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 the brain, oh-oh, a migraine is starting. This in turn leads to anxiety, activation of the fight-or-flight response and soon a real migraine begins. Actually, when a patient comes in with pages and pages of notes that describe each migraine attack with possible triggers, detailed description of each attack, medications taken and their side effects, I know that this patients will be harder to help.

In case of migraine headaches we do have a very good substitute for a daily diary. It is a Migraine Disability Assessment Scale, or MIDAS, which assesses migraine-related disability over the previous three months. This is a simple 5-question scale that was validated by comparing a daily diary with patient recollection. Surprisingly, the correlation was very strong and the scale gives reliable information. We ask patients to complete MIDAS on every visit. At a glance, it tells us how disabling the migraines are and how aggressive we need to be in starting preventive therapies, such as Botox, drugs, and the new monoclonal antibodies. This score is also helpful for patients who may not remember how disabling the headaches were before they started a particular treatment. It also shows the insurance companies how well an expensive treatment such as Botox works, so that they approve continued therapy.

As far as identifying triggers, most are obvious and patients do not need a diary to tell them that alcohol, lack of sleep, skipping meals, stress, etc. are causing their attacks. Yes, for some patients a diary can identify gluten sensitivity, menstrual cycle, or another trigger that was not obvious, so I would not discourage anyone from keeping a diary. But do it for a few months and if no useful information can be gleaned from it, stop.

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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 there is only a suspicion of an allergic component. It is also useful when anxiety is a contributing factor, which is not unusual since those suffering from migraines are 2-3 times more likely to also have anxiety. For many patients it is too sedating to be taken during the day, unless they are treating an acute attack. Most people take 25 or 50 mg nightly, although some tolerate and benefit from 25 mg taken three times a day.

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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.

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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. Read More

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 long-term opioid maintenance, but the number of such patients in our practice is also exceptionally low.

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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 entire WSJ article.

I’ve written several times about the dangers of long-term treatment with PPIs, acid reducing drugs, such as Prilosec and Nexium. Among other side effects, they interfere with the absorption of vitamin B12 and other vitamins and minerals.

As far as headaches, vitamin B12 deficiency can be a contributing factor and taking vitamin B12 along with other B vitamins can relieve migraines.

Pain of facial neuralgia was found to be due to vitamin B12 deficiency in case studies of 17 patients and their pain resolved with vitamin B12 injections.

As the WSJ article suggests, many patients with neurological symptoms require regular injections rather than taking vitamin B12 pills. A couple of hundred of our patients come for monthly vitamin B12 injections, often along with an infusion of magnesium – another very common and highly underdiagnosed deficiency. It is not only migraines and other headaches that improve, but also fatigue, dizziness, and other symptoms.

Here is an old article from the Educational Materials section of our website.

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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 list of preventive therapies, also tends to appeal to men, but my second recommendation, meditation much less so.

Men are more receptive to the idea of taking a shot for their problem and here they are also correct – taking an injection of sumatriptan (Imitrex) stops an attack of migraine within 10-20 minutes, while a pill of sumatriptan can take up to two hours and may not work as well.

The new class of CGRP monoclonal antibodies (Aimovig, Ajovy, Emgality) also obviates the need for taking a pill every day – they are injected once a month (Ajovy can be injected every three months) to prevent migraines.

The bottom line – if you know a man who admits to having headaches, chances are they are suffering more than they let on. Tell them to see a headache specialist.

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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 used when other acute migraine therapies have failed. The neurological side effects are more common with continued daily use of haloperidol and other neuroleptics in psychiatric disorders.

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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. However, setrons have the advantage of not having the potential to cause serious neurological side effects. These include severe restlessness and involuntary movements (tardive dyskinesia), which in rare cases can become permanent.

We do treat patients with an acute migraine in the office and after an infusion of magnesium usually start with ondansetron and a pain medicine such as ketorolac (Toradol), but in some people, metoclopramide is consistently more effective. If metoclopramide causes restlessness, intravenous diphenhydramine (Benadryl) almost always stops it.

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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.

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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.

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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 recent review confirmed that cluster headaches respond well to inhalation of oxygen. The only FDA-approved treatment for the treatment of cluster headaches is injection of sumatriptan to treat each attack. To stop the entire cluster we give occipital nerve blocks and prescribe short courses of prednisone (corticosteroid). If headaches persist, a blood pressure medication, verapamil can be effective if given in high doses. The new migraine drugs, CGRP monoclonal antibodies (Aimovig, Ajovy, and Emgality), appear to be very effective for some patients with cluster headaches, although they are not yet FDA-approved for this type of headaches.

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