophylactic drugs. --- ### More serious risks of Prilosec and similar drugs - Published: 2012-03-10 - Modified: 2012-03-10 - URL: https://www.nyheadache.com/blog/more-serious-risks-of-prilosec-and-similar-drugs/ - Categories: Uncategorized New risks of Prilosec (omeprazole), Nexium, and other similar drugs (so-called proton-pump inhibitors, or PPIs) are being highlighted by the FDA. They can increase the risk of Clostridium difficile-associated diarrhea, a serious infection. This probably occurs because lowering stomach's acidity allows this bacterium grow more easily. In additional to watery diarrhea, this sinfection causes abdominal pain, and fever, especially after recent antibiotic use. This as another reason to try to limit the use of PPIs. Their use is also associated with a small increase in the risk of pneumonia, bone fractures, vitamin B12 deficiency, and magnesium deficiency. Having diarrhea from a bowel infection will worsen these deficiencies. It is not easy to stop a PPI because heartburn and other symptoms will first get worse, due to "rebound" increase in acidity. This is why once you start taking a drug like Prilosec, it is very difficult to stop. The way to do it is to first lower the dose, then extend the dosing interval to every other day, every third day, etc. Temporarily taking an H2-blocker (Zantac, Pepcid) and antacids can also help in getting off PPIs. PPIs include Prilosec, Prevacid, Protonix, Nexium, Dexilant, and Aciphex. What does this have to do with headaches? PPIs can sometimes cause headaches directly, but more often they worsen migraines by interfering with the absorption of magnesium and other vitamins. This is a class effect, so switching from one drug to another will not help. Taking a magnesium, vitamin B12 and other supplements may help,... --- ### Daily use of triptans - Published: 2012-03-04 - Modified: 2012-03-04 - URL: https://www.nyheadache.com/blog/daily-use-of-triptans/ - Categories: New treatments A small number of my patients take triptan medications daily. Many doctors, including neurologists and headache specialists think that taking these drugs daily makes headaches worse, resulting in rebound, or medication overuse headaches (MOH). However, there is no evidence to support this view. Sumatriptan (Imitrex, Treximet), rizatriptan (Maxalt), zolmitriptan (Zomig), naratriptan (Amerge), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova) have revolutionized the treatment of migraines. I started my career in 1986, five years before the introduction of sumatriptan when treatment options were limited to ergots with and without caffeine (Cafergot), barbiturates with caffeine and acetaminophen (Fioricet), and narcotic or opioid drugs (codeine, Vicodin, Percocet). These drugs were not only ineffective for many migraine sufferers, but they also made headaches worse. Dr. Richard Lipton and his colleagues followed over 8,000 patients with migraine headaches for one year. Results of their study showed that taking barbiturates (Fioricet, Fiorinal) and narcotic pain killers increased the risk of migraines become more frequent and even daily and resulting in chronic migraines. We know from many other studies that withdrawal from caffeine and narcotics can result in headaches. However, taking triptans and non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin (Migralex), naproxen (Aleve), ibuprofen (Advil, Motrin) does not lead to worsening of headaches. Only those patients who were taking NSAIDs very frequently to begin with were more likely to develop even more frequent headaches at the end of the year. Aspirin, in fact, was found to have preventive properties - if you were taking aspirin for your... --- ### Sinus infection usually does not require antibiotics - Published: 2012-02-23 - Modified: 2012-02-23 - URL: https://www.nyheadache.com/blog/sinus-infection-usually-does-not-require-antibiotics/ - Categories: Uncategorized Migraines are often mistaken for sinus infections, and are treated with antibiotics. The reson for this confusion is that migraines can cause pain in the area of sinuses and some people will even have a clear discharge from their nose during a migraine attack. Sinus infection is really easy to diagnose - it usually causes a yellow or green discharge from the nose. But even if you do have a true sinus infections antibiotics are usually unnecessary because the infection is caused by a virus and viral infections do not respond to antibiotics. This well-know fact is confirmed in a new study which was just published in the Journal of the American Medical Association. The study involved 166 adults with a sinus infection who were given either a placebo or an antibiotic for 10 days. There was no difference between the two groups in the satisfaction with the treatment, the amount of time missed from work, and every other parameter measured. The authors (doctors at Washington University in St. Louis) do recommend starting antibiotics if the condition does not after 5 - 7 days. --- ### A new way to stop migraines - Published: 2012-02-21 - Modified: 2012-02-21 - URL: https://www.nyheadache.com/blog/a-new-way-to-stop-migraines/ - Categories: New treatments, Uncategorized We are conducting a trial of a very novel treatment for migraine headaches. ElectroCore is a company that developed a small hand-held device which is placed at the front of the neck during a migraine and which painlessly stimulates the vagus nerve. The idea for this device came from my study of 6 patients who had a vagus nerve stimulator implanted in the neck. The results of this study was published in 2005 in the journal Cephalalgia. All six patients had very debilitating headache which did not respond to dozens of drugs, Botox injections, nerve blocks, acupuncture and a variety of other treatments. Two of them had cluster headaches and both improved. Four had chronic migraines and two of these also improved. Implanting a device to stimulate the vagus nerve is an invasive and expensive procedure, so having a small portable and non-invasive device offers great advantages. This device is approved in Europe and id currently in clinical trials in the US. --- ### How does Botox relieves migraine headaches? - Published: 2012-02-15 - Modified: 2012-02-15 - URL: https://www.nyheadache.com/blog/how-does-botox-relieves-migraine-headaches/ - Categories: New treatments Botox, or onabotulinumtoxinA was recently approved by the FDA for treatment of chronic migraine based on the results of two large studies. Botox is the only prophylactic therapy specifically approved for chronic migraine. Many patients and doctors alike wonder about the mechanism of action of Botox. We originally thought that Botox works by relaxing tight muscles around the scalp. Studies have shown that during a migraine attack, the muscles in the forehead, temples and the back of the head are in fact contracted. It is also typical for a person with a migraine to rub their temples or the neck, which provides some temporary relief. However, I have seen some patients who would report that injecting muscles around the head eliminated pain in the injected areas, but that they still had pain on the top of the head. There are no muscles on the top of the head and we usually do not inject Botox there, but in those patients who do have residual pain on the top, injecting Botox stops the pain. Recent research has shown that Botox in fact also exerts a direct analgesic (pain-relieving) effect. This is supported by my and other doctors' observation that Botox also helps other types of pain, such as that of shingles or trigeminal neuralgia. These are so called anecdotal reports and cannot be relied on to make definitive conclusions - we need large trials can prove this. It appears that Botox helps by reducing pain messages sent to the brain from... --- ### Emergency treatment of headaches with intravenous magnesium - Published: 2012-01-25 - Modified: 2012-01-25 - URL: https://www.nyheadache.com/blog/emergency-treatment-of-headaches-with-intravenous-magnesium/ - Categories: New treatments Intravenous infusion of magnesium for the treatment of an acute migraine is receiving more attention and is mentioned in the recent issue of journal Headache. In the first of three articles Drs. Nancy Kelley and Deborah Tepper of the Cleveland Clinic describe the use of triptans (such as sumatriptan, or Imitrex), DHE (dihydroergotamine), and magnesium for the emergency treatment of migraines. In their article they included seven reports of the use of magnesium infusion, all with positive results. We published the very first article on the use of intravenous magnesium for migraines in 1995. In the same year we published our results of the use of this treatment for cluster headaches, also a first and since that time have been promoting the use of this safe and effective treatment in many articles, lectures, and symposia. We've found that 50% of patients with migraines and 40% of those with cluster headaches responded to magnesium infusion. Unfortunately, many patients seen in the emergency room still do not receive magnesium, but in the best case sumatriptan or ketorolac injection, in the worse, narcotic drugs. An infusion of magnesium should be always tried first. We actually discourage our patients from going to the emergency room during office hours - instead they come to our office and are given an infusion of magnesium. If it is ineffective, then we proceed with sumatriptan, ketorolac, dexamethasone, other drugs, and sometimes nerve blocks. Oral magnesium is not suitable for the acute treatment of a severe headache because it... --- ### Acupuncture is again shown to relieve migraine headaches - Published: 2012-01-11 - Modified: 2012-01-11 - URL: https://www.nyheadache.com/blog/acupuncture-is-again-shown-to-relieve-migraine-headaches/ - Categories: Alternative Therapies Acupuncture has been widely used for the treatment of migraine headaches and it has been subjected to many clinical trials. A new study published in the Canadian Medical Association Journal confirms what previous research has shown - that acupuncture in fact is effective. This study was performed by Chinese researchers and it involved 480 patients. It was a well-designed and rigorously conducted study. The doctors divided patients into 4 groups with 3 groups receiving different types of real acupuncture and the fourth one receiving sham acupuncture. Sham acupuncture group had needles inserted, but they were not manipulated to elicit a specific "qi" sensation, which was done in the real groups. Patients in all three groups receiving real acupuncture did better than those in the sham group. The benefit persisted for at least three months after the treatment. The difference was statistically significant (meaning it did not occur by chance) but not very large, mostly because the sham group also improved. In summary, this study strongly supports the results of previous clinical trials in migraines, which showed positive effects of acupuncture. It also showed that the type of acupuncture is not important, but needles need to be inserted properly and probably need to have electrical stimulation (all groups in this study had electrical stimulation). One difficulty in following the treatment used in this study is the need for doing acupuncture five days a week for 4 weeks. Many people may have difficulty finding the time (and money) for such a regimen.... --- ### How much sumatritpan (or another triptan) is too much? - Published: 2012-01-01 - Modified: 2012-01-02 - URL: https://www.nyheadache.com/blog/how-much-sumatritpan-or-other-triptans-is-too-much/ - Categories: Headache medications How much sumatriptan (or another triptan) is too much is not clear. The initial FDA-approved daily dose of oral sumatriptan (Imitrex) for the treatment of an acute migraine was up to three 100 mg tablets. Several years later the maximum daily dose was reduced to 2 100 mg tablets a day, to be taken at least 2 hours apart. There was no scientific or safety reason for the reduction of the dose. Two other triptans, rizatriptan (Maxalt) and frovatriptan (Frova) are still allowed to be taken three times a day. The maximum dose of eletriptan (Relpax) is 2 40 mg tablets, however, in Europe it is 2 80 mg tablets. Some doctors are very strict in adhering to these arbitrary limits. Some patients will tell me that they always need to repeat the dose of a triptan 2 hours after the first dose. It makes sense to have them take a double dose at once and the results can be much better - the headache will go away and will not return. It is true that the higher the dose the more side effects you can expect. In patients who are sensitive to drugs or weight less than 100 lbs, it is prudent to try half of the usually dose and in everyone else the standard dose should be used at first. If the standard dose is not fully effective, another triptan can be tried, but if none provide sufficient relief and do not cause side effects I first recommend... --- ### Swearing helps pain, to a point - Published: 2011-12-24 - Modified: 2011-12-24 - URL: https://www.nyheadache.com/blog/swearing-helps-pain-to-a-point/ - Categories: Alternative Therapies Swearing is a common response to pain. A study just published in The Journal of Pain examines whether swearing can actually help pain. Oxford English Dictionary defines swearing as the use of offensive or obscene language. Prior studies by the same researchers at the Keele University in the UK showed that for most people swearing produces a pain lessening effect. In this new study Richard Stephens and Claudia Umland looked at the effect of repeated daily swearing on experimental pain. They took 71 healthy undergraduate students (who else? ) and subjected them to pain using a standard research procedure - submerging subjects' hand into cold water. They again showed that swearing reduces pain and increases heart rate. The latter suggests that swearing reduces pain not only by distraction, but through physiologic effect on the body. They also found that people who tended to swear frequently throughout the day had less of a pain relieving effect from swearing when subjected to pain. So, listen to your mother and don't swear all the time - save it for when it can do some good for you. --- ### Likeable patients may recieve better pain treatment - Published: 2011-12-10 - Modified: 2011-12-10 - URL: https://www.nyheadache.com/blog/likeable-patients-may-recieve-better-pain-treatment/ - Categories: Pain Research Likeable patients may receive better care for their pain, according to a study by Belgian researchers. The researchers asked 40 doctors to look at photos of six different patients. Each photo was accompanied by a description such as friendly, egoistic, arrogant, honest, faithful, hypocritical, or reserved. Then the doctors were asked to evaluate the severity of pain in these six patients after they watched a video in which the patients were being evaluated for shoulder pain. Patients with positive descriptions were thought to have more pain than those with negative ones. Most doctors are probably convinced that they treat all patients equally, but this is clearly not true. Doctors and medical students should be informed of these findings so that they constantly remind themselves of the potential bias. --- ### NSAID use increases the risk of miscarriage - Published: 2011-12-09 - Modified: 2011-12-09 - URL: https://www.nyheadache.com/blog/nsaid-use-increases-the-risk-of-miscarriage/ - Categories: Headache medications Pregnant women who take NSAIDs such as naproxen (Aleve), ibuprofen (Advil), diclofenac (Volaren, Cambia), celecoxib (Celebrex), and other are two and a half times more likely to have a miscarriage. This is a finding of Canadian researchers who examined the records of 4,705 women who had a miscarriage. Surprisingly, they did not find that the risk was higher with a higher dose of NSAIDs. NSAIDs are particularly dangerous in the third trimester, when they can also cause heart problems in the fetus. Instead of NSAIDs pregnant women can try taking acetaminophen (Tylenol), which unfortunately is not a very effective pain killer. Narcotic or opioid drugs, such as codeine, Vicodin and similar drugs are not safe in pregnancy either, but can be used occasionally, although they are not very effective for migraine headaches. Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax) and other while not approved for pregnant women, may be safer and much more effective than either NSAIDs or narcotics. If a pregnant woman has frequent headaches, prevention with intravenous magnesium, biofeedback, and Botox injections should be tried before resorting to daily preventive drugs. --- ### Botox improves quality of life - Published: 2011-11-08 - Modified: 2011-11-08 - URL: https://www.nyheadache.com/blog/botox-improves-quality-of-life/ - Categories: New treatments The FDA approved Botox for the treatment of chronic migraine because of the two large double-blind and placebo controlled trials which involved close to 1,400 patients (in which we, at the NYHC also participated). These studies showed that Botox reduced the number of days with headaches and it also improved many other related aspects. A study just published in Neurology looked at the effect of Botox on the quality of life of patients that participated in these trials. It is possible to have a treatment that reduces the number and even the severity of migraines without improving patients' quality of life because of its side effects. This is seen with some patients who take topiramate (Topamax) - their headaches may be much better but the quality of life is not because of memory impairment or fatigue, which makes them unable to function. The same is true with other medications, such as antidepressants. However, the quality of life of patients receiving Botox in these two studies was significantly better than in those receiving placebo injections. This is because their headaches improved dramatically and because Botox rarely caused any side effects. Unfortunately, many insurance companies will pay for Botox only after the patient fails to improve on 2 or 3 prophylactic medications, even though these medications are not approved by the FDA for chronic migraines. --- ### High blood pressure increases the risk of trigeminal neuralgia - Published: 2011-11-08 - Modified: 2011-11-08 - URL: https://www.nyheadache.com/blog/high-blood-pressure-increases-risk-of-trigeminal-neuralgia/ - Categories: Pain Research Hypertension appears to increase the risk of trigeminal neuralgia, according to a new study published in Neurology by Taiwanese researchers. They looked at 138,492 people with hypertension and compared them to 276,984 people of similar age and sex who did not have hypertension. The risk of trigeminal neuralgia was one and half times higher in those with high blood pressure. Trigeminal neuralgia is an extremely painful condition with electric-like pain in one or more branches of the trigeminal nerve, which supplies sensation to the face. The likely cause of trigeminal neuralgia is compression of the trigeminal nerve by a blood vessel at the site where the nerve is coming out of the brainstem. Persistently elevated blood pressure tends to make blood vessels harder and more tortuous. Hypertension has been show to be a factor in a similar condition - hemifacial spasm, which results from the compression of the facial nerve by a blood vessel. The usual treatment of trigeminal neuralgia starts with medications, such as oxcarbazepine (Trileptal), carbamazepine (Tegretol), phenytoin (Dilantin), baclofen (Lioresal) and other. If medications are ineffective, invasive treatments are recommended. Botox injections have been reported to provide some patients with good relief, although Botox is probably more effective for hemifacial spasm. ANother procedure is the destruction of the tigeminal nerve ganglion with heat from a radiofrequency probe. This is done under X-ray guidance. Radiofrequency ablation is often effective, but the pain may recur and the procedure may need to be repeated. A more drastic but also more... --- ### Cyclic vomiting in children is not always migraine - Published: 2011-11-08 - Modified: 2011-11-08 - URL: https://www.nyheadache.com/blog/cyclic-vomiting-in-children-is-not-always-migraine/ - Categories: Science of Migraine Cyclic vomiting in childhood is often a precursor of migraines in adulthood. Usually a child has attacks of vomiting with or without a headache that can occur 10 - 20 times in a 24-hour period. Most children have family history of migraines and as they get older they develop migraines themselves. A study from the Cleveland Clinic led by Dr. David Rothner (a regular speaker at our annual headache symposium) shows that one third of these children may actually have a metabolic disorder and not just migraine. Most children feel perfectly fine between these episodes of vomiting. If these attacks are frequent Dr. Rothner recommends amitriptyline (Elavil), cyproheptadine (Periactin), and ondansetron (Zofran) to treat this condition. Some of the metabolic disorders could be possibly treated with supplements such as CoQ10, riboflavin (vitamin B2), as well as magnesium. --- ### When is blood pressure too high? - Published: 2011-10-23 - Modified: 2011-10-23 - URL: https://www.nyheadache.com/blog/when-is-blood-pressure-too-high/ - Categories: Science of Migraine High blood pressure is not a common cause of chronic headaches. The pressure has to suddenly increase (from say 100/70 to 150/90) or to be very high (like 170/110, or higher) to cause a headache. Mild hypertension is called a silent killer because it does not cause headaches or any other symptoms for many years. Doctors have been debating for a long time what to consider normal blood pressure. A study by University of California researchers just published in Neurology looked at 12 previous studies that involved over half a million people. They determined that what was considered normal blood pressure in the past (130-139 systolic and 85 to 89 diastolic, sometimes called "prehypertension") in fact is associated with a significant increase in the risk of strokes. This has a practical application in people suffering from migraine headaches. One of the three categories of drugs used for preventive treatment of migraines is drugs used to treat high blood pressure. So, someone with blood pressure is 130/85 may want to request that the doctor prescribes a blood pressure medication rather than a drug from two other categories - epilepsy drugs (Topamax, Depakote, Neurontin) or antidepressants (Elavil, Pamelor, Effexor, Cymbalta, etc). Fortunately, in most cases blood pressure medications tend to have fewer side effects than drugs in the other two categories. Some of the blood pressure medications that have been shown to be effective for the prevention of migraines are beta blockers, such as propanolol (Inderal), timolol (Blocadren), atenolol (Tenormin), nebivolol (Bystolic),... --- ### Cluster headaches are relieved by steroid block of the occipital nerve - Published: 2011-10-21 - Modified: 2011-10-21 - URL: https://www.nyheadache.com/blog/cluster-headaches-are-relieved-by-steroid-block-of-the-occipital-nerve/ - Categories: New treatments Cluster headaches are relieved by steroid injections in the back of the head, according to a study by French doctors, published in The Lancet. 43 patients with chronic and episodic cluster headaches were recruited into this blinded study where some patients received a steroid (cortisone) injection and some received saline water. The injections were given in the back of the head under the skull, on the side of headache. Injections were repeated every 2 - 3 days for a total of 3 injections. There was a significant improvement in patients who received cortisone. This study supports the wide use of a similar procedure, an occipital nerve block to relieve cluster headaches. In this study patients were allowed to take oxygen and sumatriptan (Imitrex) as needed. They were also started on verapamil for the prevention of cluster headaches and the injections were used for short-term relief while awaiting for the effect of verapamil to kick in. In my experience, some patients, especially those with episodic cluster headaches, may have complete resolution of their headaches just from the nerve block. Sometimes a single block is sufficient, but occasionally it helps for only a few days and needs to be repeated. It is likely that the injection technique and doctor's experience can make a difference. Another option to stop cluster headaches is to take an oral steroid medication, such as prednisone, but taking it by mouth is more likely to cause side effects. Verapamil is an effective preventive drug, but it usually needs... --- ### High cholesterol is more common in those with migraine with aura - Published: 2011-10-10 - Modified: 2011-10-10 - URL: https://www.nyheadache.com/blog/high-cholesterol-is-more-common-in-those-with-migraine-with-aura/ - Categories: Science of Migraine Having migraines with aura increases the risk of having increased total cholesterol and triglycerides. This was found to be the case in a population-based study of 1,155 older people (average age 69) presented by Dr. Tobias Kurth at the International Headache Congress in Berlin. Although only 23 had migraines with aura the statistical data seems strong enough to warrant this conclusion. Having migraine with aura carried a six-fold increase in the risk of having abnormal levels of lipids. It is an established fact that people suffering from migraine with aura are at slightly higher risk of strokes and heart disease but the reason for this association is not known. It is possible that elevated cholesterol and triglycerides in those with migraine with aura lead to cholesterol deposits and clogging of the arteries. It is important to screen all older patients with migraine with aura for abnormal lipid levels. They also need to exercise and try to control other risk factors for strokes and coronary artery disease, such as high blood pressure, high blood glucose, obesity, and smoking. --- ### Brain dysfunction in migraine - Published: 2011-10-04 - Modified: 2011-10-04 - URL: https://www.nyheadache.com/blog/brain-dysfunction-in-migraine/ - Categories: Science of Migraine Difficulty thinking and speaking is not unusual at the onset of a migraine attack. It is not always severe as with the reporter Serene Branson who jumbled words and appeared confused on camera. Many patients report that they have difficulty finding words, remembering well known facts, or unable to say what they want to say. This often happens at the beginning of a migraine attack, according to a study presented at the last scientific meeting of the American Headache Society. The doctors tested attention, processing speed, visual-motor reaction, and other brain functions and found that many patients had significantly lower scores at the onset of a migraine than between attacks. They also found that there was no correlation with the severity of pain - you can have severe cognitive dysfunction with a mild headache. Similarly, many patients get a very severe headache after a visual aura but others get a mild headache or no headache at all. There are no acute treatments that would stop an aura or the cognitive brain dysfunction once it starts. However, preventive treatments can be very effective. We always start with elimination of triggers, aerobic exercise, biofeedback, magnesium (sometimes intravenously) and CoQ10 supplements, and then Botox and preventive drugs. Some patients find that after the first Botox treatment they no longer develop a headache, but may still get an aura or have some other warning symptoms, including cognitive dysfunction. However, with repeated injections of Botox both headaches and other symptoms subside. This probably happens because... --- ### NSAIDs, but not aspirin, can cause dangerous irregular heart beat - Published: 2011-10-02 - Modified: 2011-10-02 - URL: https://www.nyheadache.com/blog/nsaids-but-not-aspirin-can-cause-dangerous-irregular-heart-beat/ - Categories: Headache medications Risk of irregular heart beat, heart attacks, and death increases in people taking NSAIDs, such as ibuprofen (Advil), naproxen (Aleve), diclofenac (Cambia, Voltaren, Cataflam), and celecoxib (Celebrex). The risk with these drugs in people who suffer from hypertension and heart failure is well-known, but two recent large studies provide additional information on this risk. A study in the British Medical Journal that reported on 32,602 patients with atrial fibrillation suggested that patient who developed atrial fibrillation (dangerous irregular heart beat, which is often called A fib) were more likely to have been taking NSAIDs (but not aspirin) when this heart condition occurred. Another study conducted by Danish doctors and published in the journal Circulation looked at 83,677 patients who suffered a heart attack. They discovered that taking an NSAID drug (but again, not aspirin) for as little as one week increased the risk of having a second heart attack and dying by 45%. Taking NSAIDs for three months increased the risk by 55%. It is particularly unfortunate for heart patients who suffer from migraine headaches because they are also not allowed to take migraine drugs, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other triptans. This leaves them with aspirin (or Migralex - a combination of aspirin with magnesium, developed by Dr. Mauskop) and pain drugs that can make headaches worse (Fioricet, codeine, Vicodin, and other). Another option for these patients is to use preventive treatments, such as magnesium (which is also very beneficial for heart conditions), CoQ10, biofeedback, Botox injections,... --- ### Exercise is as good as drugs for migraine - Published: 2011-09-26 - Modified: 2011-09-26 - URL: https://www.nyheadache.com/blog/exercise-is-as-good-as-drugs-for-migraine/ - Categories: Alternative Therapies Yet another study finds that exercise is as good for the prevention of migraines as drugs. The research report in journal Cephalalgia by Swedish doctors shows that 40 minutes of exercise three times a week was as effective as taking topiramate (Topamax) or doing relaxation exercises. Topiramate is one of the most popular drugs for the prevention of migraine headaches, but it can have many potential serious side effects, including kidney stones in 20% of patients, glaucoma, memory and other cognitive problems. The same group of researcher published a large study of over 46,648 Swedes which showed a strong inverse correlation between exercise and any type of headaches, including migraines. So, before resorting to drugs or even Botox injections it is worth trying a regimen of avoiding triggers such caffeine, adhering to a regular sleep schedule, taking magnesium and other supplements, and regular exercise. --- ### Aspirin is First-Line Treatment for Migraine and Episodic Tension-Type Headache Regardless of Headache Intensity - Published: 2011-08-30 - Modified: 2011-08-30 - URL: https://www.nyheadache.com/blog/aspirin-is-first-line-treatment-for-migraine-and-episodic-tension-type-headache-regardless-of-headache-intensity/ - Categories: Headache medications Aspirin is the first-line treatment for migraine and tension-type headaches regardless of headache intensity, according to a report published by three leading headache experts (from Austria, Germany, and Norway) in the journal Headache. Some headache expert advise using a prescription drug such as sumatriptan (Imitrex) or another triptan (Maxalt, Zomig, Relpax, etc) from the outset if the headache is severe and to use aspirin or similar drugs when the headache is less severe. However, this review of published data from large clinical trials suggests that aspirin works equally well for both moderate and severe headaches. This is true for both migraine and tension-type headaches. The six migraine trials reviewed included 2,079 patients (1165 with severe and 914 with moderate attacks) treated with 1,000 mg of aspirin and one tension-type headache trial had 325 patients (180 with moderate and 145 with severe attacks) treated with 500 mg and 1,000 mg of aspirin. Prior studies have also shown that 1,000 mg of aspirin is as effective as 100 mg of sumatriptan in the treatment of migraine headaches and aspirin had fewer side effects. Disclosure: I have patented and developed Migralex, an over-the-counter drug which contains (in 2 tablets) 1,000 mg of aspirin and 150 mg of magnesium. --- ### A promising new migraine drug from Merck is shelved - Published: 2011-08-15 - Modified: 2011-08-15 - URL: https://www.nyheadache.com/blog/a-promising-new-migraine-drug-from-merck-is-shelved/ - Categories: New treatments, Uncategorized Merck discontinued the development of telcagepant, a promising new drug which represents a new class of migraine drugs, so-called CGRP antagonists. These drugs appear to be as effective as sumatriptan (Imitrex) and other triptans in aborting a migraine attack, but do not carry an increased risk of strokes and heart attacks which can occur, albeit very rarely, with triptans. Telcagepant was also tested as a daily preventive drug for migraines and in those trials some patients developed minor liver abnormalities. At first, Merck continued to pursue the development of telcagepant for abortive treatment, but recently decided that the risk of not getting it approved by the FDA because of the liver problems was to high. This again demonstrates that part of the reason why new drugs are so expensive - for every one that makes it to the market there are many that after an investment of hundreds of millions of dollars do not. It is likely that Merck and other companies will continue to do research to find a CGRP antagonist without serious side effects. --- ### Showing up is half the battle - predictor of improvement of headache disability - Published: 2011-08-14 - Modified: 2011-08-14 - URL: https://www.nyheadache.com/blog/showing-up-is-half-the-battle-predictor-of-improvement-of-headache-disability/ - Categories: Pain Research At the NYHC, just like at all headache clinics, we see many patients with severe disability. A very interesting study just published in the journal Pain seems to tell us how to predict which of these disabled patients will respond to treatment. Researchers at the Ohio University compared patients whose severe disability improved with treatment and those whose did not. They carefully examined a wide variety of possible factors, including race/ethnicity (African American versus Caucasian American), psychiatric comorbidity, headache management self-efficacy, perceived social support, locus of control, number of headache diagnoses, migraine versus tension-type headache diagnosis, chronic versus episodic headache diagnosis, headache days per month, headache episode severity, and whether the patient attended all scheduled treatment appointments. The only factor that seemed to predict whose disability will improve and whose will not was the attendance of the 3 follow-up visits. Those who came for follow-up visits were much more likely to improve than those who did not - showing up is half the battle. --- ### New drug for cluster headaches - Published: 2011-08-09 - Modified: 2011-08-09 - URL: https://www.nyheadache.com/blog/new-drug-for-cluster-headaches/ - Categories: New treatments Chronic cluster sufferers may benefit from sodium oxybate (Xyrem), according to a report in the leading neurology journal,Neurology. Xyrem is a drug approved for the treatment of narcolepsy but it is also being evaluated for the treatment of pain of fibromyalgia, chronic fatigue, and other conditions. It is well established that patients with cluster headaches often suffer from sleep disorders and cluster attacks often wake patients from sound sleep in the middle of the night. It is logical to consider drugs that affect sleep in the treatment of cluster headaches. However, traditional sleeping medications do not help cluster sufferers. Approximately 10% of patients with cluster headaches suffer from chronic clusters, which means that they have headaches for years without a break, while the other 90% have cluster periods lasting a few weeks to a few months every year or every several years. The article in Neurology describes 4 patients with chronic clusters who were treated with Xyrem with excellent long-term results. In one patient relief lasted 8 months while in the other three for up to two years. Side effects consisted mostly of dizziness, some memory difficulties, vomiting, and weight loss, however they were not severe enough to stop taking this medication. Xyrem is a controlled drug with potential for abuse and is dispensed only through a single centralized pharmacy. --- ### Botox for low spinal fluid pressure - Published: 2011-07-11 - Modified: 2011-07-11 - URL: https://www.nyheadache.com/blog/botox-for-low-spinal-fluid-pressure/ - Categories: New treatments Botox has been shown to relieve headaches of low spinal fluid pressure in a case reported at the last annual scientific meeting of the American Headache Society in Washington DC. Low spinal fluid headache usually occurs after a spinal tap (lumbar puncture) or rarely without an obvious cause. The diagnosis is made by doing a spinal tap which normally shows low pressure and by a characteristic appearance of the MRI scan of the brain. The woman who was treated by doctors from the Mayo Clinic had a spontaneous leak of the spinal fluid and did not respond to blood patches which is the first-line treatment for this condition and consists of injections of person's own blood into the area around the leak. She also did not respond to a variety of medications. Botox injections provided her with relief for the first time in 20 years. She has continued to receive Botox injections for three years now with sustained results. It somewhat surprising that Botox would help because the cause of low pressure headaches is thought to be tugging on the nerves due to sagging of the brain, which normally is floating in the spinal fluid. It is possible that Botox just stops pain sensations regardless of the cause, whether it is due to migraine, shingles or other nerve disturbance. --- ### Abdominal migraine is underdiagnosed - Published: 2011-05-13 - Modified: 2011-05-13 - URL: https://www.nyheadache.com/blog/abdominal-migraine-is-underdiagnosed/ - Categories: Science of Migraine Abdominal migraine was the subject of a study by a group of doctors from a children's hospital in Norfolk, VA was just published in the journal Headache. The physicians examined the records of 600 children with recurrent abdominal pain. They found that 4% of these children had definite and 11% had probable abdominal migraine. Shockingly, they also discovered that none of these children received correct diagnosis. Making a correct diagnosis is the first step to the correct treatment of this condition. Abdominal migraine is defined as a recurring condition which consists of abdominal pain, typically lasting one to 72 hours. The pain is usually in the middle of the abdomen or the child cannot localize it precisely. The pain is dull and aching and is of moderate or severe intensity. During the bout of pain the child usually has two other of the following features: loss of appetite, nausea, vomiting, or paleness. It is also very important for the doctors to make sure that there is no other possible cause for these attacks. Treatment usually involves avoiding foods which may trigger these attacks, including chocolate, caffeine, hot dogs, cheese and other known migraine-inducing foods. Irregular sleep schedule, skipping meals and stress are also frequent triggers. Regular sleep schedule, frequent exercise, biofeedback or relaxation training can all help. Magnesium and CoQ10 supplements have also been shown to help prevent migraines in kids. Migraine medications, such as sumatriptan (Imitrex) can be tried for severe attacks. When abdominal migraine occurs frequently preventive drugs,... --- ### Risk of a neck artery dissection is higher in migraine sufferers - Published: 2011-04-29 - Modified: 2012-07-10 - URL: https://www.nyheadache.com/blog/risk-of-a-neck-artery-dissection-is-higher-in-migraine-sufferers/ - Categories: Science of Migraine Dissection of the cervical artery is a dangerous condition which can lead to a stroke and even death, although in some it can be a benign condition with no lasting effects. A recently published study by Germain researchers in the journal Cephalalgia indicates that this condition is two times more common in people with migraine headaches. Dissection means that the wall of the artery is split and this can close off blood flow in the artery. In most people closing off of an artery is not a problem because there are 4 arteries in the neck that carry blood to the brain. However, in some one artery carries a large portion of the blood and the remaining 3 arteries cannot compensate, leading to a stroke. The dissection usually causes severe neck pain and if blood flow is compromised it also leads to neurological symptoms, such as a droopy eyelid, weakness or numbness on one side, difficulty speaking and other symptoms of a stroke. Neck pain is often the earliest and in benign cases the only symptom. Because migraine sufferers frequently have neck pains, this complaint can be dismissed by doctors as a symptom of their migraine. So, if someone's neck pain is very severe and different from their usual neck pains it is very important to seek medical attention and insist on an evaluation. The diagnosis is made my an MRA (magnetic resonance angiography) scan. This increased risk of dissection is another reason why migraine sufferers particularly should avoid chiropractic... --- ### Invasive treatments for trigeminal neuralgia - Published: 2011-04-29 - Modified: 2011-04-29 - URL: https://www.nyheadache.com/blog/invasive-treatments-for-trigeminal-neuralgia/ - Categories: New treatments Trigeminal neuralgia is an excruciatingly painful disorder which affects about one in a thousand people. Patients describe the pain of TN as an electric shock going through the face. The pain is brief, but can be so frequent as to become incapacitating. Eating and talking often triggers the pain, so some patients become malnourished and depressed. The good news is that most people can obtain relief from this condition by taking medications, such as Tegretol (carbamazepine), Trileptal (oxcarbazepine), Dilantin (phenytoin), or Lioresal (baclofen). Patients who do not respond to medications have several surgical options available. According to a new Dutch nationwide study of three invasive treatments for trigeminal neuralgia published in journal Pain shows that every year about 1% of those suffering from TN undergo surgery. Of the three most common types of surgery, percutaneous radiofrequency thermocoagulation (PRT) is by far most popular - in  a three year period in Holland, 672 patients underwent PRT, 87 underwent microvascular decompression (MVD), and 39 underwent partial sensory rhizotomy (PSR). The latter two procedures a performed by neurosurgeons (MVD requires opening of the skull), while PRT is usually done by anesthesiologists (a probe is inserted through the cheek to the nerve ganglion under X-ray guidance). MVD was most effective, but caused more complications than PRT, although fewer than with PSR. More patients having PRT had to have a repeat procedure, but it was still safer than the other two. Very often the physician under-treats during the first treatment of PRT in order to... --- ### Topamax recall - Published: 2011-04-14 - Modified: 2011-04-14 - URL: https://www.nyheadache.com/blog/topamax-recall/ - Categories: Headache medications - Tags: acupuncture, Botox, magnesium, migraine, Topiramate Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This recall affects only two lots of 100 mg tablets. This recall does not affect topiramate, generic copies of this brand. Since the generic form is much cheaper, most patients have switched to it from branded Topamax. This adds another problem to this beleaguered drug. It was recently reclassified by the FDA from pregnancy category C to category D, which means that it is much more dangerous for the fetus than originally thought. Topiramate is also associated with a high incidence of kidney stones (20%) and can cause other serious problems. This is why we always emphasize non-drug approaches (exercise, acupuncture, biofeedback magnesium, Botox, etc), which can be more effective and are much safer than drugs. --- ### Bariatric surgery relieves migraine headaches - Published: 2011-03-28 - Modified: 2011-03-28 - URL: https://www.nyheadache.com/blog/bariatric-surgery-relieves-migraine-headaches/ - Categories: New treatments - Tags: bariatric, headache, migraine, obesity, weight loss Obese people are more likely to suffer from more frequent and severe migraine headaches. The question that remained unanswered was whether losing weight helps relieve headaches. A new study just published in the leading neurology journal, Neurology suggests that this may be the case. Researchers from Brown University in Providence, RI examined 24 severely obese patients before and after bariatric (weight reduction) surgery. Their mean body mass index (BMI) was 46 and their mean age was 39. A direct correlation between the amount of weight loss and the reduction in the number of headache days was observed. Weight loss was also associate with reduced disability. This study gives scientific support to the idea that weight loss may improve migraine headaches. --- ### Migraine and chronic fatigue syndrome - Published: 2011-03-09 - Modified: 2011-03-09 - URL: https://www.nyheadache.com/blog/migraine-and-chronic-fatigue-syndrome/ - Categories: Science of Migraine Migraine headaches are very common in chronic fatigue syndrome (CFS) sufferers, according to a new study just published by researchers from Georgetown University. Migraine headaches were present in 84% of patients with CFS (60% had migraine without aura and 24% had migraine with aura) and tension-type headaches were present in 81% of CFS sufferers. Only 4% of CFS patients had no headaches at all. This compares to 12% of the general population, or 18% of women (two thirds of CFS patients were women) who suffer from migraines. Fibromyalgia (diffuse muscle pains in four quadrants of the body) was much more common in CFS patients with migraines (about 50%) compared to healthy controls. The authors speculate that the same brain disturbances which cause migraine headaches may be also responsible for the fatigue in patients with CFS and that successful treatment of migraines may improve symptoms of CFS. It is well known that migraine sufferers have increased excitability of their brains, even between attacks, compared to healthy individuals. This may be why migraine sufferers are more likely to have other pain syndromes, such as fibromyalgia, back pain, irritable bowel syndrome, TMJ syndrome, and other. More importantly, several treatments have been shown to be effective (to various degrees) for all of these conditions. These include biofeedback and cognitive-behavioral therapy, tricyclic antidepressants, acupuncture, and aerobic exercise. --- ### Temporo-mandibular joint disorder and headaches - Published: 2011-03-06 - Modified: 2011-03-06 - URL: https://www.nyheadache.com/blog/temporo-mandibular-joint-disorder-and-headaches/ - Categories: Science of Migraine Temporo-mandibular joint disorders (TMD) have long been known to be associated with headaches.   A very interesting study conducted in Brazil and published in the Clinical Journal of Pain examined this association in 300 patients with TMD. The researchers carefully evaluated the type of TMD and its severity as well as the type of headache that might have been also present. Compared to those without TMD, patients with myofascial type of TMD were more likely to have chronic daily headaches, migraines and tension-type headaches. The more severe was TMD pain, the more likely it was that these headache conditions were present. An important question which is not answered by this study is, what comes first - TMD or headaches? It is likely that having one condition can cause and make the other worse, forming a vicious cycle. I see patients who can clearly identify that they first developed pain in the jaw and then headaches came along, but treating only their TMD does not seem to help. There are many more patients who present with headaches as the main complaint but who also have TMD. The treatment should always be directed at both conditions and many treatments we use have been shown to be effective for people with only TMD or only headaches. These treatments include regular aerobic exercise, biofeedback, acupuncture, Botox injections, massage, and medications. The list of medications include NSAIDs, such as aspirin (or Migralex), Advil, and Aleve, antidepressants, such as Elavil, Pamelor, and Cymbalta, epilepsy drugs, such... --- ### Warnings about Topamax (topiramate) - Published: 2011-03-04 - Modified: 2011-03-04 - URL: https://www.nyheadache.com/blog/warnings-about-topamax-topiramate/ - Categories: Headache medications Topiramate (Topamax) increases the risk of birth defects, such as cleft lip and palate, warned the Food and Drug Administration (FDA). Topiramate is an epilepsy drug which is also approved for the preventive treatment of migraine headaches. It is a very popular drug, in part because it can cause weight loss in some patients. In clinical trials only half of migraine patients who started taking this drug remained on it for more than a few months because it was ineffective for some and caused intolerable side effects in others. One of the main side effects which makes people stop taking this drug is difficulty speaking and thinking. Topiramate is also known to cause kidney stones and the initial data suggested that less than 1% of patients taking it developed kidney stones. However, a recent report suggested that up to 20% of people taking topiramate for a period of two years will develop kidney stones. Half of the patients who developed kidney stones were not aware of it. Kidneys stones not only can be very painful, but in severe cases can impair kidney function. These two newly discovered dangers are additional reasons to avoid taking topiramate and if possible, to avoid taking any medications. While we do prescribe many medications, including topiramate, we always begin with life style modification (diet, sleep, exercise), biofeedback or meditation, magnesium, CoQ10, and other supplements, acupuncture, and Botox injections. --- ### Migraine prevention is most effective when drug and behavioral management are combined - Published: 2011-02-23 - Modified: 2011-02-23 - URL: https://www.nyheadache.com/blog/migraine-prevention-is-most-effective-when-drug-and-behavioral-management-are-combined/ - Categories: Alternative Therapies Migraine prevention is most effective when a preventive medication and behavioral management are combined together. A study by Dr. Holroyd and his colleagues published in the British Medical Journal showed that a beta blocker alone and behavioral management alone did not help patients with migraine headaches. However, combining these two resulted in a significant improvement. This was a very rigorous trial involving 232 patients who were divided into 4 groups: behavioral management alone (with a placebo pill), beta blocker alone, both interventions, and no intervention group (they did receive placebo pills). Patients and doctors did not know which patient received a beta blocker or placebo. Every patients was seen every month for four months and had 3 telephone calls in these four months. During each visit the behavioral management group received one hour of training. All patients were given optimal acute therapy with a triptan and if needed, ibuprofen and a nausea medication. All patients were evaluated 10 and 16 months later and the combined group was improved compared to the other 3 groups both in the number of attacks, number of migraine days, and in the quality of life. This confirms the validity of our usual practice of combining several approaches at once rather than trying one at a time. The list of our typical recommendations includes combination of several of these options: avoidance of caffeine, aerobic exercise, behavioral management, magnesium and other supplements, Botox injections, non-prescription medications, such as ibuprofen, naproxen, and Migralex, as well as triptans and... --- ### Announcement of Body-Mind Self-Care Program - Published: 2011-02-09 - Modified: 2011-02-09 - URL: https://www.nyheadache.com/blog/announcement-of-body-mind-self-care-program/ - Categories: Alternative Therapies - Tags: body-mind, coaching, mind-body, self-care Body–Mind, Self-Care Program: Everything you do – eat, drink, sleep, move, sit, stand, think, feel, interact – adds up to how you feel and function. In a body-mind program, as with one for diet or exercise, by changing your daily practices, you will get a different result. Headache Coach Jan Mundo will guide you to wellness and help you overcome your pain. Lessons, accompanied by handouts, individualized coaching, and assessments, include: tracking your triggers, headache-healthy diet, stress relief, and harnessing the power of your body and mind for healing. The New York Headache Center, located at 30 East 76th Street, New York, NY generously offered its space for this program to be held weekly from March 8 until April 12, 2011, at 6 - 8:15 pm. For more information see Jan Mundo's site --- ### Mixing triptans - Published: 2011-02-04 - Modified: 2011-02-04 - URL: https://www.nyheadache.com/blog/mixing-triptans/ - Categories: New treatments Taking two different triptans (drugs such as Imitrex, or sumatriptan, Maxalt, or rizatriptan and other) within 24 hours of each other is contraindicated according to the FDA. However, there is no scientific reason for such prohibition. You are allowed to take a second dose of the same triptan 2 hours after the first dose, so it makes no sense why you could not take a different one. Most of the triptans (five out of seven) get washed out from the body within 2 - 3 hours, so even if there was an interaction between different triptans (and there is absolutely no evidence for that) it would be safe to give a different one 3 hours later. A report in the latest issue of the journal Headache by Dr. Rothrock studied 200 patients who "mixed triptans", that is took a shot of sumatriptan and two hours before or after a tablet of either rizatriptan (Maxalt, zolmitriptan (Zomig), almotriptan (Axert), or eletriptan (Relpax). He found that not only there were no problems, patients were highly satisfied with this approach. I also hear from my patients that sometimes they know that one tablet of a triptan will not be enough for their severe attack and they will take two at once. Many doctors strongly advise their patients against it, but there is no evidence of any great danger from a higher dose. These dosages were arrived at by looking for an optimal dose which provides good relief and few side effects and for... --- ### Botox helps headaches, makes you happier - Published: 2011-02-04 - Modified: 2011-02-04 - URL: https://www.nyheadache.com/blog/botox-helps-headaches-makes-you-happier/ - Categories: New treatments, Pain Research Botox is now approved for chronic migraine headaches. However, it may help you feel happier not only because your headaches improved. Several studies suggest that the inability to frown caused by Botox makes people happier too. Psychologists at the University of Cardiff in Wales showed that healthy people (not headache sufferers) who had cosmetic Botox injections were happier and less anxious than those who hadn't. Another study published in the Journal of Pain showed that people who grimaced during a painful procedure felt more pain than people who did not. In an experiment by German researchers, healthy people were asked to make an angry face while their brains were being scanned by a functional MRI. Those who received Botox injections had much less activation in areas of the brain that process emotions than those who had no injections. My patients who receive Botox for headaches also report that because they cannot make an angry face they feel less angry. We need a large study of the effect of Botox injections on the mood, so that if this finding is confirmed, Botox can be recommend for the treatment of mood disorders. --- ### Melatonin does not help prevent migraines - Published: 2010-12-28 - Modified: 2010-12-28 - URL: https://www.nyheadache.com/blog/melatonin-does-not-help-prevent-migraines/ - Categories: New treatments - Tags: cluster, headache, insomnia, jet lag, melatonin, migraine Melatonin does not seem to be effective for the prevention of migraine headaches, according to a study published in Neurology. The researchers from Norway gave 2 mg of extended release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo and neither the doctors nor the patients knew whether the first treatment was with melatonin or placebo (so called double-blind crossover trial). Migraine frequency did improve from an average of 4. 2 a month to 2. 8, but the same results were observed while on melatonin as on placebo. This study confirms a well established observation that taking a placebo helps, or perhaps that what helps is just keeping track of your headaches and seeing a medical provider on a regular basis. One argument against the validity of the study is that the dose of melatonin might have been too low because one small trial of 10 mg of melatonin in cluster headache sufferers did show benefit. Another possibility is that the dose was too high. There is a study that suggests that taking 0. 3 mg (or 300 mcg) helps insomnia, while 3 mg does not. Anecdotally, I find that for me and many of my patients 0. 3 mg works better for insomnia and jet lag than 3 mg. --- ### How does Botox help headaches? - Published: 2010-12-07 - Modified: 2010-12-07 - URL: https://www.nyheadache.com/blog/how-does-botox-help-headaches/ - Categories: New treatments - Tags: Botox, botulinum toxin, chronic, migraine Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by relaxing tight muscles around the scalp.   However, several recent studies determined that besides relaxing muscles, Botox also stops the release of several neurotransmitters from the nerve endings.   These neurotransmitters are released by messages sent from the brain centers that trigger a migraine attack.   In turn the released neurotransmitters send pain messages back to the brain completing a vicious self-sustaining cycle.   A meticulous study just published in the journal Pain by Danish researcher confirmed that injections of Botox stop the release of neurotransmitters and reduce sensitivity of rat's chewing muscles.   Not knowing the exact way how Botox works makes many doctors skeptical about its efficacy.   However, we have no idea how preventive medications, such as beta blockers, antidepressants and epilepsy drugs prevent headaches either.   These drugs, like Botox, were also discovered to help headaches by accident.   This does not and should not stop us from using them.   Botox is more effective and safer than medications taken by mouth and is an excellent option for over 3 million Americans who suffer from chronic migraines. --- ### Intranasal sumatriptan powder - Published: 2010-10-23 - Modified: 2010-10-23 - URL: https://www.nyheadache.com/blog/intranasal-sumatriptan-powder/ - Categories: New treatments - Tags: Imitrex, nasal, powder, sumatriptan Intranasal sumatriptan powder seems to be a new and very promising way to deliver a migraine drug.   Sumatriptan (Imitrex) nasal spray has been available for many years, however it is not very effective or at least is not consistently effective.   The liquid tends to leak out of the nose, get swallowed, or just not get absorbed.   Nasal spray of Zomig (zolmitriptan) appears to be more effective, perhaps because of the smaller volume of the liquid and a finer spray particles.   The new product, OptiNose nasal powder seems to be even more effective.   It is a sophisticated device which does not allow for the powder to enter the lungs and deposits the medicine only in the nasal cavity.   In a study of 117 patients, 57% were pain-free and 80% had pain relief 2 hours after receiving 20 mg of sumatriptan powder, which was very significantly better than with placebo.   The nasal powder seems to be three times more effective than the nasal spray and almost as effective as an injection.   We hope that the FDA will approve this product in the near future. --- ### Even a brief course of CBT improves TMD treatment outcomes - Published: 2010-10-17 - Modified: 2010-10-17 - URL: https://www.nyheadache.com/blog/even-a-brief-course-of-cbt-improves-tmd-treatment-outcomes/ - Categories: TMJ Temporo-mandibular joint dysfunction (TMD) treated with a brief course of cognitive-behavioral therapy (CBT) in addition to standard care improves long-term outcomes, according to a new study published in journal Pain.   A group of 101 patients who had pain in TMJ for at least 3 months were included in this study. Standard treatment included splinting, soft diet and an anti-inflammatory drug and was given to all patients. Fifty two patients also received six weekly sessions of cognitive-behavioral therapy. Both those who received standard therapy alone and those who also received CBT improved, however addition of CBT provided additional pain relief, particularly in those people who were open to it and prepared to use it. --- ### Botox is approved for chronic migraines - Published: 2010-10-15 - Modified: 2010-10-16 - URL: https://www.nyheadache.com/blog/botox-is-approved-for-chronic-migraines/ - Categories: New treatments - Tags: Botox, botulinum toxin, chronic, migraine Botox was just approved by the FDA for the treatment of chronic migraine headaches.   This is great news to the more than 3 million chronic headache sufferers in the US (people who have more than 15 days with headaches each month).   In Dr. Mauskop's opinion Botox is one of the most effective treatments for frequent and severe headaches and it is the first treatment approved FDA for chronic migraines. Dr. Mauskop was one of the first headache specialists to begin using this treatment more than 15 years ago. He has published several scientific articles and book chapters on the use of Botox for headaches. His most recent chapter on Botox for headaches was just published a month ago in the 97th volume of the Handbook of Neurology (Elsevier).   Dr. Mauskop has trained over 200 doctors from all across the US, Canada and Europe who traveled to the New York Headache Center to learn this technique.   Initial reports of the use of Botox for headaches were met with disbelief, while strong skepticism about the efficacy of this treatment persisted for many years. The main reason for this skepticism was the fact that migraine headaches are known to originate in the brain, while Botox affects only muscles and nerves on the outside of the skull. A large amount of research led to our current understanding of how Botox works: while the brain begins the headache process, it requires feedback from nerves and muscles on the surface of the... --- ### New motion sickness treatment for migraineurs - Published: 2010-09-24 - Modified: 2010-09-24 - URL: https://www.nyheadache.com/blog/new-motion-sickness-treatment-for-migraineurs/ - Categories: New treatments - Tags: eletriptan, Imitrex, maxalt, migraine, motion sickness, relpax, rizatriptan, sumatriptan, triptan, vertigo A new treatment for motion sickness in patients with migraines was reported by a group of doctors from Pittsburgh.   Giving migraine sufferers who are prone to motion sickness a migraine drug, rizatriptan (Maxalt) prevented motion sickness . There were 25 subjects in the study and 15 of them developed motion sickness after being rotated in the darkness. Of these 15 patients, 13 showed decreased motion sickness after being pretreated with rizatriptan. This was a small study and not all patients benefited, but this is an option that should be considered in patients who suffer from severe motion sickness.   It is likely that the effect is not specific to rizatriptan, but that sumatriptan (Imitrex), eletriptan (Relpax) and other triptans are also effective.   However, just like when treating migraine attacks, it is possible that some patients will respond better to one triptan and others to another. --- ### Headache coach - Published: 2010-09-19 - Modified: 2010-09-19 - URL: https://www.nyheadache.com/blog/headache-coach/ - Categories: Alternative Therapies Headache coach, Jan Mundo will be conducting classes at the New York Headache Center (this is a second announcement).    The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27.   Jan's course is "for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies. "  For details and registration go to http://www. mundolifework. com.   Facebook page:  http://www. facebook. com/pages/The-Headache-Coach/72585407316? v=app_2344061033#! /event. php? eid=102475893145453&index=1. . --- ### Aspirin is as good as sumatriptan (Imitrex) with fewer side effects - Published: 2010-09-04 - Modified: 2010-09-04 - URL: https://www.nyheadache.com/blog/aspirin-is-as-good-as-sumatriptan-imitrex-with-fewer-side-effects/ - Categories: Science of Migraine - Tags: aspirin, cochrane, metoclopramide, migraine, naproxen, review Aspirin is as effective as Imitrex (sumatriptan) in the treatment of migraine headaches with fewer side effects, according to an authoritative Cochrane review published earlier this year.   The review examined 13 high-quality studies which involved 4,222 patients.   Having such a large number of patients in well-conducted studies makes the data highly reliable.   Some of the studies utilized 900 mg of aspirin and some 1,000 mg, some with and some without a nausea medicine, metoclopramide (Reglan).   Aspirin was compared to both Imitrex, 50 or 100 mg and placebo.   The authors concluded that “there are no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use are mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin. ” In a previous post I mentioned the review of 16 studies of naproxen sodium (Aleve) for the treatment of migraines.  That review found that aspirin was more effective for the treatment of migraines than naproxen sodium (Aleve).  So far, aspirin seems to be the best drug for the initial treatment of migraine headaches.  However, there are many sufferers with severe migraines who do not respond to aspirin and there is a clear need for prescription drugs, such as Imitrex, although they do have a higher risk of side effects.  New migraine drugs are being developed with the goal of reducing the incidence of side effects, while improving their... --- ### Vertigo as a menopausal migraine - Published: 2010-09-04 - Modified: 2010-09-04 - URL: https://www.nyheadache.com/blog/vertigo-as-a-menopausal-migraine/ - Categories: Science of Migraine Vertigo and dizziness are common in migraine sufferers.   It is much less common for vertigo to be the only symptom of migraines.   This seems to be the case with vertigo that begin at menopause, according to a recent report presented at the last meeting of American Academy of Neurology.   The report describes symptoms in 12 women, so its conclusions cannot be accepted as definitive.   All of the women had history of menstrual migraines and all had a normal ear-nose-throat examination and a normal MRI scans.   They all suffered from vertigo for at least a year.   Treatment with standard migraine medications and hormonal therapy reduced attacks of vertigo by 50% and was more effective than non-hormonal treatment alone.   It is not surprising that the hormonal therapy helped because some women with menstrual attacks also improve with hormonal therapy, such as continuous contraception.   This report should raise awareness of the fact that menopausal women with vertigo may be suffering from migraines and may respond to hormonal and migraine therapies. --- ### Headache Coach, Jan Mundo - Published: 2010-08-16 - Modified: 2010-08-16 - URL: https://www.nyheadache.com/blog/headache-coach-jan-mundo/ - Categories: Alternative Therapies Headache coach, Jan Mundo will be conducting classes at the New York Headache Center.    The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27.   Jan's course is "for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies. "  For details and registration go to http://www. mundolifework. com. --- ### Medication overuse headaches - Published: 2010-08-11 - Modified: 2010-08-11 - URL: https://www.nyheadache.com/blog/medication-overuse-headaches/ - Categories: New treatments Medication overuse (rebound) headache (MOH) has been the subject of many studies and reports.   Another review of this subject appeared in the latest issue of journal Pain by Italian neurologists. This review addressed possible causes, predisposing factors, and possible treatments. The list of possible drugs which can lead to overuse headaches included in this article includes every possible headache medicine. However, the authors do not mention that for some drugs there is more scientific evidence than for other. For example, only caffeine and opioid (narcotic) analgesics have been proven to cause MOH, while drugs such as aspirin may actually prevent the development of MOH. There is only anecdotal (case reports) evidence for triptans (sumatriptan, or Imitrex, rizatriptan, or Maxalt, and other). The authors suggest that both environmental and genetic factors may contribute to patient's vulnerability to substance overuse, dependence, and withdrawal in MOH. They also think that psychological comorbidities such as depression, anxiety and poor pain coping abilities may contribute to chronification of headaches. The authors report on different detox strategies, including the need for hospital admission for patients taking large doses of narcotics or barbiturates (such as butalbital, found in Fioricet, Fiorinal, Esgic). However, almost all patients seen at the New York Headache Center are successfully withdrawn on an out-patient basis. Many patients fear worsening of pain from medication withdrawal, but several treatments can make the process less painful. Botox injections, intravenous infusions of magnesium, topiramate (Topamax), gabapentin (Neurontin) and a short course of steroids are some of... --- ### Food allergies in migraine - Published: 2010-08-03 - Modified: 2010-08-03 - URL: https://www.nyheadache.com/blog/food-allergies-in-migraine/ - Categories: Alternative Therapies Many migraine sufferers feel that food allergies cause their headaches.   There is little dispute that certain foods can trigger migraines.   Some of these foods include chocolate, wine, cheese, citrus fruit, onions, smoked, cured, and pickled foods.   However, migraine that results from eating these foods is not due to an allergic reaction, but rather is due to a chemical reaction.   An allergic reaction occurs when the body's immune defense mechanisms try to isolate and attack an offending substance, called an allergen.   It is possible to evaluate this immune response by measuring blood levels of immune globuline (IgG) which is specific to to a particular food or substance.   Since there are so many different foods that we eat, literally hundreds of tests are required.   Doing such extensive testing has been controversial, in part because of its high cost.   This testing has been advocated for patients with irritable bowel syndrome.   People who are found to have high levels of of IgG to certain foods can improve their condition by eliminating those foods.   Another way to detect food allergies is by scratch test, where an extract of different foods is placed into skin scratches and then the skin reaction is measured. A sophisticated study recently published in Cephalalgia by Dr. Ertas and his colleagues looked at food allergies in migraine patients.   They tested IgG levels to 266 foods in the blood of 30 migraine sufferers.   The number of foods these 30 patients... --- ### Book on refractory migraines published. - Published: 2010-07-18 - Modified: 2010-07-18 - URL: https://www.nyheadache.com/blog/book-on-refractory-migraines-published/ - Categories: Science of Migraine - Tags: acupuncture, biofeedback, Botox, daily headaches, magnesium, migraine, refractory There are over 4 million chronic migraine sufferers in the US.   Chronic migraine is defined as a headache with migrainous features, which occurs on more than 15 days each month.   Many of these chronic migraine patients we see at the New York Headache Center have daily headaches.   By the time they come to our Center, many have seen several doctors, including neurologists and found no relief from a variety of drugs.   A new book just published by Oxford University Press may help doctors who care for headache patients to provide better care.   The book is Refractory Migraine, Mechanisms and Management.   Dr. Mauskop and Dr. Sun-Edelstein contributed a chapter to this book: Nonpharmacological Treatment for Refractory Migraine: Acupuncture, Vitamins and Minerals and Lifestyle Modifications.   An important message contained in the chapter and the one we always stress to our patients is that the best way to approach a refractory headache is not by trying one drug after another, but by combining drugs with nonpharmacological treatments, such as biofeedback, magnesium, other supplements, Botox injections, acupuncture and other therapies. --- ### Another epilepsy drug may work for headaches - Published: 2010-07-05 - Modified: 2010-07-05 - URL: https://www.nyheadache.com/blog/another-epilepsy-drug-may-work-for-headaches/ - Categories: New treatments, Uncategorized Many, but not all epilepsy drugs are also effective in preventing migraine headaches.    For example, divalproex sodium (Depakote), topiramate (Topamax), and to a lesser degree gabapentin (Neurontin), pregabalin (Lyrica), and levetiracetam (Keppra) relieve migraine headaches, while other epilepsy drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol)  do not.   A report by Drs. Krusz at the annual meeting of the American Headache Society held last month suggests that a new epilepsy drug, lacosamide (Vimpat) may also be effective for the treatment of headaches.   Dr. Krusz treated 22 patients with chronic migraines  (patients who had more than 15 headache days each month) with this medication and discovered that on average the monthly number of headaches dropped from 21 to 13.   Side effects, such as drowsiness, nausea, and cognitive impairment lead 4 patients to stop the drug.   Despite very impressive results it is premature to declare lacosamide an effective headache treatment because the study was very small and not placebo-controlled. --- ### New prescription migraine drug (actually an old, repackaged one) - Published: 2010-06-30 - Modified: 2010-06-30 - URL: https://www.nyheadache.com/blog/new-prescription-migraine-drug-actually-an-old-repackaged-one/ - Categories: New treatments - Tags: aspirin, diclofenac, migraine, nsaid Aspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers.   In a recent report 1,000 mg of aspirin was found to be as effective as 100 mg of sumatriptan (Imitrex) with fewer side effects.   Cambia is a new prescription drug, which was recently approved by the FDA specifically for the treatment of migraine headaches.   The active ingredient in this drug is diclofenac, which is also sold under Voltaren and Cataflam names.   But unlike other forms of diclofenac, Cambia is a powder which patients are supposed to dissolve in a glass of water and drink it.   Drinking a solution rather than swallowing a pill speeds absorption of the drug, which can make a difference for those migraine sufferers who need to catch their attacks early, or drugs don't help.   The drug has a "black box" warning, which cautions about possible cardiovascular side effects, as well as gastro-intestinal side effects, including bleeding and ulcers.   The cardiovascular side effects of diclofenac are similar to those of Vioxx which was taken off the market.   Other NSAIDs also carry risk of cardiovascular (and GI) side effects, but their risk is lower.   The only NSAID without cardiovascular risks is aspirin.   In fact it is used to prevent strokes and heart attacks.   Aspirin is also the only drug which prevents the development of rebound headaches - worsening of headaches from frequent intake of a headache medicines or caffeine. --- ### Genetic research in medication overuse headaches - Published: 2010-06-16 - Modified: 2010-06-16 - URL: https://www.nyheadache.com/blog/genetic-research-in-medication-overuse-headaches/ - Categories: New treatments - Tags: Botox, caffeine, genomics, medication overuse, moh Medication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin and Percocet) or dietary caffeine.   About half of the people who stop taking these drugs improve, while the other half does not.   A recent study by Dr. Andrew Hershey and his colleagues at the University of Cincinnati suggests that by doing genomic analysis of the blood we may be able to predict who is going to improve by withdrawing overused medication and who is not. This does not mean that the latter group is going to be left to suffer. However, this test could save a major effort that is involved in getting someone off medications. Instead these patients can be maintained on their medication while other preventive treatments are tried. These treatments can include biofeedback, magnesium infusions, Botox injections, prophylactic drugs, acupuncture, CoQ10, butterbur, and other treatments. --- ### Sumatriptan (Imitrex) suppositories - Published: 2010-06-12 - Modified: 2010-06-12 - URL: https://www.nyheadache.com/blog/sumatriptan-imitrex-suppositories/ - Categories: New treatments - Tags: Imitrex, Levadex, migraine, sumatriptan, suppository, Zomig Severe migraines are often accompanied by nausea and vomiting, making oral medications ineffective.   Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently).   Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex).   Injections work fast, but are painful (even the needleless injection hurts) and expensive.   Another way to get medicine into the body is rectally.   Rectal suppositories are absorbed very quickly and more consistently than nasal sprays.   Europeans are much more receptive to this route of administration than the Americans.   A group of Italian researchers compared  the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet.   The suppository was slightly more effective than the tablet.   Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order.   With Imitrex going generic, the price should be more affordable. There are two other products in development (not yet available), which will bypass oral route - a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex).   The patch is somewhat large and may be awkward to use, while the inhaler is much more promising.   Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex.   According to the published data... --- ### Depression and anxiety and response to sumatriptan - Published: 2010-06-02 - Modified: 2010-06-02 - URL: https://www.nyheadache.com/blog/depression-and-anxiety-and-response-to-sumatriptan/ - Categories: Science of Migraine Migraine sufferers are 2 - 3 times more likely to become depressed or anxious than those without migraines.   The reverse is also true - depressed and anxious people are 2 -3 times more likely to develop migraines.   According to a new study published in the journal Cephalalgia, being depressed or anxious does not prevent migraine drugs from working.   The Greek researchers gave participants in the study sumatriptan (Imitrex), 50 mg for 3 attacks, and placebo, for another 3 attacks, without the doctors or the patients knowing what they were getting for any particular migraine attack.   Presence of anxiety or depression did not have an impact on weather after taking sumatriptan the headache returned within 24 hours or not.   Unfortunately, many physicians dismiss patients with migraine headaches as neurotics and hypochondriacs and the presence of anxiety or depression makes this bias even stronger.   These doctors tend not to prescribe effective migraine drugs, which leads to unnecessary suffering.   It is true that for some patients 1,000 mg of aspirin can be as effective as 50 or even 100 mg of sumatriptan with fewer side effects, but when aspirin is ineffective, sumatriptan or another drug in the triptan family should be used.   One surprising detail of this study is that the researchers used 50 mg of sumatriptan, and not 100 mg, which should be the usual starting dose for most patients. --- ### Occipital nerve block for an acute migraine - Published: 2010-05-30 - Modified: 2010-05-30 - URL: https://www.nyheadache.com/blog/occipital-nerve-block-for-an-acute-migraine/ - Categories: New treatments Occipital nerve blocks can stop a migraine attack when other treatments fail.   This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides.   There are two branches of the nerve - greater and lesser occipital nerves and I usually inject both.   The block can help even if the headache is not strictly localized to the back of the head.   In some people headache returns after a few hours, once the effect of the local anesthetic wears off.   However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache.    Adding steroid medication to the local anesthetic does not seem to improve outcome.   However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches. Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient. --- ### Aspirin is more effective for migraine than naproxen sodium (Aleve) - Published: 2010-05-15 - Modified: 2010-05-15 - URL: https://www.nyheadache.com/blog/aspirin-is-more-effective-for-migraine-than-naproxen-sodium-aleve/ - Categories: New treatments Review of 16 published scientific articles on the efficacy of naproxen sodium as a treatment of acute migraine indicates that it is effective in the treatment of moderate to severe migraines. Naproxen sodium, 500 mg (2 tablets of Aleve) provided some relief after 2 hours to 45% of patients, complete pain relief to 17% and complete relief after 24 hours to 11%. Aspirin, 1,000 mg (2 extra-strength tablets) has been shown to do better, providing 52%, 27% and 24% of relief, respectively. Both naproxen sodium and aspirin relieve all of the migraine symptoms, including pain, nausea, sensitivity to light and noise. --- ### Use of tranqulizers for refractory migraine headaches - Published: 2010-04-10 - Modified: 2010-04-10 - URL: https://www.nyheadache.com/blog/use-of-tranqulizers-for-refractory-migraine-headaches/ - Categories: New treatments Anxiety and depression occur in migraine patients 2 to 3 times more often than in those without headaches.   The opposite is also true, those with anxiety and depression are more likely to develop migraines.   Certain antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), venlafaxine (Effexor), and duloxetine (Cymbalta) have been shown to help prevent headaches.   However, when an antidepressant (or any other drug) is being tested for the prevention of headaches, patients with depression and anxiety are usually excluded.   This is done to clearly establish if a drug works to prevent headaches directly, rather than indirectly through relieving anxiety and depression.   There have been no studies of drugs to treat people who have both conditions.   A report by Dr. Morris Meizels published in the current issue of Headache presents cases of three patients with severe migraines and anxiety who did not respond to the usual preventive medications.   They did respond very well when he prescribed clonazepam (Klonopin), which is a tranquilizer in the family of benzodiazepines.   Diazepam (Valium) and alprazolam (Xanax) are two other well-known members of that family, but they all have somewhat different clinical properties.   Dr. Meizels stresses the fact that these drugs are potentially addictive and habituating and should be used in carefully selected patients and under close supervision. --- ### Combination therapies for difficult migraines - Published: 2010-04-05 - Modified: 2010-04-05 - URL: https://www.nyheadache.com/blog/combination-therapies-for-difficult-migraines/ - Categories: Uncategorized 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. --- ### More on migraines and vertigo - Published: 2010-04-05 - Modified: 2010-04-05 - URL: https://www.nyheadache.com/blog/more-on-migraines-and-vertigo/ - Categories: Science of Migraine - Tags: migraine, vertigo, vestibular Vertigo is a common complaint of migraine patients.   Ear-nose-throat specialists at the University of Pisa examined 22 patients with migraine headaches who complained of vertigo and 22 who did not, as well as 22 control subjects without migraines.   They found that in both groups of patients with migraines a third had abnormal vestibular function on laboratory testing.   In half of the patients in both groups the abnormality was in the inner ear (peripheral dysfunction) and in half in the brain (central dysfunction).   This study confirms that both central and peripheral vertigo are common in migraine patients, whether they complain of vertigo or not.   The most important question patients ask is what can we do about it.   Fortunately, once migraines are brought under control, vertigo also subsides. --- ### Headaches due to fast heart rate on standing - Published: 2010-04-05 - Modified: 2010-04-05 - URL: https://www.nyheadache.com/blog/headaches-due-to-fast-heart-rate-on-standing/ - Categories: Uncategorized Many 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). --- ### Nerve stimulation for cluster headaches - Published: 2010-03-25 - Modified: 2010-03-25 - URL: https://www.nyheadache.com/blog/nerve-stimulation-for-cluster-headaches/ - Categories: New treatments Occipital nerve stimulation has been under investigation for the treatment of difficult to treat migraine headaches for the past several years with promising results.  A recent study at the Mayo Clinic in Scottsdale, AZ suggests that this treatment may also help relieve chronic cluster headaches.  It is less surprising that the occipital nerve stimulation works for cluster headaches than for migraines.  It is not unusual for cluster headache patients to complain of pain not only in the eye, but also in the back of the head on the same side.  Also, occipital nerve block with steroids has been shown to abort an episode of episodic cluster headaches and is widely used by headache specialists.  In chronic cluster patients this block may provide temporary relief and these patients may be good candidates for an occipital nerve stimulation.  The stimulator is usually implanted by a neurosurgeon in an out-patient procedure.  The wire electrode and the battery are embedded under the skin.  Another miniature stimulator which has been in development contains both the electrode and the battery in a very small capsule-size device.  This miniature stimulator is much easier to implant and it is less bothersome.            --- ### Two large studies confirm that Botox is effective for chronic migraine - Published: 2010-03-19 - Modified: 2013-05-13 - URL: https://www.nyheadache.com/blog/two-large-studies-confirm-that-botox-is-effective-for-chronic-migraine/ - Categories: New treatments - Tags: Botox, chronic botulinum toxin, migraine, onabotulinumtoxinA It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that Botox is effective for chronic migraine headaches.   More than 15 years ago a plastic surgeon in California, Bill Binder reported that many of his patients treated with Botox for wrinkles found relief from headaches.   Everyone was very skeptical, but having many patients who failed every other treatment and having learned that Botox is very safe if used properly, I decided to try it.   To my great surprise Botox worked exceptionally well.   My most dramatic experience was in a 76-year-old woman who suffered from daily headaches for 60 years.   She had failed a long list of medications, nerve blocks, acupuncture and other treatments.   After the first Botox treatment, for the first time in 60 years she went for three months without a single headache.   Her neurologist came to my office to learn the technique I developed and has been using Botox in his practice ever since.   More than 200 doctors from around the world came to our Center to learn how to use Botox for headaches.   They were all searching for new treatments for their desperate patients.   At the same time most of the medical community had remained very skeptical and dismissive of this approach.   They could not believe that Botox could help headaches and wanted to see double-blind, placebo-controlled trials before using it in their patients.   Well, now... --- ### Migraine, strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol are linked - Published: 2010-02-23 - Modified: 2010-02-23 - URL: https://www.nyheadache.com/blog/migraine-strokes-heart-attacks-hypertension-poor-circulation-diabetes-and-high-cholesterol-are-linked/ - Categories: Science of Migraine - Tags: aura, diabetes, heart attack, high cholesterol, hypertension, migraine, stroke A recent study by Dr. Bigal and his colleagues just published in Neurology compared more than 6,000 migraine sufferers with over 5,000 matched control subjects without migraines.    They discovered that people with migraine with aura and to a lesser extent those with migraine without aura are significantly more likely to have strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol.   This clearly does not mean that migraine causes all these diseases, but only that if you have one you are more likely to have the other.   It is important to recognize this association in migraine sufferers in order to regularly screen them for these conditions.   We know that controlling diabetes, high blood pressure, and high cholesterol can prevent strokes, heart attacks and poor circulation in extremities.   We also recommend that women who have migraine with aura should not take estrogen-based oral contraceptives or hormone replacement therapy since estrogen in these women also increases the risk of strokes.   All migraine suffererss (and everyone else) should not smoke and exercise regularly, which also reduces the risk of the conditions mentioned above. --- ### Treatment of a very severe headache - Published: 2010-02-12 - Modified: 2010-02-12 - URL: https://www.nyheadache.com/blog/treatment-of-a-very-severe-headache/ - Categories: New treatments - Tags: magnesium, migraine, severe headache, steroid, sumatriptan Some headaches, usually migraines, do not respond to the usual over-the-counter and even prescription headache medications.   Once it is clear that there is no serious underlying cause, such as an aneurysm, several injectable medications can be given in an emergency room (during office hours at the New York Headache Center we also give injections in the office). These medicines may include intravenous injections of: magnesium sulfate (which is not a medication, but a mineral), sumatriptan (Imitrex, which can be self-injected by patients at home), ketorolac (or it is also called Toradol, which is a drug in the aspirin family), dexamethasone (Decadron, a steroid drug, which can help pain of almost any type, but cannot be given for long periods of time), prochlorperazine (or Compazine, which is a nausea medication but can help pain as well), valproate sodium (Depacon), and several other drugs. --- ### Triptans appear to be safe in pregnancy - Published: 2010-02-07 - Modified: 2010-02-07 - URL: https://www.nyheadache.com/blog/triptans-appear-to-be-safe-in-pregnancy/ - Categories: Science of Migraine - Tags: Imitrex, maxalt, migraine, pregnancy, rizatriptan, sumpatriptan, trimester, triptans During pregnancy, two thirds of women stop having migraine headaches.   However, one third continues to have them, and sometimes even worsen during pregnancy.    As a general rule, only acetaminophen (Tylenol) is considered safe, but for most migraine sufferers it is completely ineffective.   Codeine is also benign, but it also either does not work or causes side effects, such as nausea and sedation.   Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other are very effective for migraines, but are not proven to be as safe.   Pregnancy registries in the US have information on over 1,500 women who took a triptan during pregnancy and so far the drugs look safe for the baby.   A new study from Norway in the February issue of Headache reports on another 1,535 women who took triptans during pregnancy and compared them to 68,000 women who did not.   This study also found no increased risk of congenital malformation, even if triptans were taken in the first trimester.   Women who took triptans in the second and third trimester also had healthy babies, but they had a slightly increased risk of atonic uterus and bleeding during labor. --- ### Preventive treatment of migraines is underutilized - Published: 2010-02-05 - Modified: 2010-02-05 - URL: https://www.nyheadache.com/blog/preventive-treatment-of-migraines-is-underutilized/ - Categories: New treatments - Tags: Botox, medications, migraine, preventive, prophylactic There are several effective preventive medications for migraine headaches, however they are prescribed to only a small number of people who could benefit from them.   A study by Dr. Richard Lipton in the journal Cephalagia and his colleagues discovered that only 13% of migraine sufferers are taking preventive medications, but those who do have significantly less disability than those who don't. Among possible reasons, doctors who don't realize how disabling migraines are, patients how think that medications are dangerous or will cause side effects. Cost does not seem to be a factor because all patients in this study had insurance and most of these medications are inexpensive. Patients are often reluctant to take medications, but would rather find and remove the cause. Unfortunately, in most cases migraine is a genetic disorder and true cure is not possible. However, for most migraine sufferers it is possible to find and remove triggers which make headaches worse. If this is not sufficient, magnesium, CoQ10, other supplements, biofeedback, Botox injections, and regular exercise can provide relief without drugs. If all this still does not provide relief, medications, such as anti-depressants, epilepsy drugs, and high blood pressure drugs can be very effective and improve the quality of life. --- ### Participate in clinical trials! - Published: 2010-02-03 - Modified: 2010-02-03 - URL: https://www.nyheadache.com/blog/participate-in-clinical-trials/ - Categories: New treatments - Tags: clinical trials, research, studies Large clinical trials are required to prove that a new drug or treatment is effective.   Without such proof doctors will not (and should not) believe that any particular medicine or device is effective.   The FDA also approves drugs by evaluating results of large trials, usually involving hundreds if not thousands of participants.   If you want to help these new treatments to become available you should consider participating in such study.   In addition to feeling good about helping science and possibly your descendants, you may also benefit from a free evaluation and treatment.   Of course, there are risks associated with new treatments and the researchers are required to explain them to you in great detail. One of the reasons for this post is to let you know about a new website which makes finding a clinical trial very easy.    You can search these trials by disease, location, and other criteria.   The site is http://www. medpedia. com/clinical-trials.   Check it out. --- ### Migraine and cognitive decline - Published: 2010-01-27 - Modified: 2010-01-27 - URL: https://www.nyheadache.com/blog/migraine-and-cognitive-decline/ - Categories: Science of Migraine - Tags: cognitive decline, headache, migraine, migraine medication Migraine and migraine medications do not appear to cause cognitive decline, according to a Dutch study just published in Headache.   After 6 years of follow-up there was no difference between those who suffered from migraines and healthy controls.   Taking migraine medications also did not have an effect on cognitive function.   This is very reassuring, especially because a recent study in rats suggested brain damage from what the researchers felt was a process similar to migraine. --- ### Blood pressure drugs for migraine headaches - Published: 2010-01-27 - Modified: 2010-01-27 - URL: https://www.nyheadache.com/blog/blood-pressure-drugs-for-migraine-headaches/ - Categories: New treatments - Tags: atacand, blood pressure, lisinopril, migraine, prevention, prophylaxis One of the oldest preventive headache medications for migraines is propranolol (Inderal), which belongs to the family of blood pressure medications called beta-blockers.   There are newer and better beta-blockers, such as nebivolol (Bystolic), which have fewer side effects than propranolol.   We also use other types of blood pressure medications, such as calcium channel blockers (verapamil or Calan, and other) and ACE inhibitors (lisinopril, or Zestril/Prinivil is one example).   The newest category of blood pressure medications is ACE receptor blockers (ARBs) which are at least as effective and have fewer side effects than ACE inhibitors.   The best scientific evidence (from a single double-blind study) for the efficacy of ARBs in migraines is for candesartan (Atacand). --- ### Headaches in kids - Published: 2010-01-13 - Modified: 2010-01-13 - URL: https://www.nyheadache.com/blog/headaches-in-kids/ - Categories: Alternative Therapies - Tags: adolescent, biofeedback, CoQ10, exercise, headache, magnesium, migraine, riboflavin 74% of girls and 52% of boys have headaches at age 17, according to a Finnish study of 6,262 twins.   At age 11, 60% of girls and 59% of boys had headaches at least once a month.    The prevalence of weekly headaches increase d in girls from 16% to 25% between ages 11 and 14.   Headaches in kids is a major problem, but unfortunately it does not receive proper attention.   Sometimes parents do not believe that their child has a headache or if they do, they are reluctant to take the child to a doctor because they don't want to resort to prescription medications.   Fortunately, many non-drug approaches are very effective in kids.   Regular sleep schedule (very hard to enforce in teenagers), regular meals, frequent aerobic exercise, biofeedback or meditation, and supplements can be very effective.   Several studies have shown that kids with headaches are often deficient in magnesium, riboflavin (vitamin B2), and Co-enzyme Q10 (CoQ10).   If a child still has headaches, a medications may also be appropriate. --- ### More on benefits of vitamin D - Published: 2010-01-12 - Modified: 2010-01-12 - URL: https://www.nyheadache.com/blog/more-on-benefits-of-vitamin-d/ - Categories: Alternative Therapies - Tags: headache, neuralgia, vitamin D Vitamin D deficiency is often found in patients with headaches and neuralgia, which I've already mentioned in previous posts.   Chronic pain patients with low vitamin D levels were also found to have poor exercise tolerance, making their rehabilitation more difficult.   Now, there is strong evidence from two independent studies, which involved over one thousand people, that those with low vitamin D levels were twice as likely to develop Alzheimer's disease, other types of dementia, and strokes.   The researchers and those commenting on this research called for more studies before any recommendations can be made.   This response of the medical establishment is typical in its lack of common sense.   Yes, there are dangers in taking too much vitamin D, but shouldn't they call for doctors to test for this deficiency and correct it when it is present?   Even if we don't know exactly if this supplementation will prevent strokes, Alzheimer's or headaches, it makes sense to keep everyone's level in the middle of the normal range. --- ### Light and headaches - Published: 2010-01-11 - Modified: 2010-01-11 - URL: https://www.nyheadache.com/blog/light-and-headaches/ - Categories: Science of Migraine - Tags: , headache, light, migraine, photophobia Migraines in blind people are made worse by light, according to Dr. Burstein and his associates at Harvard.   Rami Burstein is one of the leading headache researchers who often asks questions no one else thought to ask.   More importantly, he often finds the answers.   When he mentioned to me that he wants to find out why bright light makes headaches worse (so called photophobia), I immediately thought of a blind patient I was treating.   She was very interested in helping Rami discover the answer and helped him recruit many other blind migraine sufferers.   After several years of work, his finding were published today in Nature Neuroscience.   A recent discovery showed that in addition to rods and cones in the retina (cells that allow us to see), there are cells which react to light, but their input goes to non-visual parts of the brain.   These cells regulate sleep-wake cycle and, according to Rami Burstein's research, also magnify pain perception in headache patients. --- ### Headaches in pregnancy - Published: 2010-01-10 - Modified: 2010-01-10 - URL: https://www.nyheadache.com/blog/headaches-in-pregnancy/ - Categories: Science of Migraine - Tags: Botox, headache, magnesium, pregnancy The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study by Norwegian researchers published in Headache provides some additional details.   Women with headaches who are pregnant for the first time tend to have fewer headaches than non-pregnant women or women during subsequent pregnancies.   This is especially true in the third trimester.    Non-pregnant women who had never been pregnant were less likely to have headaches than women who had been.   If a woman does have headaches during pregnancy, the initial treatment should consist of non-drug therapies, such as biofeedback or meditation, magnesium and other supplements, acupuncture, and if headaches are frequent, Botox injections. --- ### Abuse and migraines - Published: 2010-01-09 - Modified: 2010-01-09 - URL: https://www.nyheadache.com/blog/abuse-and-migraines/ - Categories: Science of Migraine - Tags: abuse, headache, migraine, pain Childhood abuse or neglect was reported by 58% of 1,348 migraine sufferers according to a study published in the current issue of Headache.   Emotional abuse and neglect was particularly common.   Patients with other chronic pain conditions also have high incidence of emotional, sexual, and physical abuse.   Migraine patients who suffered abuse are also more likely to have anxiety and depression.   We do not know what physiological mechanisms that are triggered by abuse lead to chronic pain.   This and similar studies suggest that greater attention should be directed at the psychological factors that contribute to migraine headaches.   One possible negative outcome of this study is that some physicians, who may already consider migraine to be a purely psychological disorder, will be even more inclined to avoid treating migraine as a biological disease.   In practice, it means that these doctors will be even more reluctant to prescribe appropriate acute migraine medications, such as triptans (Imitrex and other).   Migraine is clearly a biological disorder with documented genetic predisposition and should be treated as such.   At the same time, we know that psychological factors play a major contributing role and should be also addressed when treating headache and pain patients. --- ### Science of acupuncture - 2 - Published: 2010-01-03 - Modified: 2010-01-03 - URL: https://www.nyheadache.com/blog/science-of-acupuncture-2/ - Categories: Alternative Therapies, Pain Research - Tags: acupuncture, headache, pain, placebo Acupuncture increases connections between different areas of the brain, according to Dhond and other Korean researchers who published their findings in the journal Pain.   They compared the effect of true and sham acupuncture in healthy volunteers using functional MRI of the brain.   They discovered that true acupuncture (insertion of one needle into the forearm) enhanced the "spacial extent of resting brain networks to include anti-nociceptive (pain-relieving), memory, and affective (responsible for emotions) brain regions".    The researchers felt that this enhancement of connections between various parts of the brain is probably responsible for the pain relief induced by acupuncture.    After the recent German study of acupuncture for headaches which involved over 15,000 patients there is little doubt that acupuncture works for headaches (and many other pain conditions), but this study helps provide stronger scientific evidence that the relief is not due to placebo. --- ### Music and pain - Published: 2009-12-30 - Modified: 2009-12-30 - URL: https://www.nyheadache.com/blog/music-and-pain/ - Categories: Alternative Therapies - Tags: music, pain, pleasant, sad I've written in a previous post that people exposed to pleasant music feel less pain than people listening to unpleasant music or to no music at all.   Some studies have suggested that happy music (typically music with faster tempo and major mode) is better at relieving pain than sad music.   A study by Chinese researchers published earlier this year in the journal Pain showed that both sad and happy melodies lower pain perception in healthy volunteers, as long as the melodies are pleasant.   This study adds to the growing evidence that music can indeed relieve pain and, not surprisingly, that the music has to be pleasant. --- ### Avoiding holiday headaches - part 2 - Published: 2009-12-16 - Modified: 2009-12-16 - URL: https://www.nyheadache.com/blog/avoiding-holiday-headaches-part-2/ - Categories: Uncategorized - Tags: , alcohol, beer, headache, overindulgence, vodka, wine Alcohol 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. --- ### Migralex is launched - Published: 2009-12-16 - Modified: 2009-12-21 - URL: https://www.nyheadache.com/blog/migralex-is-launched-2/ - Categories: New treatments, Uncategorized - Tags: aspirin, headache, magnesium, medicine, new Migralex 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. --- ### How to avoid holiday headaches, part 1 - Published: 2009-12-09 - Modified: 2009-12-09 - URL: https://www.nyheadache.com/blog/how-to-avoid-holiday-headaches-part-1/ - Categories: Alternative Therapies - Tags: chocolate, headache, sleep, triggers, wine Holiday headaches are quite avoidable, but to avoid them you have to have willpower.   I know myself that it is hard to resist all the chocolate that surrounds you during the holidays.   If you have a choice, pick milk chocolate over dark.   There is no scientific proof, but in my case I find that the higher the cocoa content the more likely I will get a headache.   Of course I, like many other chocoholics do not consider milk chocolate real chocolate and don't bother eating it.   For the most part I stay away from chocolate altogether because it is addictive - once you start eating it, it is hard to stop.   My headaches do respond to medication and when I do eat chocolate I make sure to have it handy.   Another way to avoid headaches from chocolate, or for that matter any other trigger, is to avoid having more than one trigger at a time.   That is if you want to have some chocolate do not also drink wine or do not eat chocolate if you did not get enough sleep. --- ### Botox vs Topamax - Published: 2009-11-24 - Modified: 2009-11-24 - URL: https://www.nyheadache.com/blog/botox-vs-topamax/ - Categories: New treatments - Tags: Botox, migraine, Topamax, treatment A blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew and published in the current issue of Headache.   They enrolled 60 patients and divided them into two groups - one group received real Botox and placebo tablets, while the second group received saline water injections instead of Botox, but were given tablets of Topamax.   At the end of 9 months and after 2 Botox treatments the efficacy of these two treatments was the same, but many more patients in the Topamax group developed side effects and dropped out of the study. --- ### Headache Relief iPhone app - Published: 2009-11-14 - Modified: 2009-11-14 - URL: https://www.nyheadache.com/blog/headache-relief-iphone-app/ - Categories: Uncategorized - Tags: diary, headache, iphone, weather Headache 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. --- ### Botox for nerve pain - Published: 2009-11-11 - Modified: 2009-11-11 - URL: https://www.nyheadache.com/blog/botox-for-nerve-pain/ - Categories: New treatments - Tags: Botox, botulinum, headache, neuralgia, pain Botox appears to be effective for peripheral nerve pain according to a study by French researchers.   This finding is consistent with my observation that injecting Botox into the skin of the top of the head in patients with headaches relieves pain in that area.   When I started injecting botulinum toxin (Botox) for headaches about 15 years ago the assumption was that Botox works by relieving spasm of muscles in the forehead, temples, back of the head, and neck.   However, some patients would come back and report that their headache was gone in the injected areas, but not on the top of the head.   When gave additional injections the top of the head pain also stopped.   I also see patients who get Botox injections for their headaches from dermatologists or plastic surgeons and do not obtain adequate relief.   This is usually because only the front of the head is injected, rather then all areas of pain.    There have been other reports of Botox relieving pain of diabetic as well as trigeminal neuralgia, however the French group conducted a very rigorous double-blind study which provides scientific proof of pain-relieving properties of Botox. --- ### Needle-free injection of sumatriptan - Published: 2009-10-25 - Modified: 2009-10-25 - URL: https://www.nyheadache.com/blog/needle-free-injection-of-sumatriptan/ - Categories: Uncategorized - Tags: Imitrex, injection, migraine, needle, sumatriptan Needle-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... --- ### Dr. Oz promotes magnesium for headaches - Published: 2009-10-23 - Modified: 2009-10-25 - URL: https://www.nyheadache.com/blog/dr-oz-promotes-magnesium-for-headaches/ - Categories: Alternative Therapies - Tags: headache, magnesium, oprah Dr. Oz : "Like Alexander Mauskop, I believe that magnesium can help—it relaxes arteries and muscles in the body, both of which can help with headaches".    This statement in the latest issue of O, The Oprah Magazine is not very surprising coming from a cardiac surgeon - magnesium is routinely used after open heart surgery.   Unfortunately, many neurologist and other physicians treating headaches still do not recommend magnesium for their headache patients.   And this is despite all the scientific evidence and despite the recommendation of the American Academy of Neurology.   I think this is in part due to their training that emphasizes the use of drugs rather than natural approaches.   This bias is reinforced by the strong influence of the pharmaceutical industry. --- ### Botox for occipital neuralgia - Published: 2009-10-18 - Modified: 2009-10-18 - URL: https://www.nyheadache.com/blog/botox-for-occipital-neuralgia/ - Categories: New treatments - Tags: Botox, occipital neuralgia Botox can relieve pain of occipital neuralgia, according to a pilot study by neurologists in Ohio, published in Headache.   Occipital neuralgia is a painful condition that manifests itself by pain in the back of the head, usually on one side.   Pain can be burning, but also sharp,or throbbing in character.   It is often the result of a spasm of occipital and suboccipital muscles, so it is not surprising that Botox would relieve this pain by relaxing these muscles.   In addition to relaxing muscles Botox also reduces activation of the sensory nerve that send pain messages to the brain.   Other treatments for occipital neuralgia include isometric neck exercise, acupuncture, medications, and occipital nerve block with corticosteroids and lidocaine. --- ### What to do about severe aura symptoms - Published: 2009-10-17 - Modified: 2009-10-17 - URL: https://www.nyheadache.com/blog/what-to-do-about-severe-aura-symptoms/ - Categories: New treatments - Tags: aura, lamotrigine, migraine, verapamil Some migraine patients are more disturbed and disabled by migraine aura symptoms than by the headache itself.   Some people do not even have pain but only auras.   In the majority the aura is visual and consists of squiggly lines, flashing lights, distorted vision, or partial loss of vision on one side of each eye.   Less often people experience numbness of one side of the body, dizziness, or vertigo.   These symptoms are sometimes more difficult to treat than the pain.   Anecdotal reports suggest that a blood pressure drug belonging to the family of calcium channel blockers can help.   Another medication that has been reported to be effective (also only in case series and not double-blind trials) is an epilepsy drug, lamotrigine (Lamictal).   The effective dose of lamotrigine varies from 100 to 500 mg day, while verapamil is usually effective at 12-240 mg, although in some patients only much higher doses are effective. --- ### New treatment for migraines is effective in a Phase III trial - Published: 2009-09-30 - Modified: 2009-09-30 - URL: https://www.nyheadache.com/blog/new-treatment-for-migraines-is-effective-in-a-phase-iii-trial/ - Categories: Uncategorized - Tags: cgrp, migriane, telcagepant, triptan A 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. --- ### Botox is proven to help chronic migraine - Published: 2009-09-20 - Modified: 2009-09-20 - URL: https://www.nyheadache.com/blog/botox-is-proven-to-help-chronic-migraine/ - Categories: New treatments - Tags: Botox, botulinum toxin, chronic migraine, headache, migraine Two large trials of Botox provide unequivocal proof of its efficacy in the treatment of chronic migraine headaches.   The results of these two double-blind, placebo-controlled studies (I participated in one of the two trials) of onabotulinumtoxinA (Botox) in chronic migraines were presented at the International Headache Congress in Philadelphia last week.   Botox was proven to reduce the number of days with headaches, improve multiple headache symptoms, and improve the quality of life.   The treatment was extremely well tolerated with very few side effects overall and no serious side effects.    Having used Botox for the treatment of various headache types for over 15 years in several thousand patients it is very gratifying to finally have well-designed trials which confirm my and my colleagues' experience.    The manufacturer is submitting the results of these trials to the FDA and we expect to have approval of Botox for the treatment of chronic migraines by the end of 2010.   FDA approval will force insurance companies to pay for this highly effective treatment and will make it affordable for people who desperately need it. --- ### Allergy tests and migraine - Published: 2009-09-20 - Modified: 2009-09-20 - URL: https://www.nyheadache.com/blog/allergy-tests-and-migraine/ - Categories: Science of Migraine - Tags: allergy, migraine Migraine headaches are more frequent in people who suffer from allergic rhinitis and who have more than 10 positive skin allergy tests.   This finding by Dr. Martin and his colleagues presented at the International Headache Congress last week is not surprising since many of my patients report that their migraines worsen during periods when their allergies flare up.   It is also not surprising because almost any medical condition affecting the head, whether it is an ear infection, a dental problem, or conjunctivitis, can trigger a migraine attack. --- ### Facial neuralgia and vitamin B12 deficiency - Published: 2009-09-20 - Modified: 2009-09-20 - URL: https://www.nyheadache.com/blog/facial-neuralgia-and-vitamin-b12-deficiency/ - Categories: New treatments - Tags: cyanocobalamine, facial neuralgia, vitamin b12 Vitamin B12 (cyanocobalamine) deficiency is known to cause a wide variety of neurological symptoms.    It also seems to produce facial neuralgia, according to a report presented at the International Headache Congress in Philadelphia a week ago.   Two physicians from Milwaukee described 17 patients who had facial pain that was not typical of trigeminal neuralgia because they had no trigger area and had numbness on the affected side.   They all had vitamin B12 deficiency and they pain improved with injections of vitamin B12.   In a previous post I mentioned another study that found an association between migraine headaches and high homocysteine levels, which can also be caused by vitamin B12 deficiency.   Oral absorption of vitamin B12 supplements is often inadequate and a nasal spray (which is expensive) or an injection are the best ways to correct this deficiency. --- ### Multiple sclerosis and migraines - Published: 2009-09-19 - Modified: 2009-09-19 - URL: https://www.nyheadache.com/blog/multiple-sclerosis-and-migraines/ - Categories: Science of Migraine - Tags: migraine, Multiple sclerosis Migraine headaches are three times more common in patients with multiple sclerosis than in people of similar age and gender without MS.  Ilya Kister and his colleagues at NYU who established this fact make a very important point – multiple sclerosis symptoms often overshadow the symptoms of migraine and this can result in migraine not being treated properly leading to additional avoidable disability.     --- ### Severe migrainous vertigo responds to steroids - Published: 2009-08-30 - Modified: 2009-08-30 - URL: https://www.nyheadache.com/blog/severe-migrainous-vertigo-responds-to-steroids/ - Categories: New treatments - Tags: corticosteroids, dexamethasone, methylprednisolone, migraine, prednisone, vertigo Migrainous vertigo seems to respond to intravenous infusion of a high dose of corticosteroids, according to a report in the latest issue of Headache by a group of Indian doctors.   Two of their patients had intermittent episodes of severe vertigo and two had chronic vertigo.   All four respond to infusions of 1 gram of methylprednisolone.   One require 3 infusions, one needed 2 and in another 2 vertigo stopped after a single infusion.   We routinely use corticosteroids for severe migraine attacks when other medications fail.   While occasional (once or twice a month) use of corticosteroids is relatively safe, frequent or daily intake of corticosteroids (besides methylprednisolone, these drugs include prednisone, prednisolone, and dexamethasone) can lead to dangerous side effects.   It is possible that oral corticosteroids will produce a similar effect as an infusion and may be worth trying when nothing else helps relieve the vertigo. --- ### Another blood pressure medicine shown to prevent migraine - Published: 2009-08-30 - Modified: 2009-08-30 - URL: https://www.nyheadache.com/blog/another-blood-pressure-medicine-shown-to-prevent-migraine/ - Categories: New treatments - Tags: ace receptor, ARBs, beta-blocker, calcium channel blocker, Cluster headache, headache, lisinopril, migraine, propranolol, telmisartan, timolol, verapamil A blood pressure medication telmisartan (Micardis) was shown to be effective in the prevention of migraine headaches by a group of German researchers led by H-C Diener.   Several blood pressure medications have been proven to prevent migraine headaches.   The oldest category of blood pressure drugs, beta-blockers have the most evidence to support their use and two of them (propranolol and timolol) are approved by the FDA for the preventive treatment of migraines.   However, beta-blockers are not high on my list because they tend to cause more side effects than other blood pressure medications.   The most common side effects are due to excessive lowering of blood pressure - lightheadedness, fatigue, and fainting.   They also slow down the heart rate, which can make it difficult to exercise, while regular aerobic exercise is the first treatment I recommend to my headache patients.   Calcium channel blockers, such as verapamil, are not as effective for migraine prevention as they are for the prevention of cluster headaches and can cause constipation, swelling and irregular heart beats.   Another blood pressure medication, lisinopril which belong to the family of ACE inhibitors has also been shown to prevent migraine headaches.   The most common limiting side effect of ACE inhibitors is coughing.   A newer group of medications, which are similar in action to ACE inhibitors is ACE receptor blockers, or ARBs.   ARBs do not cause coughing and telmisartan which is one of the ARBs caused as few side effects as... --- ### Vertigo and migraine - Published: 2009-08-24 - Modified: 2009-08-24 - URL: https://www.nyheadache.com/blog/vertigo-and-migraine-2/ - Categories: Science of Migraine - Tags: migraine, vertigo Vertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology.   In this study researchers induced vertigo in patients who had a history of migraines and in a control group.   Almost half of those who had a history of migraines developed a migraine attack within 24 hours, compared with only 5% of those who were not known to have migraines.   The study suggests that vertigo due to an inner ear problem can trigger a migraine attack.   This finding will not come as a surprise to migraine sufferers who cannot ride a roller coaster or even go on bumpy a car ride without getting a migraine. At times, migraine sufferers develop vertigo as part of their migraine attack and it can be difficult to tell if vertigo caused the migraine or was just one of the symptoms.   A detailed description of more than one attack usually gives a clear answer. --- ### Chronic daily headaches in adolescents - Published: 2009-08-23 - Modified: 2009-08-23 - URL: https://www.nyheadache.com/blog/chronic-daily-headaches-in-adolescents/ - Categories: Science of Migraine - Tags: adolescent, chronic daily headache, headache, migraine, prognosis Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to 14 who were diagnosed with this condition.   A year later 40% still had CDH, and after 2 years, 25% had symptoms of CDH.   They followed 103 of the original 122 for 8 years and found that only 12% still had daily headaches with 10 out of 12 diagnosed as having chronic migraines.   This is what we see in practice, but now we have good evidence and can be more certain when we tell our adolescent patients and their parents that they will "grow out" of their headaches.   Another piece of good news was that most kids were not actively treated and headaches improved on their own.   However, it may take months or years for headaches to improve and we should not just sit and wait while the child suffers.   Active treatment includes sleep hygiene, regular exercise, avoiding dietary triggers, biofeedback or relaxation training, magnesium, CoQ10 and other supplements, possibly acupuncture, Botox injections and medications. --- ### Surgery for migraines - an update - Published: 2009-08-02 - Modified: 2009-08-02 - URL: https://www.nyheadache.com/blog/surgery-for-migraines-an-update/ - Categories: New treatments - Tags: Botox, headache, migraine, surgery In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is a better option than surgery to permanently cut nerves and muscles.   I also wrote that there were no controlled studies to show that surgery actually works.   Now we do have one study.   The study was blinded, which means that some patients had nerves and muscles cut, while others had only a skin incision.   The results were much better in patients who had real surgery.   The plastic surgeons who performed the study tried their best to produce a blinded study, but they admit that blinding is far from perfect since patients who had real surgery can see their muscles shrink or not move.   But even if we accept that blinding was achieved and surgery indeed provides relief of headaches, all of my other arguments stand.   These include surgical risks (bleeding, infection, scarring, and persistent nerve pain) and high cost.   Yes, Botox is expensive too, but migraine usually is not a life-long illness and migraine attacks often stop for long periods of time or permanently with or even without treatment.   I have seen many patients whom I treated with Botox every 3 months and whose headaches stop after a year or two.   Two years of Botox treatments is significantly cheaper than surgery and it does not carry all of the surgical risks. --- ### Homocysteine and migraine - Published: 2009-07-24 - Modified: 2009-07-24 - URL: https://www.nyheadache.com/blog/homocysteine-and-migraine/ - Categories: Science of Migraine - Tags: aura, cyanocobalamine, folic acid, homocysteine, migraine, stroke, vitamin b12 High homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid and vitamin B12 (cyanocobalamine).   A study by Spanish doctors published in Headache found elevated homocysteine levels in patients who have migraines with aura.   Patients who have migraine with aura are known to have increased risk of cardiovascular disease and it is possible that elevated homocysteine levels are at least in part responsible for this risk.   I routinely check homocysteine, vitamin B12 and folic acid levels in all of my patients.   One caveat is that vitamin B12 levels are not very reliable - you may have a normal level, but still be deficient.   While laboratories consider a level of over 200 to be normal, clinical deficiency is often present at levels below 400.   A single case report has been published of a severe deficiency with neurological symptoms and a vitamin B12 level of over 700.   This patient lacked the ability to transport vitamin B12 from his blood into the cells.   Injections of high doses of vitamin B12 corrected the problem.   Oral magnesium supplementation is not as effective as injections because vitamin B12 is poorly absorbed in the stomach.    Other ways to get vitamin B12 is by taking it sublingually (under your tongue) or by a nasal spray (it requires a prescription and is fairly expensive).   Many of my patients a willing to self-inject vitamin B12, which they do anywhere fro... --- ### Weight and migraine treatment - Published: 2009-07-05 - Modified: 2009-07-05 - URL: https://www.nyheadache.com/blog/weight-and-migraine-treatment/ - Categories: New treatments - Tags: aura, heart attack, migraine, stroke, Topiramate, weight gain, weight loss Medications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain.   An interesting study by Dr. Bigal and his colleagues, just published in Cephalalgia looked at this effect of drugs in 331 patients.   They found that 16% of them gained weight (5% or more of their baseline weight) and 17% lost weight.   The various treatments given to these patients were equally effective in both groups.   However, not surprisingly, those who gained weight had elevation of their cholesterol, blood glucose, blood pressure and pulse.   Patients who have migraine headaches with aura (about 15-20% of migraine sufferers) already have an increased risk of strokes, so adding additional risk factors for both strokes and heart attacks should be especially avoided in this group.   The only preventive migraine drug which consistently lowers weight in many patients is topiramate (Topamax).   This drug is now available in a generic form, making it much less expensive.   While topiramate does lower weight and helps prevent migraine headaches only half of the patients stay on it.   For the other half it causes unpleasant side effects (memory impairment and other) or it does not work. --- ### Another option for trigeminal neuralgia - Published: 2009-07-03 - Modified: 2009-07-03 - URL: https://www.nyheadache.com/blog/another-option-for-trigeminal-neuralgia/ - Categories: New treatments - Tags: baclofen, carbamazepine, oxcarbazepine, phenytoin, pregabalin, trigeminal neuralgia Trigeminal neuralgia is an extremely painful condition which causes severe electric shock-like pain in one or more branches of the trigeminal nerve.   The 3 branches are mandibular, in the lower jaw, maxillary, in the upper jaw, and ophthalmic in the upper face.   It is more common in the elderly and is caused by compression of the trigeminal nerve by a hardened blood vessel inside the skull, near the brainstem.    Treatment consists of trials of different medications, which work for most patients, but a small percentage require a partial destruction of the nerve (with radiofrequency heat) or surgery.   Surgery consists of opening the skull and placing Teflon insulation between the nerve and the blood vessel.   Medications that are used for trigeminal neuralgia inlcude epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), and a muscle relaxant, baclofen (Lioresal).   A recent report suggests that a newer epilepsy drug, pregabalin (Lyrica) is also effective.   However, carbamazepine, phenytoin, and baclofen are available in a generic form, which makes them much less expensive than the other, branded products. --- ### Two other ways to administer sumatriptan - Published: 2009-06-27 - Modified: 2009-06-27 - URL: https://www.nyheadache.com/blog/two-other-ways-to-administer-sumatriptan/ - Categories: New treatments - Tags: lingual, migraine, oral spray, skin patch, sumatriptan In addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations.   No, it is not an inhaled form, which I just posted in my previous blog (dihydroergotamine inhaler), but through a skin patch and by a "lingual spray", that is a spray into the mouth.   The skin patch may work fast and will deliver medicine through the skin, bypassing the stomach, which would be very useful for people who get very nauseous and have difficulty swallowing medications.    However, it is quite a large patch and will probably cost significantly more than a tablet, particularly in the generic form.   The second new formulation, a spray into the mouth, appears to partially absorb in the mouth and partially in the stomach, making it also work faster, although so far it looks to be only as effective as a 50 mg tablet.   The usual dose is 100 mg.   Also, hopefully the company that is developing this product has been able to mask the taste of sumatriptan.   Patients who have tried the nasal spray often complain of a very unpleasant taste, which can make nausea worse. --- ### A new inhaled migraine drug - Published: 2009-06-25 - Modified: 2009-10-17 - URL: https://www.nyheadache.com/blog/a-new-inhaled-migraine-drug/ - Categories: New treatments - Tags: dihydroergotamine, ergots, inhaled, migraine Trials of an inhaled version of an old migraine drug show surprisingly good results.   The drug is dihydroergotamine and in injectable from is considered to be one of the strongest migraine medications.   It is often used intravenously to treat severe migraines that do not respond to other therapies and for medication overuse headaches.   It can be also injected into the muscle, under the skin or sprayed into the nose.   The main problem with this drug is that it often makes nausea worse or even causes severe nausea in patient who do not have it.   What is surprising about the new product being developed by MAP Pharmaceuticals (to be called Levadex if and when FDA approves it) is not that is is very effective, but that it causes significantly less nausea than the same drug in an injectable form.   Another advantage is that inhaling the medicine into the lungs results in a very quick delivery of the drug into the circulation - as quick as an injection but without a needle.   A similar product, Ergotamine Medihaler was available until about 15 years ago, but was withdrawn because of manufacturing difficulties and limited demand.   The demand for this new product will also be limited because it will be more expensive than a tablet of any migriane drug, it will be more bulky to carry around, and will be mostly utilized by patients who cannot take oral medications due to nausea or by those who... --- ### Facial Pain in Migraine - Published: 2009-06-22 - Modified: 2009-06-22 - URL: https://www.nyheadache.com/blog/facial-pain-in-migraine/ - Categories: Science of Migraine - Tags: Facial pain, migraine, TMJ Lower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in Cephalalgia by German researchers.   One of the 517 migraine patients they looked at had lower facial pain as the leading symptom of migraine.   Some of my patients with lower facial pain wonder if they have a disorder of the temporo-mandibular joint (TMJ).    Some of them do benefit from an oral appliance that reduces grinding and clenching, in most however, a successful treatment of their migraines with abortive or prophylactic medications will often relieve the jaw pain as well. --- ### Generic medications - Published: 2009-06-22 - Modified: 2009-06-22 - URL: https://www.nyheadache.com/blog/generic-medications/ - Categories: New treatments - Tags: epilepsy, generic, Imitrex, migraine, sumatriptan, Topamax, Topiramate Imitrex and Topamax are two migraine medications that recently lost their patent protection and became available in a generic form, under the names of sumatriptan and topiramate.   Many patients are concerned about the quality of generic products.   A recent study published in Neurology looked at 948 patients with epilepsy who were treated with generic Topamax (it is approved for the treatment of both migraines and epilepsy).   Compared to patients who used the branded Topamax, those on generic substitutions needed to have more of other medications, were admitted to the hospital more frequently and stayed in the hospital longer.   The risk of head injury or fracture (presumably due to seizures) was almost three times higher after the switch to a generic drug. Clearly, migraine patients do not run the same risk as epilepsy patients of having a seizure or being admitted to the hospital, however a small number of patients can have worsening of their migraines.   The main reason is the legally permitted variation in the amount of medicine in each tablet.   Taking a higher dose of the generic drug can help. The same applies to Imitrex - a small number of patients will find that the generic sumatriptan is slightly less effective.   The only, albeit significant, advantage of the generic drugs is cost savings.   At this point we have only one generic substitution for Imitrex and the price difference is only 20%, but in a few months more generics will appear and... --- ### Occipital microstimulator - Published: 2009-05-26 - Modified: 2009-05-26 - URL: https://www.nyheadache.com/blog/occipital-microstimulator/ - Categories: New treatments - Tags: headache, migraine, occipital, stimulator Occipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches.   Phase II trials performed by Medtronics, the manufacturer of one type of  stimulator, have been positive.   This stimulator requires implantation of a stimulator wire next to the occipital nerves and a separate incision to implant a stimulator device with a battery in the upper chest.   A recent report suggests that the same effect can be achieved by implanting a small self-contained device without the need for wires, large battery, or a separate incision.   This "Bion Microstimulator" has not been subjected to any extensive studies similar to ones  performed by Medtronics, but the preliminary data looks promising. --- ### Headache Diary - Published: 2009-05-22 - Modified: 2009-05-22 - URL: https://www.nyheadache.com/blog/headache-diary/ - Categories: Science of Migraine - Tags: diary, headache, migraine Headache diary plays an important role in the management of headache patients.   Drs. McKenzie and Cutrer from the Mayo Clinic compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in a questionnaire vs a daily diary.    Here are some of their findings "Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment.   As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.   209 patients completed a questionnaire and also maintained a daily diary over the 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14. 7) was not different from that documented in diaries (15. 1), P = . 056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1. 84) was worse than that documented in the diaries (1. 63), P < . 001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable. " --- ### Genetic-based personalized medicine in headaches - Published: 2009-05-12 - Modified: 2009-05-12 - URL: https://www.nyheadache.com/blog/genetic-based-personalized-medicine-in-headaches/ - Categories: Science of Migraine - Tags: migraine, pharmacogenomics, riboflavin A pharmacogenetic study by Italian researchers discovered that absence of a certain gene can predict therapeutic response in migraine patients who are treated with riboflavin (vitamin B2).    Pharmacogenomics has been a very promising field of medical science that may enable doctors to select the most effective and safe medicine for each patient based on their genetic profile.   This is a small but important step in utilizing this science to treat headache patients. --- ### Vertigo and Migraine - Published: 2009-04-20 - Modified: 2009-04-20 - URL: https://www.nyheadache.com/blog/vertigo-and-migraine/ - Categories: Science of Migraine - Tags: migraine, vertigo Vertigo is a common symptom in patients with migraine headaches.   It appears that obverse is also true - migraine is very common in patients with vertigo.   A study just published in Cephalalgia looked at 208 patients with benign recurrent vertigo.   It turned out that 87%, or 180 of these patients had migraine headaches.   Of these 180 patients, 112 or 62% had migraine with aura and 38% had migraine without aura.   Thirty percent, or 54 patients always had vertigo without any migraine symptoms, while in 70% vertigo occurred with a headache or other migraine symptoms, such as visual aura, sensitivity to light and noise.   The duration of attacks of vertigo in most patients was between one hour and one day. --- ### New forms of botulinum toxin - Published: 2009-04-19 - Modified: 2009-04-19 - URL: https://www.nyheadache.com/blog/new-forms-of-botulinum-toxin/ - Categories: Pain Research Botulinum toxin, which most people know as Botox is produced by a bacteria - Clostridium botulinum.   This bacteria actually produces 7 different type of this toxin: A, B, C, D, E, F, and G.   Botox is botulinum toxin, type A, while another commercial product, Myobloc is botulinum toxin, type B.   Researchers, Drs. Dolly, Aoki and their colleagues managed to combine type A and E, according to a report in The Journal of Neuroscience.   Test tube experiments suggest that this combination could prove to be more effective for the treatment of pain than type A alone.   This is a very promising discovery, since Botox is effective for only about two thirds of chronic migraine sufferers.   The combined toxin could be also effective for other types of pain. --- ### How to predict if Botox is going to work - Published: 2009-04-11 - Modified: 2009-04-11 - URL: https://www.nyheadache.com/blog/how-to-predict-if-botox-is-going-to-work/ - Categories: New treatments Dr. Rami Burstein of Harvard University and his colleagues discovered the way to predict who is going to respond to Botox injections.    Patients who have pain that is constricting, crushing, or "imploding" with pressure going from outside in and those with pain in the eye respond much better than those whose pain is "exploding" or with a sensation of pressure building up from inside the head.   This was true for patients with episodic, as well as chronic migraine headaches.   About 83% of non-responders had "exploding" headaches and 84 of responders had "imploding" headaches.   Fortunately, many more patients suffer from imploding headaches or headaches with pain in the eye than with "exploding"headaches. --- ### Unfair teachers cause headaches - Published: 2009-03-20 - Modified: 2009-04-09 - URL: https://www.nyheadache.com/blog/unfair-teachers-cause-headaches/ - Categories: Science of Migraine Unfair teachers can cause headaches in adolescents, according to an Italian study published in the journal Headache.   About 40% of 4,386 adolescents suffered from headaches at least once a week.   Girls were more likely to have headaches and kids who had better classmate social support had fewer headaches.   The researchers used an established  "Teacher and Classmate Support Scale" to measure these effects and also took into account other factors that could have skewed the data.   They looked at family and friend empowerment, bullying, school achievement, and trust in people, and none of those factors seemed to play a role in causing headaches.   Psychological stress worsens headaches in adults too, but it seems to have a more pronounced effect in adolescents. --- ### Stroke and migraine in pregnancy - Published: 2009-03-17 - Modified: 2009-03-17 - URL: https://www.nyheadache.com/blog/stroke-and-migraine-in-pregnancy/ - Categories: Science of Migraine, Uncategorized Strokes 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... --- ### Cannabis (marijuana) for cluster headaches - Published: 2009-03-07 - Modified: 2009-04-09 - URL: https://www.nyheadache.com/blog/cannabis-marijuana-for-cluster-headaches/ - Categories: Alternative Therapies, Uncategorized - Tags: , Cluster headache, dronabinol, marijuana 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. --- ### PTSD and migraine - Published: 2009-02-06 - Modified: 2009-02-06 - URL: https://www.nyheadache.com/blog/ptsd-and-migraine/ - Categories: Science of Migraine - Tags: migraine, PTSD, treatment Migraine headaches in patients with post-traumatic stress disorder tend to be more frequent and disabling, according to a study in soldiers led by Dr. Jay Erickson.   Soldiers with PTSD had almost twice as many headaches as soldiers without PTSD and were more likely to have chronic migraines (headaches on more than 15 days a month).   Treatment with preventive medications was slightly less effective in the PTSD group.   Botox injections were not tried in these patients.   It is a well established fact that patients with a history of abuse are more likely to have chronic pain, including headaches.   This is an important part of history since inclusion of psychotherapy may improve treatment outcomes in these patients and, at least in theory, using antidepressants rather than other classes of preventive drugs may be more appropriate. --- ### Migraines and weight - Published: 2009-02-03 - Modified: 2009-02-03 - URL: https://www.nyheadache.com/blog/migraines-and-weight/ - Categories: Science of Migraine - Tags: chronic migraine, migraine, overweight, weight Both overweight and underweight people are more likely to have migraine headaches, according to a recent study published in journal Cephalalgia.   Being overweight has been shown to increase the risk of chronic migraines in a previous large study, but the discovery of the link between being too thin and migraines is new.   These findings do not mean that regaining normal weight will lead to improvement in headaches, but only that there is an association.   This is not to say that we do not encourage our overweight patients to lose weight.   The best way to achieve this is not only by dieting, but also by engaging in frequent aerobic exercise, which has been found to be associated with fewer migraine headaches.   --- ### Trigger point injections for cluster headaches? - Published: 2009-01-29 - Modified: 2009-02-03 - URL: https://www.nyheadache.com/blog/trigger-point-injections-for-cluster-headaches/ - Categories: New treatments - Tags: Cluster headache, nerve block, trigger point injection Cluster headaches, which arguably cause the worst pain of any headache, are not likely to be cured by trigger point injections, according to a group of Spanish doctors.   They treated 12 patients with trigger point injections and some of the patients reported some relief, but they all needed medications as well.   This is a small study without placebo control, which means that no conclusions can be made about usefulness of this treatment.   We do have better evidence that occipital nerve blocks can be helpful in aborting cluster headaches.   This is a procedure similar to trigger point injections, but it involves injection not only of a local anesthetic, but also a long-acting steroid into an area of the occipital nerve on the side of the headaches.   It is a simple and safe procedure and it should be tried in most patients, particularly those who in addition to pain around the eye have pain or tenderness in the back of the head or upper neck. --- ### Lack of exercise contributes to headaches - Published: 2009-01-02 - Modified: 2009-01-02 - URL: https://www.nyheadache.com/blog/lack-of-exercise-contributes-to-headaches/ - Categories: Alternative Therapies - Tags: breakfast, exercise, headache, migraine, phsyical activity, smoking, weight Physical inactivity was strongly associated with headache disorders, according to a large study by Swedish researchers published in Headache.   They looked at 43,770 people with recurrent headaches and migraines and found that economic hardship and psychosocial factors (poor social support and experience of being belittled) seem to play a role in headache disorders.    Of lifestyle factors, physical inactivity was strongly associated with headache disorders, while smoking to a lesser extent.   Skipping breakfast, being overweight and underweight seemed to be connected to headaches. --- ### Red wine to treat migraines? - Published: 2008-12-11 - Modified: 2008-12-11 - URL: https://www.nyheadache.com/blog/red-wine-to-treat-migraines/ - Categories: Alternative Therapies - Tags: migraine, pain, red wine, resveratrol Red wine to relieve migraine?   Red wine is a well-known trigger of migraine headaches (although French tend to disagree).   A recent study published in journal Pain found that resveratrol, the active ingredient in red wine which is responsible for its health benefits, has pain relieving properties when given to rats.   There have been no reports in the literature or from my own patients that resveratrol causes headaches and judging from this study, it may in fact help. --- ### Antibiotic for daily headache? - Published: 2008-12-02 - Modified: 2008-12-02 - URL: https://www.nyheadache.com/blog/antibiotic-for-daily-headache/ - Categories: Uncategorized - Tags: antibiotic, daily headache, doxycycline, new daily persistent headache Doxycycline 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. --- ### Mindfulness meditation for chronic pain - Published: 2008-12-02 - Modified: 2008-12-02 - URL: https://www.nyheadache.com/blog/mindfulness-meditation-for-chronic-pain/ - Categories: Uncategorized Mindfulness 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. --- ### New approach to difficult menstrual migraines - Published: 2008-11-27 - Modified: 2008-11-27 - URL: https://www.nyheadache.com/blog/new-approach-to-difficult-menstrual-migraines/ - Categories: New treatments - Tags: dexamethasone, maxalt, menstrual, migraine, treximet Treatment of menstrual migraines often is more difficult than of non-menstrual attacks.   A double-blind study by Marcelo Bigal and his collaborators just published in Headache shows that a combination of 10 mg of rizatriptan (Maxalt) and 4 mg of a steroid medication, dexamethasone (Decadron) is more effective than either drug alone.   Both drugs are effective in treating many refractory migraine attacks (although I usually use 8 mg of dexamethasone), this is the first trial of two drugs together.   While the results are not very surprising, the study may lead to wider acceptance of combination therapy and better relief for many women.   While in the past the emphasis was placed on finding a single drug to treat a disease, in recent years combination therapy has become a standard approach in many conditions.   Treximet, a combination of sumatriptan (Imitrex) and naproxen (Aleve) was also shown to be better than either of the two ingredients alone. --- ### Migraine and Omega-3 fatty acids - Published: 2008-11-26 - Modified: 2009-04-09 - URL: https://www.nyheadache.com/blog/migraine-and-omega-3-fatty-acids/ - Categories: Alternative Therapies - Tags: migraine, omega-3 fatty acid Migraines may be helped by omega-3 fatty acids, a supplement that has gained well deserved popularity.   Several recent studies suggesting benefits for the cardiovascular system prompted me to look at the headache literature.   An article in Cephalalgia in 2001 by Pradalier and his colleagues concluded that this supplement is ineffective, at least when they looked at the number of headaches in the last 4 weeks of treatment.    However, the active treatment with 6 grams of omega-3 fatty acids was significantly better than placebo when they looked at the total number of attacks during the entire 4 months of treatment.   Taking into account this finding and considering that omega-3 fatty acids have other benefits while being very safe, it is worth trying to take daily 6 grams of omega-3 fatty acids if you suffer from migraine headaches. --- ### Occipital nerve stimulation for migraines - Published: 2008-11-09 - Modified: 2008-11-09 - URL: https://www.nyheadache.com/blog/occipital-nerve-stimulation-for-migraines/ - Categories: New treatments - Tags: migraine, occipital nerve, stimulation Refractory migraines may respond to occipital nerve stimulation, according to Dr. Joel Saper who led a multicenter trial of this treatment.   An electrode was surgically implanted in the back of the head, where the occipital nerve is located, and a pacemaker-size device was implanted under the skin.   The trial looked at 110 patients who had more than 15 days with migraines each month and who did not respond to a variety of medications.   66 patients completed the diary information for three months following the start of treatment.   The results were encouraging - 39% of patients improved, compared with 6% in the control group.   None of the patients had any adverse events. --- ### Breast cancer and migraines - Published: 2008-11-09 - Modified: 2008-11-09 - URL: https://www.nyheadache.com/blog/breast-cancer-and-migraines/ - Categories: Science of Migraine - Tags: breast cancer, estrogen, migraine Patients who suffer from migraine headaches are 30% less likely to develop breast cancer.   It is well established that fluctuating estrogen levels throughout the menstrual cycle can trigger migraine attacks.   These fluctuations are reduced during pregnancy and menopause, resulting in cessation of migraine attacks in two thirds of women.   At this point it is not clear what common estrogen-based mechanisms are responsible for the reduction of breast cancer risk in migraine sufferers. --- ### Migraine affects 43% of women and 18% of men! - Published: 2008-11-02 - Modified: 2008-11-02 - URL: https://www.nyheadache.com/blog/migraine-affects-43-of-women-and-18-of-men/ - Categories: Science of Migraine - Tags: incidence, migraine It is well known that if you take a snapshot of the population, about 18% of women and 6% of men suffer from migraine headaches.    However, a report by Dr. Stewart and his colleagues in the latest issue of Cephalalgia indicates that cumulative lifetime migraine incidence is much higher - 43% of women and 18% of men have migraine headaches at some point in their lives.   Migraine incidence peaked between the ages of 20 and 24 in women and 15 and 19 in men.   In 75% of cases migraine started before the age of 35. --- ### Magnesium for migraine - Published: 2008-10-19 - Modified: 2008-10-19 - URL: https://www.nyheadache.com/blog/magnesium-for-migraine/ - Categories: Alternative Therapies - Tags: headache, magnesium, migraine Magnesium is effective in preventing migraine headaches according to a new study published in the last issue of journal Magnesium Research.   The researchers found that patients treated with magnesium, compared to those treated with placebo, had fewer migraine attacks and the attacks were milder.   In addition, magnesium treated patients had improved blood flow in their brains, while those on placebo did not.   This is just another confirmation of previous findings of the efficacy of magnesium in the treatment of migraine headaches.   Since magnesium is very inexpensive and extremely safe, every patient with migraine headache should be given a trial of magnesium supplementation. --- ### Acupuncture for headaches - Published: 2008-10-19 - Modified: 2008-10-19 - URL: https://www.nyheadache.com/blog/acupuncture-for-headaches/ - Categories: Alternative Therapies - Tags: acupuncture, headache, migraine, treatment 15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by the German government.   Results published in the latest issue of journal Cephalalgia by S. Jena and colleagues indicate that "acupuncture plus routine care in patients with headache was associated with marked clinical improvements compared with routine care alone".   This study should dispel any remaining doubt about the efficacy of acupuncture in the treatment of headaches. --- ### Muscle relaxation for pain relief - Published: 2008-10-19 - Modified: 2008-10-19 - URL: https://www.nyheadache.com/blog/muscle-relaxation-for-pain-relief/ - Categories: Pain Research - Tags: headache, pain, progressive muscle relaxation Progressive muscle relaxation is an integral part of biofeedback training, but can be used by itself for the treatment of migraine and tension-type headaches.    A group of researchers at the Ohio State University published an article in the journal Pain which reports the effect of progressive muscle relaxation on experimental pain in healthy volunteers.    A single 25-minute tape-recorded session of progressive muscle relaxation resulted in a higher pain tolerance and reduced stress from pain.   It can be safely assumed that regular practice sessions will result in even better results and all pain patients, including those with headaches should be encouraged to learn this simple technique. --- ### Botox works for chronic migraines - Published: 2008-09-12 - Modified: 2008-09-12 - URL: https://www.nyheadache.com/blog/botox-works-for-chronic-migraines/ - Categories: New treatments Botox is effective for chronic migraines, according to a statement released by Allergan, maker of Botox.   The company reported that a large multi-center trial (the New York Headache Center was one of the trial sites) yielded positive results.   This report did not surprise us or our colleagues who routinely use Botox in treating patients with chronic migraines.   The excitement we feel is due to the fact that many of our colleagues have been skeptical about the efficacy of Botox.   Much more importantly, we hope that this definitive study will compel insurance companies to pay for this treatment. --- ### Zomig for cluster headaches - Published: 2008-09-07 - Modified: 2008-10-04 - URL: https://www.nyheadache.com/blog/zomig-for-cluster-headaches/ - Categories: New treatments Cluster headaches cause the worst pain imaginable, leading some patients to thoughts of suicide.   They occur in about 0. 1% of the population, while  migraine headaches afflict 12%, which may explain why so much less research has been conducted on cluster than on migraine headaches.   Injectable sumatriptan (Imitrex) is the only drug approved by the FDA for cluster headaches.   We do use many other medications "off-label" for both acute and prophylactic treatment, but none have been subjected to rigorous research.   That is none, until recently - zolmitriptan nasal spray (Zomig NS) has been shown to be effective in relieving cluster headaches within 30 minutes.   While the dose of Zomig NS for migraines is 5 mg, in this latest trial both 5 and 10 mg dose was studied.   The 10 mg dose was better than 5 mg dose in patients with episodic cluster headaches (74% vs 52%), but these two doses were equally effective in patients with chronic cluster headaches (41% vs 42%).   The advantage of Zomig NS over Imitrex injection is that it is easier to use and does not involve a painful injection, while the advantage of Imitrex is that it works faster.   Zomig NS is now approved for acute treatment of cluster headaches in Germany, Netherlands and Denmark. --- ### Thyroid dysfunction in kids with headaches - Published: 2008-09-04 - Modified: 2008-10-04 - URL: https://www.nyheadache.com/blog/thyroid-dysfinction-in-kids-with-headaches/ - Categories: Science of Migraine Children with thyroid disease are more likely to have headaches, according to a study done by Dr. David Rothner and his colleagues at the Cleveland Clinic.   36% of children with hypothyroidism and 19% with hyperthyroidism had headaches.   The types of headaches observed included chronic migraine and new daily persistent headache.   The authors conclude that thyroid testing should be part of a standard evaluation of headaches in children, just like it is in adults. --- ### Treating menstrual migraines with hormones - Published: 2008-09-03 - Modified: 2008-09-03 - URL: https://www.nyheadache.com/blog/treating-menstrual-migraines-with-hormones/ - Categories: New treatments Women with menstrual migraines who also have chronic migraines can be successfully treated with hormonal therapy, according to a study by Drs. Calhoun and Ford published in journal Headache.   Surprisingly, controlling menstrual migraines led to improvement in chronic migraines as well.   Chronic migraine is defined as a headache with migraine features that occurs on more than 15 days each month and it affects a staggering 4%-5% of the population.   Hormonal therapy usually consists of taking an oral contraceptive continuously for many months, thus eliminating menstrual periods and often headaches and PMS symptoms.   Oral contraceptives should not be taken by patients who have visual aura - visual disturbance that usually lasts 30 minutes and precedes the headache. --- ### Chronic migraine is poorly treated - Published: 2008-08-26 - Modified: 2008-09-04 - URL: https://www.nyheadache.com/blog/chronic-migraine-is-poorly-treated/ - Categories: Uncategorized Chronic 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 --- ### Migralex - first scientific presentation - Published: 2008-07-15 - Modified: 2009-10-01 - URL: https://www.nyheadache.com/blog/migralex-first-scientific-presentation/ - Categories: Uncategorized - Tags: headache, magnesium, medicine, migralex, treatment Migralex is an over-the-counter medication for the treatment of headaches, which will become available in November of 2009.   Results of the first study of Migralex were presented at the annual scientific meeting of the American Headache Society in Boston.   In an open-label study 50 patients with headaches who were being treated at the NYHC compared Migralex with their usual medication.   Half of the patients found Migralex better or much better than their usual treatment and 27 were willing to take it again.   In 31 of 50 patients the usual medication was a triptan ( a prescription migraine medication) and in 19 it was a prescription or over-the-counter pain medication.   Migralex was well tolerated, with only one patient reporting upset stomach. --- ### Vitamin D deficiency in chronic migraine - Published: 2008-07-15 - Modified: 2008-07-15 - URL: https://www.nyheadache.com/blog/vitamin-d-deficiency-in-chronic-migraine/ - Categories: Alternative Therapies - Tags: deficiency, migraine, vitamin D Vitamin D deficiency has become a very popular topic in lay and professional literature, and deservedly so.   Vitamin D is important not only for bone health, but for normal functioning of many organs.   Its deficiency appears to be much more common than it was previously suspected.   Dr. Steve Wheeler has found vitamin D deficiency in 42% of 55 patients with chronic migraine headaches.   He presented these findings at the recent meeting of the American Headache Society.   We do not have evidence that taking vitamin D will help relieve headaches, however if a deficiency is present correcting it can certainly improve overall health of the patient.   One possible cause of what appears to be increasing incidence of vitamin D deficiency is widespread use of prescription and over-the-counter antacids.   Reducing stomach acidity helps relieve heartburn and other symptoms of reflux, but it may also interfere with absorption of vitamins and minerals. --- ### What makes migraines get worse? - Published: 2008-07-09 - Modified: 2008-07-09 - URL: https://www.nyheadache.com/blog/what-makes-migraines-get-worse/ - Categories: Science of Migraine - Tags: , aspirin, caffeine, chronic, migraine A study conducted by one of the leading headache researchers, Dr. Richard Lipton looked at possible factors that worsen migraine headaches.   The study looked at people with frequent migraines (15 or more days with headache a month) and found that these patients were more likely to be female, overweight, depressed, have a lower education level and overused medications.   The overused medications included narcotics, barbiturates (Fioricet, Fiorinal and Esgic) but also over-the-c0unter drugs such as Excedrin.   The only exception was aspirin - it appeared to be protective, that is people taking aspirin were less likely to develop chronic headaches.   Dietary caffeine and stresful life events were also more common prior to development of chronic migraines. --- ### Empathy hurts! - Published: 2008-06-07 - Modified: 2008-06-07 - URL: https://www.nyheadache.com/blog/empathy-hurts/ - Categories: Pain Research, Uncategorized - Tags: empathy, pain A person  empathizing with someone in pain perceives his or her own pain as more severe and unpleasant.   Researchers at McGill University published these findings in the current issue of journal Pain.   This observation could explain, at least in part, high frequency of pain symptoms observed in spouses of chronic pain patients.    Even laboratory mice have heightened pain behavior when exposed to cagemates, but not to strangers, in pain.   Clearly, the thing to do is not to ignore your spouse's or friend's pain, but rather try to get the pain relieved.   If that is not possible, hopefully, a cognitive-behavioral psychologist may be able to devise a way to be very supportive and helpful without constantly feeling badly for the person in pain. --- ### Delaying treatment of pain has proven negative effects - Published: 2008-06-06 - Modified: 2008-06-06 - URL: https://www.nyheadache.com/blog/delaying-treatment-of-pain-makes-it-worse/ - Categories: Pain Research - Tags: delay, headache, pain treatment Patients who faced delays in the treatment of their chronic pain were found to have worsening of their condition, according to a recent review published in the journal Pain.   The review of 24 trials showed that patients had a significant deterioration of their health-related quality of life and psychological well being.   This was true for patients who waited for six or more months to receive treatment.   Studies looking at shorter wait times were less conclusive.   The authors conclude that waiting for treatment of chronic pain for six months or longer is medically unacceptable.   While our medical system is often to blame for such delays, many patients delay their treatment for a variety of other reasons as well.   It is important for friends and relatives to urge someone who suffers from chronic pain (including headaches) to seek medical attention from a qualified specialist. --- ### Facial expression of pain - Published: 2008-06-06 - Modified: 2008-06-06 - URL: https://www.nyheadache.com/blog/facial-expression-of-pain/ - Categories: Pain Research - Tags: facial expression, pain Facial expression of pain seems to make you feel worse, according to a study published in the May issue of The Journal of Pain.   Healthy volunteers were asked to make a painful expression before the pain started and without anyone appearing to be watching (to avoid "social feedback").   The pain was perceived more unpleasant when the volunteers made a painful facial expression compared to when a neutral facial expression was made.   Practical application of this study is in that people in pain should try to avoid grimacing from pain and keep their faces relaxed.   The authors discuss recent brain imaging studies which seem to confirm an old observation that facial expression can cause one to experience emotion that is being expressed.   In other words, forcing yourself to smile may improve your mood, while making an angry  face can make you feel angry. --- ### Treating migraines in adolescents - Published: 2008-05-21 - Modified: 2008-05-21 - URL: https://www.nyheadache.com/blog/treating-migraines-in-adolescents/ - Categories: New treatments - Tags: adolescent, migraine, treatment, triptan Treating migraines in adolescents presents some unique challenges.   Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks.   And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers.   The problem has been proving to the FDA that these drugs work in kids.   Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo.   Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks).    Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents.   A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age.   The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches.   I am often asked by other physicians, what is the youngest age I would prescribe a triptan?   Because of a shortage of pediatric neurologists I feel compelled to see children as young as... --- ### Blood pressure and headaches - Published: 2008-05-20 - Modified: 2008-05-20 - URL: https://www.nyheadache.com/blog/blood-pressure-and-headaches/ - Categories: Science of Migraine - Tags: blood pressure, diastolic, headache, migraine, systolic For many years headaches were thought to be triggered by elevated blood pressure.   Evidence had suggested that only very sudden increase in blood pressure triggered a headache in some patients, but the myth of high blood pressure headaches has persisted.   Norwegian researchers published a very surprising finding in the April issue of journal Neurology.    They looked at the data on 120,000 people and found that increasing systolic blood pressure was associated with a decrease in migraine and non-migraine headaches.   Even more striking was the inverse correlation with the pulse pressure (difference between systolic and diastolic pressure, for example blood pressure of 110/80 means that the pulse pressure is 30).   Patients with higher pulse pressure had fewer migraine and other headaches.   It can be speculated that hardening of arteries that occurs with elevated blood pressure makes them less likely to constrict and dilate, which is part of a migraine process. --- ### A new approach to menstrual migraine - Published: 2008-05-14 - Modified: 2008-05-14 - URL: https://www.nyheadache.com/blog/a-new-approach-to-menstrual-migraine/ - Categories: New treatments - Tags: maxalt, menstrual, migraine, steroid Menstrual migraines are at times very difficult to treat.  Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief.  Corticosteroid drugs, such as prednisone and dexamethasone can help some patients.  Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two.  Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women.  We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried.  Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects. --- ### A new approach to migraine - Published: 2008-05-10 - Modified: 2008-05-10 - URL: https://www.nyheadache.com/blog/a-new-approach-to-migraine/ - Categories: Science of Migraine - Tags: cgrp, combination, mechanism, migraine, treatment Scientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches.   They hypothesized that combining two different approaches would yield better outcomes than either one alone.   A neurotransmitter CGRP antagonists appear to be effective in the treatment of an acute migraine.   Merck has a product in late stages of development that works through this mechanism and hopefully will be the first of a new class of migraine drugs.   Based on laboratory research the Italian group suggests that combining a CGRP antagonist with a blocker of nerve growth factor may result in a more effective treatment.   This fits with a new trend in treatment of many conditions - combining drugs that work in different ways, rather than trying to always use a single medication. --- ### Doctors don't hear out migraine patients - Published: 2008-05-10 - Modified: 2008-05-10 - URL: https://www.nyheadache.com/blog/doctors-dont-hear-out-migraine-patients/ - Categories: Uncategorized - Tags: communication, disability, doctor, migraine, treatment Treatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment, but because of a communication barrier.   Doctors appear not to want to hear what migraine patients have to say about their headaches, according to a remarkable study by a top headache researcher Richard Lipton and his colleagues.   Patients and doctors agreed to be videotaped during a visit and 60 such interactions were analyzed.   The analysis showed that doctors did not ask about the disability of headaches and tended to ask closed-end short questions.   Very often the information they did obtain was incorrect.   55% of doctor-patient pairs were misaligned regarding frequency of attacks; 51% on the degree of impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention.   The authors recommended that doctors assess impairment using open-ended questions in combination with what is called the ask-tell-ask technique.   --- ### The prognosis of migraine - will it go away? - Published: 2008-05-05 - Modified: 2008-05-05 - URL: https://www.nyheadache.com/blog/the-prognosis-of-migraine-will-it-go-away/ - Categories: Science of Migraine How long will I suffer from migraines?   Will it ever go away?   These are very common questions patients ask their doctors.   Drs. Bigal and Lipton reviewed a recent large study that looked at what happens to migraine patients within one year of observation.   The study found that migraine completely went away in 10%, improved in 3% and worsened and became chronic (occurring on more than 15 days each month) in 3%.   This confirms what we've know all along – migraine headaches tend to go away with age.   In women this often happens after menopause and in men at around similar age; however this study and our experience indicates that for many people migraines may go away earlier, at any point in their lives.   The problem is that we can never predict when this will happen and in a small percentage of patients (about 3%) migraines never go away.    --- ### Treximet - a new migraine drug - Published: 2008-04-15 - Modified: 2008-04-27 - URL: https://www.nyheadache.com/blog/treximet-a-new-migraine-drugs/ - Categories: New treatments - Tags: migraine, naproxen, treatment, treximet, triptan Treximet, a new migraine treatment was approved today by the FDA.   Treximet is a combination of two old drugs - sumatriptan (Imitrex), 85 mg and naproxen (Aleve), 500 mg.   The combination is more effective than Imitrex alone because naproxen provides additional relief through its anti-inflammatory and pain relieving effects.   Imitrex is losing its patent protection and is going to be available as a generic drug in 2009.   The maker of Treximet, GlaxoSmithKline is hoping to switch most of the patients currently taking Imitrex to Treximet before patent expiration, in order to reduce its losses to generic competition.   However, it is likely that insurance companies will force physicians to prescribe generic Imitrex and generic naproxen rather than pay for Treximet.   GSK argues that the combination drug, just like Imitrex are fast-dissolving and therefore faster acting drugs than the generic naproxen is and the generic Imitrex is going to be. --- ### Migraine in left-handed - Published: 2008-04-08 - Modified: 2008-05-05 - URL: https://www.nyheadache.com/blog/migraine-in-left-handed/ - Categories: Science of Migraine - Tags: handedness, migraine For many years migraines have been thought to occur more often in left-handed people, but a new study from Germany disputes this theory.  A recent study published in journal Cephalalgia looked at 100 people with migraines and 100 controls and also reviewed five similar studies and found no difference in the incidence of migraines in left-handed and right-handed people.  This has been the observation at our headache clinic as well.   --- ### Most common time of day for migraine attack - Published: 2008-03-16 - Modified: 2008-03-16 - URL: https://www.nyheadache.com/blog/most-common-time-of-day-for-migraine-attack/ - Categories: Science of Migraine Migraine is most likely to occur at noon, according to an article just published in Headache by Norwegian researchers.   Although only 58 patients participated in this year-long study, there was a very clear peak of occurrence at noon.   This finding is different from what was reported in previous studies, which suggested that the most likely time for a migraine attack is in early morning hours.   The authors speculate that the restorative effects of sleep and work stress may be responsible for their finding. --- ### Botox helps tension headaches - Published: 2008-03-16 - Modified: 2008-03-16 - URL: https://www.nyheadache.com/blog/botox-helps-tension-headaches/ - Categories: New treatments - Tags: Botox, headache, tension Botulinum toxin injections relieve tension headaches, according to a study just published in the European Journal of Neurology .   Most of the previous studies had been conducted in patients with migraines or chronic migraines (more than 15 days of headaches a month).   There is much less evidence that Botox also helps tension headaches.   Our experience at the NYHC treating patients with tension headaches with Botox injections has been also very positive.   In this European study doctors used Dysport - a version of botulinum toxin type A that is not available in the US.   However, Dysport is very similar to Botox.   On the other hand, Myobloc, which is botulinum toxin type B,  is a very different version of botulinum toxin and in several aspects is inferior to Botox. --- ### Histamine for difficult to treat migraine and cluster headaches - Published: 2008-03-02 - Modified: 2008-03-02 - URL: https://www.nyheadache.com/blog/histamine-for-difficult-to-treat-migraine-and-cluster-headaches/ - Categories: New treatments - Tags: cluster, headache, histamine, migraine Migraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine.   Dr. Seymour Diamond of the Diamond Headache Clinic in Chicago has pioneered the use of histamine in cluster headaches.   We have found that in cluster headache patients for whom nothing else works histamine often provides excellent relief.   A recent study published in the journal European Neurology suggests that histamine injections may also help migraine patients.   --- ### Music relieves migraine headaches and pain - Published: 2008-02-20 - Modified: 2008-05-05 - URL: https://www.nyheadache.com/blog/music-relieves-migraine-headaches-and-pain/ - Categories: Alternative Therapies - Tags: migraine migraine pain headache Two recent studies suggest that music can relieve migraine headache in children and relieve experimentally-induced pain.   In a study of 58 children with migraine headaches published in the European Journal of Pain music therapy was compared to a placebo pill and an herbal supplement, butterbur.   Both music therapy and butterbur provided significantly better relief than placebo.   In the second study published in journal Pain, healthy volunteers were subjected to pain by heating up a spot on their forearms.   The volunteers were divided into three groups: a silent control group, a group listening to pleasant music and another group listening to unpleasant music.    Those who listened to pleasant music felt less pain than the other two groups.   These two studes provide scientific support to the use of music therapy for painful conditions, including migraine headaches.   --- ### New drug for migraine prevention - Published: 2008-02-13 - Modified: 2008-02-13 - URL: https://www.nyheadache.com/blog/new-drug-for-migraine-prevention/ - Categories: New treatments - Tags: beta-blocker, migraine, nebivolol, treatment A new drug may be better for the prevention of migraines than the old ones in the same category.   A study just published in Headache suggests that nebivolol, a beta-blocker just approved in the US for the treatment of high blood pressure may be as effective as old beta-blockers, but with significantly fewer side effects.   Beta-blockers, such as propranolol (Inderal), timolol (Blocadren) metoprolol (Toprol), atenolol (Tenormin) and nadolol (Corgard) have been used for the prevention of migraines for many years.   However, many patients could not tolerate them because of side effects, mostly fatigue, slow heart beat and low blood pressure.   Nebivolol appears to cause these side effects 50% less often, while preventing migraine attacks with equal efficacy.   --- ### Treating migraine with epilepsy drugs - Published: 2008-02-12 - Modified: 2008-02-12 - URL: https://www.nyheadache.com/blog/treating-migraine-with-epilepsy-drugs/ - Categories: New treatments - Tags: epilepsy, migraine, oxcarbazepine, treatment Anti-epilepsy drugs such as Neurontin (gabapentin), Topamax (topiramate) and Depakote (divalproex) have been proven to prevent migraine headaches.   Each drug works for about half of the patients who try it.   The other half either does not get any benefits or develops side effects.   This does not seem to be that effective, but these drugs do beat placebo in blinded trials.   We also know that not all anti-epilepsy drugs work for headaches.   Tegretol (carbamazepine) was never shown to help and a study just published in Neurology confirms our impression that its cousin, Trileptal (oxcarbazepine) does not work either.   We do occasionally see good results with two other epilepsy drugs, Keppra (levetiracetam) or Lamictal (lamotrigine), but large  clinical trials proving their efficacy are lacking. --- ### Memantine for migraines - Published: 2008-02-08 - Modified: 2008-02-08 - URL: https://www.nyheadache.com/blog/memantine-for-migraines/ - Categories: New treatments - Tags: memantine, migraine, nmda, treatment Memantine is an old medication which has been available in Europe for over 30 years, but was only recently introduced in this country for the treatment of Alzheimer's disease.   Memantine blocks a specific receptor in the brain cells.   Activation of this so called NMDA receptor is responsible for many negative effects, including pain and nerve cell damage.   As soon as the drug was introduced in the US pain and headache specialists tried using it for pain, but probably because it is a weak blocker of the NMDA receptor our experience with this drug has not been very impressive.   However, in the recent issue of journal Headache Greek doctors report that one patient with chronic migraines obtained complete relief due to memantine.   One case report clearly does not prove that memantine is going to work for any significant percentage of patients.   However, this drug has relatively few side effects and if the usual treatments fail it may be worth trying. --- ### Topamax side effects - Published: 2008-01-30 - Modified: 2008-02-08 - URL: https://www.nyheadache.com/blog/topamax-side-effects/ - Categories: New treatments - Tags: migraine, side effects, Topamax, Topiramate, word fluency Topamax is a popular drug for the prevention of migraine headaches.   IT works for about half of the patients who try it.   The main problem that makes people stop taking the drug is cognitive side effects.   Patients tell us that they feel "stupid" on this drug.   An article just published in the European Journal of Neurology pinpoints the main cognitive problem, which turns out to be word fluency.   This means having trouble coming up with the right word.   --- ### More on colored lenses and migraines - Published: 2008-01-30 - Modified: 2008-01-30 - URL: https://www.nyheadache.com/blog/more-on-colored-lenses-and-migraines/ - Categories: Alternative Therapies - Tags: lenses, light, Maxsight, migraine Bright light can trigger migraine headaches and many migraine sufferers have increased sensitivity to light during an attack.   A recent report has suggested that wearing amber colored lenses (Nike Maxsight) can relieve the light sensitivity.   For some of our patients wearing these lenses has allowed them to go outdoors on a sunny day without getting a migraine.   A new report in the journal Drug Development Research proposed a theory that each patient might best benefit from an individually selected tint (PSF, or precision spectral filters).   The article, Prevention of visual stress and migraine with precision spectral filters presents a convincing argument which should be relatively easy to test.   PSF appears to be more easily available in the UK where most of the research has been conducted.    --- ### Preventing migraines with a stroke drug? - Published: 2007-12-28 - Modified: 2007-12-28 - URL: https://www.nyheadache.com/blog/preventing-migraines-with-a-stroke-drug/ - Categories: New treatments - Tags: migraine, Plavix, stroke, treatment Clopidogrel, which is also known as Plavix, is a drug used to prevent strokes and heart attacks.   It works by preventing platelets from sticking together and causing a blood clot which can block a vessel in the heart or brain.   Platelets also tend to become sticky in patients during a migraine attack, which is how this drug might help migraine sufferers.   A British physician reported that a small number of patients given this drug stopped having migraine headaches after many years of unsuccessful treatments.   A large study is currently under way to prove that this drug in fact works better than a placebo.   --- ### Acupuncture for back pain - Published: 2007-12-07 - Modified: 2007-12-07 - URL: https://www.nyheadache.com/blog/acupuncture-for-back-pain/ - Categories: Alternative Therapies - Tags: acupuncture, back, headache, pain German researchers showed that acupuncture relieves back pain significantly better than combination of medications, physical therapy and exercise.   They enrolled over one thousand patients with chronic back pain in a study that compared traditional Chinese acupuncture (where acupuncture sites selected based on pulse diagnosis and other traditional methods and needles are placed along specific meridians on the body) with sham acupuncture (needle are placed superficially and outside the traditional points) and conventional approach.   It turns out that 10-15 sessions of both traditional and sham acupuncture treatments were better than conventional treatment, providing relief in 47. 6%, 44. 2% and 27. 4% of patients respectively.   This large study clearly proves the efficacy of acupuncture in back pain, regardless of the acupuncture technique.  Similar results have been found in headache patients.   --- ### More Botox studies - Published: 2007-12-03 - Modified: 2009-04-09 - URL: https://www.nyheadache.com/blog/more-botox-studies/ - Categories: New treatments - Tags: Botox, headache, migraine Botox has been shown to relieve migraine headaches in another two studies published in Headache.   One study compared the efficacy of Botox and an epilepsy drug, Depakote and found them to be equally effective.   However, Depakote caused more side effects, which resulted in more patients taking Depakote dropping out of the study.   The second study was done in patients who had difficulty complying with daily preventive medications.   Half of them were injected with Botox and the other half with saline water.   Neither the doctor nor the patient knew who received which treatment (double-blind study).   The impact of migraines on patients' lives was significantly improved by Botox.   These two studies by leading headache specialists provides additional proof that Botox is effective for the relief of migraine headaches. --- ### Migraine does not cause brain damage - Published: 2007-11-25 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/migraine-does-not-cause-brain-damage/ - Categories: Science of Migraine - Tags: brain, genetics, migraine, twins Migraine does not cause cognitive impairment, according to a new Danish twin study.   This important finding reassures millions of migraine sufferers and confirms our clinical observation.    Another recent study in mice suggested that inducing brain changes similar to what occurs during a migraine attack in humans can cause brain damage.   This report was widely circulated in the media and has caused unnecessary anxiety in many migraine sufferers.   Clearly, whatever those mice experienced was not a migraine attack and, more importantly, brains of mice are very different from human brains.   The Danish study looked at 139 pairs of twins where one of the twins had migraines and the other one did not.   Comparing their cognitive abilities revealed no difference for those who had migraine with or without aura, even after taking into account age, age of onset, duration of migraine history and number of attacks.   Presence of aura is thought to indicate a more serious condition with a slight increase in the risk of stroke.   However, on one cognitive test, men with migraine with aura did better than their twin without migraines. --- ### Botox for arthritis? - Published: 2007-11-21 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/botox-for-arthritis/ - Categories: New treatments - Tags: arthritis, Botox, pain Botox relieves migraine headaches and other painful conditions, such as sciatica, neuralgias and neck pain.   A recent study of 43 patients with arthritis of the shoulder suggests that Botox may relieve arthritis pain as well.   This was a double-blind study where half of the patients were given Botox and the other half saline injections.   Neither the doctor nor the patient knew what was being injected.   The results clearly favored Botox and the difference was statistically significant.   This adds another possible indication to a long list of conditions that Botox might relieve.   The safety of Botox in this study was as remarkble as in all previous studies, which now number in hundreds.    --- ### Migraine Brain - Published: 2007-11-21 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/migraine-brain/ - Categories: Science of Migraine - Tags: brain, migraine A recent study published in Neurology showed that migraine sufferers have thicker gray matter in the part of the brain that perceives pain.   Thickening of the gray matter indicates larger number of brain cells in that area, which is not necessarily a bad thing.   However, all of the commentary in the media suggests that this is another indication of brain damage in migraine patients.   This study is not a cause for alarm and all of the previous research also indicates that the vast majority of migraine sufferers are not at risk of brain damage. --- ### How long do you have to take medicine? - Published: 2007-11-12 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/how-long-do-you-have-to-take-medicine/ - Categories: New treatments - Tags: migraine, Topamax, treatment This is a common question people ask when we suggest that they start taking a daily preventive medication.   A groundbreaking study just published by Hans-Christoph Diener and his colleagues answers this question.   Over 800 patients were placed on topiramate (Topamax), a popular epilepsy drug used to treat headaches.   After 26 weeks half of the patients were switched to placebo and the other half contined on Topamax for another 26 weeks without doctors or patients knowing who was taking what.   It turns out that stopping Topamax did worsen headaches, but not that much - in a 28-day period those on Topamax had one fewer day with migraine than those on placebo.   This suggests that what most headache specialists have suspected from their experience all along is correct.   That is many patients can stop taking their daily medication after about six months without significant worsening.   However, there are some patients who may need to stay on a medication for longerer periods of time. --- ### Vitamin D and exercise - Published: 2007-11-09 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/vitamin-d-and-exercise/ - Categories: Pain Research - Tags: exercise, pain, vitamin D We always recommend exercise as one of the most effective preventive treatments for migraines and tension-type headaches.   However, it appears that some patients may have difficult time exercising because of low vitamin D levels.   Vitamin D receptors are located within muscle and are important for normal muscle activity.   Michael Hooten and colleagues discovered that pain clinic patients who had low vitamin D levels had lower exercise tolerance as well as lower general health perception than patients with normal levels.   Most people are familiar with the role of vitamin D in bone health.   However, it has many other functions in the body.   In addition to exercise tolerance, another unexpected effect of vitamin D deficiency is to worsen symptoms of gastro-esophageal reflux, which causes heartburn and other symptoms.   Taking vitamin D supplements relieves reflux symptoms in some patients.   Many people are not taking sufficient amounts of vitamin D.   If deficiency is documented by a blood test, patients usually need to take 1000-2000 units a day. --- ### Sex differences in response to opioid drugs - Published: 2007-11-09 - Modified: 2007-11-09 - URL: https://www.nyheadache.com/blog/sex-differences-in-response-to-opioid-drugs/ - Categories: Pain Research It appears that women respond better to morphine than men and men respond better to a different opioid (narcotic) drug, butorphanol.   This was the conculsion of a study presented at the American Pain Society.   The next step that the researchers plan is to look at possible genetic factors which may explain this difference.   Although the study was small and needs to be confirmed, such knowledge could have an important practical impact.   Opioid drugs are rarely used for the treatment of headaches, but when necessary it would be useful to know which one has a better chance of success. --- ### Science of acupuncture - Published: 2007-11-09 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/science-of-acupuncture/ - Categories: Alternative Therapies - Tags: acupuncture, fibromyalgia, pain A recent study by Richard Harris presented at the American Pain Society's meeting of 18 patients with fibromyalgia showed different brain mechanisms for true and sham acupuncture.   It appears that placebo response in sham acupuncture can be differntiated from the true acupuncture response by measuring binding properties of the mu opioid receptor in the brain.   This study further confirms the fact that one of the most important mechanisms of action of acupuncture is through the endogenous opioid system and that it is different from the mechanism of the placebo effect. --- ### MSG and headaches - Published: 2007-11-09 - Modified: 2007-12-03 - URL: https://www.nyheadache.com/blog/msg-and-headaches/ - Categories: Pain Research - Tags: headache, msg, pain Many patients tell me that monosodium glutamate (MSG) gives them headaches, but we never had a scientific study to explain or support this observation.   A study by Brian Cairns and his colleagues in the November issue of journal Pain reveals possible mechanism by which this happens.   The researchers found that rats given MSG had an elevated level of glutamate in their muscles and that MSG made the muscles more sensitive to pressure.   Glutamate is a neurotransmitter that promotes pain transmission in the nerveous system and therefore the authors concluded that MSG could increase pain sensitivity in humans as well.   The bottom line, if you are prone to headaches or have chronic pain, stay away from MSG. --- ### Anne Frank's headaches - Published: 2007-10-25 - Modified: 2007-10-25 - URL: https://www.nyheadache.com/blog/anne-franks-headaches/ - Categories: Uncategorized - Tags: Anne Frank, headache, migraine "Anne Frank's headache" is the title of an article just published by RF de Almeida and PA Kowacs in the journal Cephalalgia.   This is an abstract of the article: "There are a significant number of famous people who suffered from frequent headaches during their lifetime while also exerting an influence of some kind on politics or the course of history. One such person was Anneliese Marie Frank, the German-born Jewish teenager better known as Anne Frank, who was forced into hiding during World War II. When she turned 13, she received a diary as a present, named it ‘Kitty’ and started to record her experiences and feelings. She kept the diary during her period in hiding, describing her daily life, including the feeling of isolation, her fear of being discovered, her admiration for her father and her opinion about women's role in society, as well as the discovery of her own sexuality. She sometimes reported a headache that disturbed her tremendously. The ‘bad’ to ‘terrifying’ and ‘pounding’ headache attacks, which were accompanied by vomiting and during which she felt like screaming to be left alone, matched the International Headache Society criteria for probable migraine, whereas the ‘more frequent headaches’ described by Anne's father are more likely to have been tension-type headaches than headaches secondary to ocular or other disorders. " --- ### Postpartum headaches - Published: 2007-10-17 - Modified: 2014-12-29 - URL: https://www.nyheadache.com/blog/postpartum-headaches/ - Categories: New treatments - Tags: eclampsia, magnesium, migraine, postpartum, pregnancy, spinal headache, tension Postpartum headaches are very common and are usually benign. A study presented at the meeting of the Society for Maternal-Fetal Medicine by Dr. Caroline Stella and her colleagues looked at 95 women with severe headaches that started 25 hours to 32 days after delivery and were not responsive to usual doses of pain medicines.  Half of these women eventually were diagnosed to have migraine or tension-type headaches and they all responded to higher doses of pain drugs.  In one quarter of patients headaches were due to preeclampsia or eclampsia and were relieved by intravenous magnesium or magnesium and high blood pressure medications. Fifteen women had spinal headaches due to complication of epidural analgesia and they responded to a "blood patch" procedure. Only one woman had a brain hemorrhage and one had thrombosis (occlusion) of a vein in the brain. The authors suggested that all these conditions should be considered when evaluating women with postpartum headaches and appropriate testing needs to be performed. In another study presented at this meeting Dutch researchers found that women who suffered from an episode of eclampsia had persistent cognitive dysfunction 6-8 years later. This contradicts the widely held belief that women with eclampsia can expect full recovery. This study suggests that eclampsia needs to be treated early and aggressively (magnesium infusion is one of the main treatments) to prevent permanent brain injury. It is also important to understand that persistent cognitive dysfunction is not psychological in nature and that it should be treated with cognitive rehabilitation. --- ### Good news - migraine goes away! - Published: 2007-10-17 - Modified: 2007-10-17 - URL: https://www.nyheadache.com/blog/good-news-migraine-goes-away/ - Categories: Science of Migraine Migraine is known to subside in most people, often when they reach their 40s or 50s.    A recent report from Sweden suggests that even patients with more severe migraines who end up going to a headache clinic have favorable long-term prognosis.   One third of both men and women reported complete cessation of their migraines.   Of the other two thirds the majority reported reduction in frequency and duration of attacks 12 years after their initial visit to the headache clinic.   The bad news is that many of the patients who continued to have headaches still had some impairment of quality of life. --- ### Promising new medicine. - Published: 2007-10-09 - Modified: 2016-09-09 - URL: https://www.nyheadache.com/blog/promising-new-medicine/ - Categories: New treatments Results of a phase II study of a new headache medicine was published in journal Neurology. Merck and Co. is starting phase III trials of this drug, which works by blocking the release of a neurotransmitter CGRP. Previous migraine medicines, such as sumatriptan (Imitrex), rizatriptan (Maxalt), eletriptan (Relpax) and other in the triptan family worked on serotonin receptors. While the triptans are very safe they very rarely can constrict blood vessels in the heart and cause a heart attack. The new medicine, which is known as MK-0974 does not constrict blood vessels. In the published trial it was at least as effective as Merck's older drug, Maxalt. If phase III studies go well we could see this medicine on the market in a couple of years. --- ### Dental migraine - Published: 2007-09-29 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/dental-migraine/ - Categories: Science of Migraine Pain of migraine can be localized to the face and around the mouth according a two recent reports. Dr. Gaul and colleagues reported in journal Cephalalgia on two patients who had dental pain as well as typical migraine symptoms, including throbbing, sensitivity to light and noise and in one of the patients visual aura (flickering colorful lights) preceding the attack. This report confirms the fact that pain of migraine can occur anywhere in the head, including teeth, eyes, ears, forehead, top or back of the head. --- ### New formulation of Imitrex Injection - Published: 2007-09-27 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/new-formulation-of-imitrex-injection/ - Categories: New treatments The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. We find that Imitrex injections are very underutilized, mostly because doctors don't offer them as an option to their patients. Surprisingly, surveys indicate high acceptance of injections by patients. This should not be so surprising at all considering how disabling migraines can be. The ideal candidates for injectable Imitrex include patients who have severe nausea, those who wake up with a severe attack and need prompt relief, patients for whom oral triptans do not provide adequate relief and those with cluster headaches. We typically prescribe 6 mg injections and use 4 mg ones for patients who are very sensitive to drugs, have small weight or have side effects from 6 mg. --- ### How Botox relieves migraines - Published: 2007-09-22 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/how-botox-relieves-migraines/ - Categories: New treatments It is not clear how Botox relieves migraine headaches. Oliver Dolly, an Irish researcher who devoted many years of his work to the study of botulinum toxin, has just published results of a new study which may help explain this question. Twelve years ago when I started using Botox for the treatment of headaches the only possible explanation for the way it worked was that it relaxed tight muscles. It is true that during a migraine attack muscles go into a contraction and many patients find some relief by massaging their temples, back of their head and neck. However, some people reported to me that injecting Botox relieved their headaches in the temples, forehead and back of the head, but not on the top of the head. I did not inject the top of the head because there are no muscles there. When I did inject those areas to my surprise pain on the top of the head improved as well. This has been also observed by many of my colleagues around the country. Dr. Dolly's experiment showed that in addition to relaxing muscles, Botox prevents the release of CGRP (a chemical messenger - neurotransmitter) from nerve endings and stops painful messages from being transmitted along the nerves. It appears that relaxing muscles may be less important than stopping nerves from sending pain messages to the brain. --- ### Exercise, depression and migraines - Published: 2007-09-20 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/exercise-depression-and-migraines/ - Categories: Alternative Therapies Depression (and anxiety) is 2-3 times more common in those suffering from migraines than in people without migraines. Depression is not caused by migraines because patients who develop depression first are 2-3 times more likely to develop migraines than people without depression. It is likely that abnormalities in the function of certain brain chemicals (serotonin, norepinephrine and other) that cause one condition predispose people to develop the other one as well. Certain types of antidepressants prevent migraine headaches even in patients who have none of the signs of depression. It appears that treatments that work for depression can help with migraines as well. At the NYHC we showed this to be true for an experimental treatment using vagus nerve stimulation. We have always advised our patients that one of the best preventive treatments for migraines is to engage in aerobic exercise for 20-30 minutes five days a week. Possible reasons why this treatment works include relief of stress, improved blood circulation in the brain and the release of endorphins - natural painkilling substances. We did not have scientific studies to prove that we were right, but the majority of patients who followed this advice improved. Now we have a scientific study that indirectly supports this treatment. The study by James Blumenthal and his colleagues, published in the journal Psychosomatic Medicine, included 202 men and women who were diagnosed with major depression. They were randomly assigned to one of four groups: one that worked out in a supervised, group setting three... --- ### Acupuncture for migraines - Published: 2007-09-20 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/acupuncture-for-migraines/ - Categories: Alternative Therapies It is no big news that acupuncture helps migraine patients. Nevertheless, it is good to see yet another study confirming this. Maybe, once the health care mess is straightened out and common sense prevails, the insurance companies will notice all these studies and start paying for acupuncture. The latest study published in the September issue of journal Headache was controlled and randomized, that is it was scientifically sound. The Italian researchers led by Dr. Facco compared true acupuncture with sham acupuncture and no preventive treatment. They found that three and six months after the start of treatment patients in the true acupuncture group did significantly better. --- ### Botox for migraines - success predictors - Published: 2007-09-16 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/botox-for-migraines-success-predictors/ - Categories: New treatments A study just published by Dr. Mathew and his colleagues in the journal Headache reports that patients with chronic migraine headaches responded to Botox better than patients with chronic tension headaches. Patients who had headaches predominantly on one side and those with scalp tenderness had a better response to Botox. Scalp muscle tenderness was also a predictor of response in chronic tension headaches. Overall, Botox was highly effective in patients with chronic migraine - 76%, (54 out of 71 patients) obtained relief. Of those 54 patients 37 or 69% had one-sided headaches. Having headaches on both sides does not preclude success with Botox - 17 patients with bilateral headaches also responded. This study confirms what I have observed in my 12 years of treating thousands of patients with Botox - it is a highly effective and safe treatment for frequent migraine headaches. --- ### Cervical disk prolapse, headaches and Botox - Published: 2007-09-11 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/cervical-disk-prolapse-headaches-and-botox-prolapse-or-herniation-of-the-upper-cervical-disc-is-known-to-cause-not-only-neck-pain-but-also-so-called-cervicogenic-headaches/ - Categories: New treatments Prolapse or herniation of the upper cervical disc is known to cause not only neck pain but also so called cervicogenic headaches. Dr. Diener and his German colleagues reported (in journal Cephalalgia) on 50 patients who had prolapse of lower cervical disks and used as controls 50 patients with lumbar disk herniations. They found that 12 out of 50 patients with lower cervical disk herniations developed a headache and in 8 out of 12 headache stopped within a week following surgery. Only two of the patients with lumbar disk herniations developed a headache. Three months after surgery seven of 12 had no headaches and three were improved. It is not very surprising that these patients had headaches - neck muscles overlap all along the neck and form a supporting collar for the cervical spine. Muscle spasm in the lower neck that accompanies a herniated disk will often cause this spasm spread up the neck and cause a headache. Even patients with migraines at times develop a migraine attack from spasm of muscles in the neck or even shoulders. When treating these patients, both with migraines and cervicogenic with Botox injections are usually given not only into the muscles around the head, but also in the neck and shoulders. This makes Botox treatment significantly more effective. --- ### Food colorings and migraine - Published: 2007-09-07 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/food-colorings-and-migraine/ - Categories: Alternative Therapies A study just published in the British medical journal Lancet reports on the effect of food colorings in children. This study found that food colorings cause symptoms of attention deficit disorder in young children. Many of my patients report that food colorings, and more often food preservatives, trigger their migraines. The role of colorings, preservatives and sugar substitutes in causing migraine headaches has not been evaluated as rigorously as it was done in this Lancet study of children and remains controversial. However, this study clearly indicates that food colorings can have a negative effect on the brain, which makes it very likely that some migraine sufferers may benefit from eliminating colorings (and preservatives and sugar substitutes) from their diets. --- ### Migraine and abuse - Published: 2007-09-05 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/migraine-and-abuse/ - Categories: Science of Migraine Dr. Tietjen reports in the current issue of Neurology on a survey performed at six headache clinics. A total of 949 women with migraine completed the survey: 40% had chronic headache (that is headaches occuring on more than 15 days each month) and 72% had "very severe" headache-related disability. Major depression was recorded in 18%. Physical or sexual abuse was reported in 38%, and 12% reported both physical and sexual abuse in the past. Migraineurs with current major depression reported physical and sexual abuse in higher frequencies compared to those without depression. Women with major depression were more likely to report sexual abuse occurring before age 12 years and the relationship was stronger when abuse occurred both before and after age 12 years. Women with major depression were also twice as likely to report multiple types of maltreatment compared to those without depression. Similar findings have been reported in patients with chronic pain other than headaches. Brains of migraine sufferers have been found to be more excitable than brains of people without migraines. It is likely that trauma of abuse makes the nervous system even more excitable and more prone to developing chronic pain and headaches. --- ### Hemiplegic Migraine - Published: 2007-09-01 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/hemiplegic-migraine/ - Categories: New treatments Hemiplegic migraine can be safely treated with triptans (drugs like Imitrex, Maxalt and other). This is the conclusion of a study published in the September issue of journal Cephalalgia. A group of Finnish doctors gave triptans to 76 patients who suffered from hereditary and non-hereditary forms of hemiplegic migraine - migraine that is accompanied by temporary paralysis of one side of the body. They found that triptans worked well and none of the patients had strokes or any other serious reactions. According to the FDA, triptans are not to be given to patients suffering from hemiplegic migraine because they potentially could cause a stroke. No strokes have ever been reported, but it was thought that constriction of blood vessels in the brain during hemiplegic migraine is responsible for the weakness and giving triptans could worsen this constriction and cause a stroke. In the past several years we have learned that weakness is caused by a disturbance of brain neurons rather than constriction of blood vessels. Many headache specialists use Imitrex and similar drugs in patients with hemiplegic migraine and several years ago Drs. Klapper and Mathew have already reported on their positive experience in a small group of patients. --- ### MRI scan as Treatment - Published: 2007-08-31 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/mri-scan-as-treatment/ - Categories: Science of Migraine Researchers at several companies are using brain images obtained by an MRI machine to train people with chronic pain how to control their pain. These MRI images are not of the type that are routinely taken to look at the brain structure. Instead, these are images obtained by "functional MRI" which show how different parts of the brain react to pain. By seeing these images of pain displayed as a flame patients are able to reduce the size of the flame and also reduce their pain. It is similar to what is done during old-fashioned biofeedback sessions where patients monitor their temperature or muscle tension and by learning to control these functions of the body are also able to reduce their pain and prevent migraine headaches. It is possible that functional MRI feedback training will prove to be more effective, but it is also likely to be much more expensive. --- ### Noise and Migraines - Published: 2007-08-31 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/noise-and-migraines/ - Categories: Alternative Therapies Noise is a well-known trigger of migraines. Recent findings by WHO researchers indicate that excessive exposure to noise causes other health hazards as well. Noise from daytime traffic can result in chronic stress with an increase in the risk of heart attacks and strokes. Installing noise-insulating windows and using noise-cancelling ear phones can be helpful, albeit expensive. Listening to music to drown out the noise is another option, but can be hazardous when walking in the streets of a big city. Mayor Bloomberg's recent focus on reducing noise pollution in New York City is a step in the right direction. --- ### Drug side effects - Published: 2007-08-28 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/drug-side-effects/ - Categories: Alternative Therapies A recent survey by Beatrice Golomb and her colleagues which was reported by Reuters Health discovered that when patients reported adverse reactions to drugs their doctors routinely denied that the drug was responsible for these side effects. To a great extent this is due to doctors’ lack of knowledge about potential side effects, but I suspect it is also because doctors have an unreasonable degree of reliance and faith in drugs. Pharmaceutical companies are doing a great job selling benefits of drugs to doctors, but the education about potential side effects is clearly lacking. Medical school training also makes doctors biased toward drugs and against alternative therapies. In treating migraine patients I often see people who were prescribed by their doctor 2-3 daily medications and who were never offered any alternatives. The efficacy of many of the supplements (magnesium, CoQ10, alpha-lipoic acid and others) is as good as that of many drugs doctors use for headaches. Eliminating caffeine, regular exercise, dietary changes, biofeedback and even Botox injections are some of the other excellent approaches that should be tried before drugs. --- ### Surgery for migraines - Published: 2007-08-09 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/surgery-for-migraines/ - Categories: New treatments I just received an announcement for the “2nd Annual Surgical Treatment of Migraine Headaches. ” The event is sponsored by Case Western Reserve University and presented by its Department of Plastic Surgery. Ten of the 12 speakers on the program are plastic surgeons. Their premise is that since Botox injections relieve migraines, why not go a step further and cut those muscles in the forehead for permanent relief. When I asked my friend Ken Rothaus, a plastic surgeon at the New York Hospital, about this approach, he was not excited—despite the potential new pool of patients. Here is what he said: "I think that when there exists a relatively non-invasive procedure such as Botox that works so well and costs less than the corresponding surgical procedure, it represents the better first line choice for the patient. All surgery has risks and complications, Botox can be injected in all the involved areas not just the glabellar, and the cumulative cost of 3-5 years of Botox may be less than that one surgical procedure. " Another strong argument against surgery is the very nature of migraines. They come and go for long periods of time, and on their own improve with age in most patients. An additional reason, and perhaps the most compelling: Plastic surgeons lack training in diagnosing and treating headaches. They do not know how to properly diagnose different types of headaches, how to detect potential triggers, and how to combine different treatments into a comprehensive plan. A case can... --- ### Headaches and suicide - Published: 2007-08-06 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/headaches-and-suicide/ - Categories: Science of Migraine In a study presented at the recent meeting of the American Psychiatric Association Dr. Stephen Woolley found that adults suffering from severe headaches have a 30% to 50% increased chance of having suicidal thoughts or behaviors, independent of the presence of anxiety or depression. The recommendation for the doctors is to routinely screen patients suffering from severe headaches for suicidality even if they do not suffer from anxiety or depression. Family members and friends should also be aware of this fact and discuss it openly with headache sufferers. A study published in a recent issue of journal Neurology found that adolescents who suffer from chronic daily headache, particularly if they also had migraine with aura had a six times higher risk of suicide than their headache-free peers. This was a community-based study conducted by Dr. Shuu-Jiun Wang in Taiwan. Almost half of adolescents with headaches had at least one psychiatric disorder. The most common disorders were major depression which was found in 21% and panic disorder in 19%. --- ### Brain damage - Published: 2007-07-26 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/brain-damage/ - Categories: Science of Migraine Brain damage from migraines? Maybe, if you are a mouse. A recent study published in the journal Nature Neuroscience discovered that a process that simulates migraine in mice leads to brain damage similar to that seen with repeated ministrokes. It is true that patients with migraines with aura (visual disturbance that precedes headaches, which occurs in about 15% of migraine sufferers) have an increased risk of strokes, but this risk is still very low. The vast majority of migraine sufferers stop having migraines in their 40s and 50s and we have no evidence that having migraines for many years causes any permanent brain damage. What happens to mice can never be directly extrapolated to humans. (See my comments on Fox News under NYHC in the News) --- ### Menstrual cluster - Published: 2007-07-19 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/menstrual-cluster/ - Categories: Science of Migraine Cluster headaches are much more common in men. Cluster headaches are much more common in men. However, they do occur in women and in the latest issue of journal Headache Dr. T. Rozen presents the first report of a woman who was having cluster attacks only with her menstrual cycle. --- ### RLS - Published: 2007-07-18 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/rls/ - Categories: New treatments Restless leg syndrome (RLS) affects 10% of the population with 3% suffering from severe symptoms. Patients suffering from RLS complain of difficulty falling asleep because of uncomfortable sensation in their legs which is temporarily improved by moving their legs or getting up and walking around. The movement of the legs persists in sleep and interferes with the deep restful stages of sleep leading to tiredness during the day. Many patient do not realize they have a problem because they've had it all their lives and because one of their parents also had it. Researchers reporting in the recent issue of journal Nature Genetics say they have found proof of the genetic nature of RLS. However, not all patients with these symptoms have RLS. Iron deficiency, peripheral nerve damage and antidepressant medications can cause symptoms of RLS. Another sleep disorder, such as sleep apnea can at times mimic RILS and a sleep study may be needed to establish the diagnosis. Treatment of RLS involves the use of medications such as Requip, Mirapex, which belong to a category of drugs called dopamine agonists (they are also used to treat Parkinson's disease, but these two conditions are not related). Some epilepsy drugs, including Neurontin and Topamax and particularly opioid analgesics, such as hydrocodone and oxycodone can be effective. Sleep deprivation or poor quality of sleep can be a major trigger for migraine headaches. We see many patients with RLS at the NYHC and treating their RLS will often improve their headaches. --- ### Amber contact lenses - Published: 2007-07-18 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/amber-contact-lenses/ - Categories: New treatments A recent small study suggests that wearing red colored contact lenses can relieve pain of a migraine attack. A recent small study suggests that wearing red colored contact lenses can relieve pain of a migraine attack. At the NYHC we have tried this approach and in a several patients it made a dramatic difference. One woman has found that she no longer has to be confined to a dark room and is able to go outside wearing these lenses without developing a migraine from bright daylight. Some patients wear these lenses all the time, while others only when they have a headache. Sunglasses do not offer the same level of light filtering,uinless they are of wraparound type and fit tightly around the eyes. --- ### Endometriosis - Published: 2007-07-17 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/endometriosis/ - Categories: Science of Migraine Women with migraine have a higher chance of also having endometriosis. A study by Dr. Gretchen Tietjen and her colleagues published in the latest issue of journal Headache looked at 171 women with migraine and 104 controls. Endometriosis was reported more commonly in migraineurs than in controls (22% vs 9. 6%). Frequency of chronic headache was higher in migraineurs with endometriosis ompared to without it and headache-related disability scores were also higher in the endometriosis group. Depression, anxiety, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis were more common in migraine with endometriosis group than in controls. Anxiety, interstitial cystitis and chronic fatigue syndrome were more common in migraine with endometriosis group, than in the patients with migraine without endometriosis. --- ### Brain lesions in migraine - Published: 2007-07-13 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/brain-lesions-in-migraine/ - Categories: Science of Migraine However, presence of any brain lesion is worrisome to most patients and according to some researchers may be indicative of small strokes or another type of brain damage. Some researchers have been concerned, although without any evidence, about possible accumulation of these lesions with progressive brain damage. A report in the June issue of Cephalalgia by Dr. Todd Rozen presents a case where a brain lesion seen on the first MRI scan was no longer seen on the second one 16 days later. We have always reassured our patients about the benign nature of these lesions, but it is good to have this additional evidence. --- ### Migraine in pregnancy and CVD - Published: 2007-07-13 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/migraine-in-pregnancy-and-cvd/ - Categories: Science of Migraine Migraines at the end of pregnancy and soon after the delivery increase the risk of strokes and other vascular complications (cerebro-vascular disease, or CVD). Dr. Bushnell and her colleagues presented these findings at the last annual meeting of the American Academy of Neurology. They looked at almost 17 million pregnancies and identified almost 34,000 women who had migraines. There was an increase in migraines with increased maternal age. Women who had migraines around the time of delivery were 19 times more likely to have a stroke, five times more likely to have a heart attack, three times more likely to have a pulmonary embolus, more than twice the risk of deep venous thrombosis, nearly four times he risk of thrombophilia, twice the risk of heart disease and more than twice the risk of preeclampsia/gestational hypertension. About two thirds of women stop having migraines during their pregnancies, but if headaches are present at the end of pregnancy close observation is warranted. It is possible that magnesium supplementation as well as regular exercise, proper diet and other life style changes may help prevent these serious complications. Long-term risk for strokes and heart attacks is higher in women who keep additional weight gains after pregnancy. --- ### Migralex - Published: 2007-07-11 - Modified: 2009-10-01 - URL: https://www.nyheadache.com/blog/migralex-migralex%e2%84%a2/ - Categories: Uncategorized - Tags: aspirin, headache, magnesium, treatment Migralex - A Breakthrough in the Treatment of Headaches. Migralex is a headache medication developed and patented by Dr. Alexander Mauskop, Director and Founder of the New York Headache Center. Migralex is a product of 15 years of research and development. It will become available for purchase at the end of 2009 at www. Migralex. com and www. Amazon. com. --- ### Alpha lipoic acid relieves migraine headaches - Published: 2007-07-11 - Modified: 2009-03-08 - URL: https://www.nyheadache.com/blog/alpha-lipoic-acid-alpha-lipoic-acid-relieves-migraine-headaches/ - Categories: Alternative Therapies According to a recent study by Magis and colleagues (Headache 2007;47:52-57) daily dose of 600 mg of alpha lipoic acid (also known as thioctic acid) was significantly better than placebo in reducing the frequency of migraine attacks, headache days and pain severity. This natural supplement is being investigated as a treatment for multiple sclerosis and HIV disease and it may be helpful for patients with Alzheimer's and Parkinson's as well as diabetes, strokes and heart attacks. Since the publication of this study we have been recommending alpha lipoic acid to many of our migraine patients. --- ### Medication overuse - Published: 2007-07-10 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/medication-overuse-headache-medication-overuse-headache-moh-does-not-respond-to-steroids/ - Categories: New treatments Medication overuse headache (MOH) does not respond to steroids according to a new study published in the July 3 issue of journal Neurology. Patients who take Fioricet, Fiorinal, Esgic, Excedrin and other, mostly caffeine-containing drugs often have a headache that is perpetuated by the constant intake of these drugs. This is less likely to happen from triptans, such as Imitrex, Maxalt and Relpax or ibuprofen and acetaminophen. When we try to stop these medications headache usually worsens for several days or weeks before it gets better. We do use corticosteroids (prednisone, dexamethasone, methylprednisolone) to treat not only headaches that result from medication withdrawal but also severe migraines that do not respond to the usual migraine drugs. Corticosteroids are safe when taken occasionally, but can cause many different and often dangerous side effects if taken for long periods of time (weeks and months). We limit the use of corticosteroids to a few days a month. The editorial which accompanies this report comments on the fact that a previous, larger but less rigorous study found that steroids are beneficial for MOH. The possible reasons for this discrepancy are: 1. the dose of prednsione used in the study was not high enough; 2. corticosteroids are only effective for MOH in patients who suffer from migraines and not tension-type headaches (both were included in this study); and 3. the older and larger study was not blinded and placebo might have played a bigger role. The bottom line is that because of our positive experience... --- ### New report on topiramate (Topamax) - Published: 2007-07-08 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/new-report-on-topiramate-topamax/ - Categories: New treatments Chronic migraine headaches can be helped by topiramate (Topamax) even in those patients who are having rebound headaches from daily intake of pain or migraine medications, according to a report in the latest issue of Cephalalgia. Chronic migraine headaches can be helped by topiramate (Topamax) even in those patients who are having rebound headaches from daily intake of pain or migraine medications, according to a report in the latest issue of Cephalalgia. Common thinking is that in order for a preventive drug, like topiramate to work the patient first has to stop drugs that cause rebound headaches. This study suggests that patients can obtain relief even without stopping the drug that causes rebound. We find that the same is true for Botox - it can also help relieve chronic migraines without the patient having to first get off drugs such as Fioricet and Excedrin. --- ### Women with migraine - Published: 2007-07-07 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/women-with-migraine/ - Categories: New treatments Women with migraine have a higher frequency of excessive and/or prolonged menstrual bleeding and endometriosis, according to a study published recently in Headache, the journal of the American Headache Society. While as many as 60% of women experience migraine in conjunction with their menstrual periods, there is little information regarding the relationship between migraine and menstrual disorders. (1,2). A study published in 2004 found an increased prevalence of migraine in women with endometriosis (a condition in which the endometrial tissue is outside of the uterus) (3), but the reason for this association is unknown. Menstrual problems are common, and unusually heavy bleeding over several cycles in a row occurs in about 30% of women. 4 Endometriosis affects 0. 5% to 5% of fertile women and 25% to 40% of infertile women. (5-7) To understand more about the association between menstrual disorders and migraine, Dr. Gretchen Tietjen of the Medical College of Ohio in Toledo, and colleagues, enrolled 50 female migraineurs (diagnosed according to the International Headache Society criteria) of childbearing age and 52 age-matched women. They were asked to complete a questionnaire regarding migraine and migraine-related disability, menstrual history, other bleeding history, vascular event history, and vascular risk factors. The frequency of smoking, oral contraceptive use, and hormone replacement therapy was similar between the two groups of women. Twenty-three of the 50 migraineurs reported that migraine was associated with their menstrual period, and 36% suffered from chronic headache (15 or more days/month). More migraineurs reported unusually heavy periods (63% vs.... --- ### Another study of Botox for migraines. - Published: 2007-07-06 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/another-study-of-botox-for-migraines/ - Categories: New treatments Curtis Schreiber and Roger Cady reported their study at the recent annual meeting of the American Academy of Neurology. This was a randomized, double-blind, placebo controlled study Another study of Botox for migraines. Curtis Schreiber and Roger Cady reported their study at the recent annual meeting of the American Academy of Neurology. This was a randomized, double-blind, placebo controlled study (that is the most reliable kind of a study) of patients who had disabling headaches and had difficulty complying with their previous prophylactic treatment. 60 received Botox and 21 received placebo injections. There was a significant improvement in headache frequency, headache impact (so called HIT-6 measure) and treatment satisfaction in patients who received Botox compared to those who received placebo. There are about 100 published reports on the use of Botox for migraine headaches and the experience of most headache experts in the US is very positive. However, many insurance companies will not cover Botox because the FDA has not yet approved it for migraines. Allergan, the company that manufactures Botox is conducting the FDA-required trials (we at NYHC are participating in one of the two trials), but the earliest possible time for approval is 2009. --- ### Combining drugs to treat migraine headaches - Published: 2007-07-05 - Modified: 2009-10-01 - URL: https://www.nyheadache.com/blog/combining-drugs-to-treat-migraine-headaches/ - Categories: Uncategorized - Tags: headache, magnesium, migralex "Old Drugs In, New Ones Out", a story in the New York Times on July 1, 2007 reports on a growing trend in the pharmaceutical industry where two existing generic drugs are combined into a new more effective product. "Old Drugs In, New Ones Out", a story in the New York Times on July 1, 2007 reports on a growing trend in the pharmaceutical industry where two existing generic drugs are combined into a new more effective product. One example is Trexima, a drug developed by Pozen and GlaxoSmithKline, which contains sumatriptan (Imitrex) and naproxen (Aleve). Combining drugs with different mechanisms of action results in an improved efficacy, although side effects could also add up. The New York Headache Center has participated in the trials of Trexima, which is expected to be approved by the FDA in August of this year. Another example of combining two old ingredients is Migralex, a medication for the acute treatment of headaches, which is being developed by Dr. Alexander Mauskop. Migralex is expected to be available to patients by the end of 2009. It will contain a combination of aspirin and magnesium.   Migralex will have an improved side effect profile because magnesium has a protective effect on the stomach lining. --- ### Distress and sciatica - Published: 2007-07-03 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/distress-and-sciatica/ - Categories: Pain Research Presence of anxiety and depression (“distress”) at the time of initial diagnosis of sciatica predict worse outcome of both surgical and non-surgical treatment three years after the onset of pain according to a report in the July issue of journal Pain. Presence of anxiety and depression (“distress”) at the time of initial diagnosis of sciatica predict worse outcome of both surgical and non-surgical treatment three years after the onset of pain according to a report in the July issue of journal Pain. The authors speculate that the reason could be lower self-management efforts and maladaptive coping strategies. In fact previous studies have shown that adaptive coping skills training produces improvement in pain that lasts for months and years beyond the actual training. This training is usually performed by cognitive psychologists. --- ### Acupuncture treatment - Published: 2007-06-21 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/acupuncture-treatment/ - Categories: Alternative Therapies A study just published in the journal Pain looked at the effect of patient expectations on outcome of acupuncture treatment. Four large studies were analyzed and one of the four A study just published in the journal Pain looked at the effect of patient expectations on outcome of acupuncture treatment. Four large studies were analyzed and one of the four involved treatment of migraines and one of tension-type headaches. Patients who prior to the start of treatment thought that acupuncture was effective or highly effective did much better than those who were skeptical about it's efficacy. The difference persisted 6 months following the treatment. These finding are not very surprising, but they do have an important practical application. If you do not believe acupuncture will work you are better off trying another treatment. (Linde K, Witt, C, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain 128 (2007) 264-271) --- ### Heart surgery to prevent migraine - Published: 2007-04-11 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/heart-surgery-to-prevent-migraine/ - Categories: New treatments Patients who suffer from chronic migraines say they would do anything to rid themselves of the pain-but heart surgery? Click here to download the full article ( . pdf ) --- ### Study of Occipital Nerve Stimulation - Published: 2007-02-13 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/study-of-occipital-nerve-stimulation/ - Categories: New treatments Medtronic Begins Study of Occipital Nerve Stimulation for Chronic, Refractory Migraine Headaches; Implanted Device Delivers Electrical Impulses to Occipital Nerves. Medtronic Begins Study of Occipital Nerve Stimulation for Chronic, Refractory Migraine Headaches; Implanted Device Delivers Electrical Impulses to Occipital Nerves Medtronic, Inc. today announced the first patient implant in a preliminary study to evaluate if an implanted device might help some of the thousands of Americans who suffer the agony of chronic migraine headaches that have not responded to other treatments. More on occipital nerve block: The current issue of journal Headache presents a report of two patients whose prolonged hemiplegic migraine aura resolved with greater occipital nerve block. It is hard to explain how blocking a nerve would stop this brain dysfunction, but Botox which we routinely use to treat migraines, also seems to affect brain processes through peripheral nerves. I might try occipital nerve block for my next patient with a prolonged aura, but only if an intravenous infusion of one gram of magnesium sulfate fails. --- ### Cluster headache news - Published: 2006-03-15 - Modified: 2007-10-03 - URL: https://www.nyheadache.com/blog/cluster-headache-news/ - Categories: Alternative Therapies Intranasal use of capsaicin (on the side of the headache) has been reported to relieve cluster headaches. Capsaicin is an extract of hot peppers and can cause burning pain and irritation of the nasal mucosa. It must be used twice a day for several days before improvement is noticed. Intranasal use of capsaicin (on the side of the headache) has been reported to relieve cluster headaches. Capsaicin is an extract of hot peppers and can cause burning pain and irritation of the nasal mucosa. It must be used twice a day for several days before improvement is noticed. A study published in Neurology, the journal of the American Academy of Neurology, indicates that oral zolmitriptan (Zomig) is effective in the treatment of cluster headaches. The study used a 10 mg dose, which exceeds the FDA-approved maximum dose of 5 mg for migraines. However, oxygen inhalation and injectable sumatriptan (Imitrex), when effective, usually provide faster relief. Prophylactic treatment Several reports suggest that in addition to such standard therapies as Depakote, verapamil, and lithium a nightly 10 mg dose of over-the-counter melatonin can prevent cluster headaches in some patients. Since a short course of melatonin is very safe, it is worth a try after consultation with your physician. ---