Headache NewsBlog

If two antidepressants fail, TMS may offer relief.

By: Dr. Mauskop

11-08-2024

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 respond to multiple standard therapies. About half of these patients respond well. However, we do not have large controlled trials to confirm that TMS effectively treats migraines.

Focused ultrasound to specific brain regions relieves pain

By: Dr. Mauskop

04-08-2024

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 to TMS applied to the motor cortex, which can provide improvements in chronic pain in certain groups of patients. The key difference is that ultrasonic waves can directly modulate the deep brain regions involved in chronic pain, including the anterior cingulate cortex. Transcranial magnetic stimulation is believed to modulate deep brain regions only indirectly, which may contribute to its variable response and the need for frequent re-administrations. Nonetheless, the effects of both modalities may be complementary, and their combined application may provide stronger effects than either approach alone.”

Another MRI study attempts to diagnose migraine

By: Dr. Mauskop

22-07-2024

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

By: Dr. Mauskop

09-07-2024

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

By: Dr. Mauskop

23-06-2024

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 supplements. Your pancreas and kidneys can also make around 1 gram of creatine each day. Creatine is one of your body’s natural energy sources.

Nearly 95% of the creatine in your body is stored in your skeletal muscles and is used during physical activity. As a dietary supplement, creatine is commonly used to improve exercise performance in athletes and older adults.”

There is not enough evidence to routinely recommend creatine for the treatment of migraine headaches. I do, however, recommend to my older patients taking 5 to 7 grams of creatine an hour before or after exercise. I am 67 and do take it when I exercise.

Another study confirms that candesartan relieves migraines

By: Dr. Mauskop

12-06-2024

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 days per month and both were significantly more effective than placebo.

Abnormal functional connectivity in patients with post-traumatic headaches

By: Dr. Mauskop

03-06-2024

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), a non-invasive technique that can modulate brain activity in specific regions. By stimulating the areas with abnormal connectivity, rTMS may help restore normal brain function and alleviate headache symptoms and other neurological and psychiatric symptoms. When possible, we perform fMRI scans on individual patients to identify the specific brain regions involved in their headache disorder. However, fMRI is still only a research tool, and when individual fMRI data is not available, studies like this one provide information on common brain changes associated with post-traumatic headaches that can be targeted with TMS.

Abnormal functional connectivity in brains of patients with vestibular migraine

By: Dr. Mauskop

27-05-2024

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 research foundations will provide the funds needed to study this promising treatment.

Our brains are getting bigger, and hopefully, we are getting smarter.

By: Dr. Mauskop

13-05-2024

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

By: Dr. Mauskop

05-05-2024

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 high-dose EPA supplement. Overall, the high dose of EPA from fish oil was able to significantly reduce migraine frequency and severity, improve psychological symptoms, and boost the quality of life for these episodic migraine patients over the 12 weeks. No major side effects were seen.

The cheapest and the highest quality product that will give you such a high amount of EPA is a prescription drug, icosapent ethyl (Vascepa). Most insurers will not cover it for migraines but a 60-day supply (120 capsules) will cost you $77, according to GoodRx.com. You do need a doctor to prescribe it to you.

PPIs are the worst, but all heartburn drugs increase the risk of severe headaches

By: Dr. Mauskop

28-04-2024

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 help mitigate potential nutrient deficiencies. Vitamin B12 is often poorly absorbed and getting a monthly injection is more reliable. Some of our migraine patients, even some who are not on acid-suppressing drugs, also require monthly infusions of magnesium.

Visit with the Nolan Williams’ TMS team at Stanford

By: Dr. Mauskop

24-04-2024

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.