Headache NewsBlog

Dramatic weight loss with a diabetes drug; may help migraines and other neurological problems

By: Dr. Mauskop

01-04-2021

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 FDA approval will compel insurance companies to pay for it. The out-of-pocket cost of 4 pen-like syringes is $735.

Bidirectional association between loneliness and pain

By: Dr. Mauskop

21-03-2021

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 experiences that impact well-being and quality of life. The researchers concluded that the relationships between pain and loneliness are bidirectional.

Low cerebrospinal fluid pressure headache

By: Dr. Mauskop

13-03-2021

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 did not change with the change of position and 1% had no headache but only other symptoms.

The five most common symptoms of SIH besides headaches, were nausea, neck pain or stiffness, tinnitus (ringing in the ears), dizziness, and hearing problems.

The diagnosis can be made by an MRI scan with an intravenous injection of gadolinium, which is a contrast dye. According to Dr. Matharu’s review, however, MRI was normal in 19% of patients. A spinal tap to measure the pressure can be a useful test, although it was normal in one-third of patients. This is explained by the fact that intracranial pressure often fluctuates. In some patients, a spinal tap can make headaches worse. Another test is an MRI of the spine to detect an accumulation of the leaking CSF. This test was helpful only in a little more than half of the patients. A more advanced test done when other tests are negative and a blood patch is ineffective is a digital subtraction myelogram. So even when SIH is suspected – and often it is not – it may be difficult to prove the diagnosis.

In 28% of patients, bed rest and hydration were sufficient to heal the leak. A single or repeated blood patch was effective in 64% of patients. When the site of the leak is not found, most specialists do a blind patch at the lumbar level. A larger volume of blood, 20-30 ml is more effective than smaller volumes. In a small proportion of patients, surgical repair of the leak is necessary and it is done by a neurosurgeon.

Postural orthostatic tachycardia syndrome (POTS) and migraine

By: Dr. Mauskop

06-03-2021

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 suffer from two or more of the many symptoms listed below. Not all patients with POTS have all these symptoms.
High blood pressure/low blood pressure.
High/low heart rate; racing heart rate.
Chest pain.
Dizziness/lightheadedness especially in standing up, prolonged standing in one position, or long walks.
Fainting or near-fainting.
Exhaustion/fatigue.
Abdominal pain and bloating, nausea.
Temperature deregulation (hot or cold).
Nervous, jittery feeling.
Forgetfulness and trouble focusing (brain fog).
Blurred vision.
Headaches and body pain/aches (may feel flu-like); neck pain.
Insomnia and frequent awakenings from sleep, chest pain and racing heart rate during sleep, excessive sweating.
Shakiness/tremors especially with adrenaline surges.
Discoloration of feet and hands.
Exercise intolerance.
Excessive or lack of sweating.
Diarrhea and/or constipation.

Cyclic vomiting, a migraine variant

By: Dr. Mauskop

25-02-2021

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 (Emend) can be given by injection. Prochlorperazine (Compazine) and promethazine (Phenergan) are available in rectal suppositories.

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

Low dietary intake of magnesium increases the risk of migraines

By: Dr. Mauskop

18-02-2021

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

By: Dr. Mauskop

12-02-2021

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 likely to have an episode of TGA.

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

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

In a new study prednisone relieves cluster headaches

By: Dr. Mauskop

01-02-2021

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 attacks in a week may not seem that significant, but only to those who’ve never had a cluster headache. And these mean numbers hide the fact that for some prednisone is highly effective, while for others, not at all. Also, the pain intensity was lower and the number of attacks in the prednisone group remained lower during the fourth week.

Clusters tend to occur once or twice a year or once every few years. Once we find a treatment that works well, including prednisone, it tends to work well for every subsequent attack

No serious side effects occurred in the prednisone group. However, this was a relatively small study and we know that serious side effects can happen even from a short course of prednisone.

About a quarter of my patients get very good immediate relief from an occipital nerve block and avoid taking prednisone. Some of these patients don’t even need Emgality or verapamil. They stay headache-free until the next cluster period.

Even when a preventive treatment is very effective, occasional attacks may still occur. This is why I also always prescribe treatment to stop an individual attack. This is usually sumatriptan injections and occasionally, zolmitriptan nasal spray or inhalation of oxygen.

Just published – The End of Migraines: 150 Ways to Stop Your Pain

By: Dr. Mauskop

17-01-2021

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

By: Dr. Mauskop

14-01-2021

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 60 mg a day.

One of the articles cited above was accompanied by an editorial that recommends using a steroid nasal spray. This sounds reasonable for milder cases, but if I were to completely lose my sense of smell, I would take at least 30 mg of prednisone.

Persistent loss of smell can be a devastating condition. According to Healthline, the loss of the sense of smell can lead to
1. an inability to taste food, which can lead to eating too much or too little
2. an inability to smell spoiled food, which can lead to food poisoning
3. increased danger in the event of a fire if you cannot smell smoke
4. losing the ability to recall smell-related memories
5. loss of intimacy due to the inability to smell perfume or pheromones
6. losing the ability to detect chemicals or other dangerous odors in your home
7. lack of empathy from family, friends, or doctors
8. inability to detect body odors
9. mood disorders such as depression
10. lack of interest in social situations, which might include being unable to enjoy the food at a social gathering

Prolonged postconcussion headaches after mild head injury

By: Dr. Mauskop

08-01-2021

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 therapy, multimodal treatment, and acceptance and commitment therapy can reduce catastrophizing.

Nerivio relieves migraine in adolescents

By: Dr. Mauskop

03-01-2021

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.