Headache NewsBlog

New daily persistent headache (NDPH) is an unhelpful myth

By: Dr. Mauskop

26-12-2020

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 “new daily” disease.

There does not appear to be any justification for having NDPH as a distinct condition. It does not have a typical clinical presentation and it has not led to any research or treatment. When you search for this condition on the internet, you will not find any effective treatment for it. The suffering of many patients is magnified by the loss of hope, worsening depression, and flagging will to live.

Most importantly, some patients with NDPH do respond to treatment. According to anecdotal reports and in my experience, Botox injections, intravenous magnesium, preventive drugs for migraines, and other treatments can be effective.

Stiff from too much time at a computer? Feldenkrais to the rescue.

By: Dr. Mauskop

20-12-2020

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 each lesson is communicated effectively and will help maximize your benefits.

DO ONLY WHAT IS EASY: Make each movement easy and
comfortable. Do not strain or stretch. Doing only what is
easy will facilitate your ability to pay attention to the
quality of your movement.
MAKE EACH MOVEMENT SMALL: Small movements, done easily, enable your body to improve most effectively. Large movements, done with effort, reduce your ability to heal and improve.
GO SLOWLY: Do each movement slowly. This will give you time to sense and feel what you are doing, so that you can easily detect and reduce unnecessary effort and strain.
PAUSE BETWEEN EACH MOVEMENT: Do not repeat the movements quickly, one after another. Awareness Through Movement® is most effective when you pause and relax completely for a moment after each movement, allowing your brain time to absorb new and useful sensory information.
REDUCE UNNECESSARY EFFORT: Small, slow, and easy movements allow you to detect the unnecessary effort in your body. With reduced effort, your movement will automatically improve.
DON’T TRY: Your improvement will be greater and quicker if you do not ‘try to succeed’. When you try, you are more likely to use more effort than necessary.
TAKE RESTS: Fatigue causes unnecessary and inefficient effort in your movement, interfering with your ability to heal and improve. If at any time during a lesson you feel a need to rest, simply pause until you are ready to continue.
AVOID PAIN AND DISCOMFORT: You should never experience discomfort or pain while doing Awareness Through Movement. Only do the small amount that feels comfortable and easy. If you experience pain or discomfort, use even less effort and make each movement even smaller and slower, or try doing the movements in your imagination.
USE YOUR KINESTHETIC IMAGINATION: When you visualize doing a movement, your brain sends essentially the same message to your muscles as when you are actually moving. To use your imagination, close your eyes and imagine doing the movements with ease and with as much kinesthetic detail as you can.
CONTINUE YOUR PROGRESS: By doing Awareness Through Movement® often, you will initiate a process of steady improvement. You can also maximize the benefits by periodically recalling the movements of a recent lesson, including your feelings and sensations.

What to try first, Botox or CGRP mAbs?

By: Dr. Mauskop

13-12-2020

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%; fremanezumab: 55%; galcanezumab: 45%).

Not all of my patients begin with Botox. Some prefer mAbs because they don’t like the idea of having multiple injections over their face and head. Others cannot obtain insurance coverage for Botox. During COVID, some patients were reluctant to come to the office for Botox injections and they preferred to start a mAb at home. Three of the four available mAbs can be self-administered. The fourth one, eptinezumab (Vyepti) is given intravenously every 3 months.

100 Migraine Drugs, A to Z: zonisamide

By: Dr. Mauskop

09-12-2020

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

By: Dr. Mauskop

03-12-2020

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

By: Dr. Mauskop

28-11-2020

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, Tosymra contains 10 mg of sumatriptan while the original spray contains 20 mg. However, it comes out in smaller droplets and contains an ingredient that allows for better absorption. This formulation of sumatriptan spray appears to be as effective as Zomig NS.

Zolmitriptan nasal spray is expensive (as is Tosymra) because it is available only as a branded product. It will lose its patent protection in 2021.

Virtual reality for pain relief

By: Dr. Mauskop

22-11-2020

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 vertigo, similar to motion sickness. This is why VR sessions are often limited to a maximum of 30 minutes.

It appears that there are several possible approaches to the treatment of pain using VR. One is by using VR for distraction. Another, by utilizing VR to facilitate biofeedback, which is proven to relieve migraine and tension headaches. The third way, yet to be proven, is by altering body perception.

100 Migraine Drugs, A to Z: verapamil

By: Dr. Mauskop

14-11-2020

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

By: Dr. Mauskop

06-11-2020

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 25 years of using Botox for migraines, I’ve given it to more than a dozen pregnant women. A few of them continued to receive Botox throughout more than one pregnancy.

Botox has been in use for over 30 years and millions of women have been treated with it with no reports of fetal problems. Unlike oral or injected drugs, it has only a local effect. The amount of Botox given for chronic migraines is measured in nanograms. After injections, it cannot be detected in the blood. All this suggests that Botox is safer than drugs taken by mouth or given by injection.

Dry eyes and migraine

By: Dr. Mauskop

01-11-2020

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

By: Dr. Mauskop

24-10-2020

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

By: Dr. Mauskop

18-10-2020

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 warranted. It is probably better to spend the money on trying to reduce alcohol consumption.