Headache NewsBlog

Botox for TMJ; the effect on clenching and grinding of teeth

By: Dr. Mauskop

24-02-2018

TMJ syndrome is a disorder which often coexists with migraine and tension-type headaches and is characterized by pain in the jaw joint and surrounding muscles. It is very common, but the exact cause remains unclear. In many people TMJ is a sleep disorder, which can occur in the absence of overt stress, but stress definitely plays a role in most people. Headaches in patients with traumatic brain injury can be also worsened by bruxism (clenching and grinding of teeth), while treating bruxism contributes to the relief of headaches.

Dentists usually advise patients to sleep with a custom-made bite guard, but it only reduces grinding and may not stop clenching.

The standard injection protocol for migraines includes injections into the temples (temporalis muscles), which are involved in clenching, but my 25 years of using Botox suggests that many patients get much better results if lower jaw (masseter) muscles are also injected.

A study just published in Neurology tested the safety and efficacy of onabotulinumtoxin-A (Botox) injections into those muscles (masseter and temporalis) in patients with sleep bruxism.

This study included adults with sleep bruxism which was confirmed by an overnight sleep study. The study was randomized and placebo-controlled (half received Botox and the other half, placebo), with an open-label extension (when everyone receives Botox). Participants were injected with 200 units of Botox – 60 into each masseter and 40 into each temporalis muscle or placebo (by comparison, a total of 155 units is used to treat chronic migraine headaches). They were examined 4 to 8 weeks after the initial treatment. Global impression scale and perceived change in bruxism and in pain were assessed. .

Of the 22 participants who completed the study (19 women, mean age 47 years), 13 were given Botox and 9 received placebo. Global impression, pain and bruxism favored the Botox group. Two participants who received Botox reported a cosmetic change in their smile. No other side effects were reported. I find that many patients like the cosmetic effect of injections into the lower jaw muscles – they often acquire a more rounded face, instead of a square-jawed one. On the other hand, if temporalis muscles are injected too far towards the front of the temple, it can lead to an unattractive caved-in appearance.

In addition to Botox and an oral appliance, many patients with bruxism and headaches benefit from stress reduction techniques, such as meditation, biofeedback, progressive relaxation, yoga, and other. When medications are needed, we most often prescribe muscle relaxants and antidepressants.

gammaCore for migraine

By: Dr. Mauskop

12-02-2018

Alternative Therapies, Migraine, neurostimulation

An electric stimulation device, gammaCore has received clearance from the U.S. Food and Drug Administration (FDA) as an acute treatment of pain associated with migraine in adult patients. gammaCore is a hand-held device that stimulates the vagus nerve in the neck through the skin and was developed following and based on my 2005 publication describing the use of implantable vagus nerve stimulator for refractory chronic cluster and migraine headaches. This adds to the approval gammaCore received for the acute treatment of pain associated with episodic cluster headache in adult patients in April 2017. The clearance is limited to pain of migraine, rather than migraine attacks, meaning that the device relieves pain and may not relieve other migraine symptoms, such as nausea and sensitivity to light and noise.

The FDA clearance of gammaCore for the acute treatment of pain associated with migraine was supported by the results of the multicenter, randomized, double-blind, sham-controlled trial that demonstrated that “treatment with gammaCore for the acute treatment of pain associated with migraine was superior to sham, and also enabled patients to reach pain freedom more frequently by 30, 60, and 120 minutes compared with sham treatment”. Just like with all other studies with gammaCore, the therapy was found to be well tolerated by patients.

gammaCore is also available outside of the U.S., including in Canada and the European Economic Area. The manufacturer offers a free trial of the device, which cannot be purchased, but only rented. Some insurance plans may pay for the rental.

Here are a few disclaimers and warnings from the manufacturer:

The safety and effectiveness of gammaCore (non-invasive vagus nerve stimulator) has not been established in the acute treatment of chronic Cluster Headache.
This device has not been shown to be effective for the prophylactic treatment of chronic or episodic cluster headache.
The long-term effects of the chronic use of the device have not been evaluated.
Safety and efficacy of gammaCore has not been evaluated in the following patients, and therefore is NOT indicated for:
Patients with an active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device
Patients diagnosed with narrowing of the arteries (carotid atherosclerosis)
Patients who have had surgery to cut the vagus nerve in the neck (cervical vagotomy)
Pediatric patients
Pregnant women
Patients with clinically significant hypertension, hypotension, bradycardia, or tachycardia

Patients should not use gammaCore if they:
Have a metallic device such as a stent, bone plate, or bone screw implanted at or near their neck
Are using another device at the same time (eg, TENS Unit, muscle stimulator) or any portable electronic device (eg, mobile phone)

The Feldenkrais method

By: Dr. Mauskop

03-02-2018

Alternative Therapies, Brain disorders

A recent article in the New York Times by the health columnist, Jane Brody, Trying the Feldenkrais Method for Chronic Pain, described her very positive experience with the Feldenkrais method. Then, at about the same time a patient told me that Feldenkrais lessons made a big difference in her neck and back pain. I started to read about Feldenkrais (download an article from the Smithsonian Magazine), took a lesson with my patient’s teacher, and then invited this teacher to work in our office.

This method was developed by a Russian-born Israeli engineer Dr. Moshe Feldenkrais (1904-1984). He was a physicist who was educated at Sorbonne and worked with Frédéric Joliot-Curie, then worked in the British survey office and during the war, as a science officer in the Admiralty. In 1936, while in France, he became one of the first Europeans to earn a black belt in judo.

A knee injury led Feldenkrais to develop a movement method named after him. He did not call it therapy and always insisted that he did not treat patients, but rather taught lessons on how to move naturally. At the same time, his lessons often led to a dramatic relief of pain, improved movement and functioning in individuals who suffered from cerebral palsy, strokes, multiple sclerosis, back, and neck pains. He felt that the key to healing was to become aware of what one is doing. Dancers, artists, and athletes have been using Feldenkrais lessons to improve their performance and to heal and avoid injuries. In the early 1950s Feldenkrais worked with the first Prime Minister of Israel, David Ben-Gurion, whose decades-long chronic back pain dramatically improved. Feldenkrais quit his position as the first director of the electronics department of the Israeli Defense Force and decided to devote all of his time to teaching his movement method. He had trained hundreds of practitioners all around the world and they in turn trained the next generation of teachers.

Feldenkrais emphasizes gentle and often small movements that re-educate and re-establish the connection between the body and the brain. It also makes you do movements that do not come naturally and that we never do, such as turning your head to one side and moving your eyes in the opposite direction. It is difficult to describe this method in words, but even a single lesson can show its dramatic potential. Try this simple exercise. Check the range of movements in your neck – how far can you turn your head to one side, then the other without straining. Then, put palms of your hands on your cheeks and attach your arms to the body. Now, turn your body at the waist from the midline to the left and back to the midline, again only as far as you can comfortably do it. Repeat this 10 times and then 10 times from the midline to the right. Now, put down your arms and test your range of movements again. Most people, including those who have very tight neck muscles, will noticed a significant and a very surprising improvement. Surprising, because it happened without moving your neck. You can watch me doing this exercise on youtube; I also show another exercise that improves the lateral flexion of your neck.

A possible explanation is that our brains get visual cues indicating that our head moved far to one side, but the brain cannot tell if the movement came from turning the torso or the neck. Repeating the move 5-10 times trains our brain to allow such movement even when we only move the neck. This explanation has some scientific support. When vision and proprioception were incongruent, participants were less accurate and initially relied on vision and then proprioception over time.

This explanation has some scientific support. The authors of an article in the Experimental Brain Research, Untangling visual and proprioceptive contributions to hand localisation over time, conclude that “When vision and proprioception were incongruent, participants were less accurate and initially relied on vision and then proprioception over time” (proprioception is our sense of the relative position of our body parts).

Another fascinating phenomenon that provides Feldenkrais method additional scientific support is the observation that when we cross our hands, we feel less pain in the hand. The Journal of Pain published an article “Seeing One’s Own Painful Hand Positioned in the Contralateral Space Reduces Subjective Reports of Pain…” Scientific research using functional MRI images of the brain led to the publication of another article in the same journal: Crossing the line of pain: FMRI correlates of crossed-hands analgesia.

It appears that our visual cues are very important to our ability to move and feel pain and this may be one of the ways the Feldenkrais method improves movement and relieves pain.

Individual lessons can be expensive ($100-$200 an hour), but Feldenkrais is often taught in groups, which makes it more affordable. You can also learn it by reading books, such as Awareness Heals: The Feldenkrais Method For Dynamic Health , audio recordings – The Feldenkrais Lessons: Awareness Through Movement by Bruce Holmes , and youtube videos

Feverfew for migraines

By: Dr. Mauskop

28-01-2018

Alternative Therapies, Migraine

Feverfew (tanacetum parthenium) is one of the oldest herbal remedies for the treatment of migraine headaches. It was first mentioned as a treatment for inflammation 2,000 years ago. Feverfew is a member of the daisy family and all above-ground parts of the plants are safe to ingest and it is usually consumed as dried leaves or tea made of dried flowers. Besides migraine, it has been used for the treatment of fevers, rheumatoid arthritis, stomach aches, toothaches, insect bites, psoriasis, allergies, asthma, tinnitus, dizziness, nausea, and vomiting, infertility, problems with menstruation and labor during childbirth.

We do have some scientific evidence for the effectiveness of feverfew in the prevention of migraine headaches. Here is a brief description of two of the five published trials of feverfew.

A study, Randomized double-blind placebo-controlled trial of feverfew in migraine prevention was published in the Lancet by British researchers led by JJ Murphy. 60 patients completed this study, in which half of the migraine patients received feverfew and the other half, placebo. After four months the treatment was switched (so called crossover study). Patients in the feverfew group had 4.7 fewer attacks, while placebo resulted in 3.6 fewer attacks. Global assessment of improvement was 74 vs 60. Feverfew also reduced the severity of nausea and vomiting.

Another, more rigorous study by German researchers led by HC Diener was published in Cephalalgia. It was entitled, Efficacy and safety of 6.25 mg t.i.d. feverfew CO2–extract (MIG-99) in migraine prevention – a randomized, double-blind, multicenter, placebo-controlled study.
This study enrolled 170 migraine sufferers with 89 receiving a special extract of feverfew and 81, placebo. The number of migraine attacks dropped by 1.9 in the feverfew group and by 1.3 attacks in the placebo group. The difference in the global assessment of efficacy was also statistically significant.

As far as side effects, mouth sores have been reported and, like with any herbal product, feverfew can cause upset stomach or an allergic reaction.

An issue with feverfew that applies to all herbal products is that every manufacturer processes the plant differently. In some cases, the product contains very little of active ingredients, such as parthenolides. The British researchers in the study cited above grew their own feverfew in the back yard of the hospital. An easier solution is to buy products of companies with good reputation, such as Nature’s Way, Source Naturals, and Oregon’s Wild Harvest.

Terrorism and headaches

By: Dr. Mauskop

22-01-2018

Chronic migraine, Headaches, Headaches in children, Psychology of headaches

Survivors of terrorist attacks are four times more likely to suffer from migraines and three times more likely to suffer from tension-type headaches, according to a study just published in Neurology. The researchers evaluated 213 of 358 adolescent survivors of the 2011 massacre at a summer camp in Norway that resulted in deaths of 69 people. These survivors were compared to over 1,700 adolescents of the same sex and age who were not exposed to terrorism. The survivors were not only much more likely to suffer from migraines and tension-type headaches, but were also much more likely to have daily or weekly attacks.

Many previous studies have shown that physical, sexual, and emotional abuse in childhood and posttraumatic stress disorder (PTSD) are strong risk factors for the development of migraines and chronic pain in many previous studies. Having a family history of migraines further increases this risk, as does head trauma, and having other painful or psychological disorders. Headache is also one of the first symptoms reported by adolescent girls and women who were raped.

The authors of the current report cite evidence that “Childhood maltreatment during periods of high developmental plasticity seems to trigger modifications in genetic expression, neural circuits, immunologic functioning, and related physiologic stress responses. It is plausible that exposure to interpersonal violence could induce functional, neuroendoimmunologic alterations, affecting central sensitization and pain modulation and perception. Central sensitization, expressed as hypersensitivity to visual, auditory, olfactory, and somatosensory stimuli, has long been thought to play a key role in the pathogenesis and chronification of migraine.”

It is likely that early intervention after a traumatic event will result not only in better psychological outcomes, but also in fewer and milder headaches. One such intervention is cognitive-behavioral therapy. However, there are several different types of such therapy and a study just published in JAMA Psychiatry compared 12 sessions of cognitive processing therapy (CPT) with 5 sessions of written exposure therapy (WET) for the treatment of posttraumatic stress disorder. WET was shown to be at least as good as CPT with fewer treatment sessions required. This makes WET more efficient and affordable and patients are more likely to complete it.

My previous blog posts mention online self-administered courses of cognitive-behavioral therapy for PTSD, anxiety, depression, OCD, insomnia, chronic pain, and other conditions. The site is ThisWayUp.org.au and the researchers behind it have published scientific data indicating that their approach is very effective. It is also very inexpensive – some courses are free and some cost about $50.

Migraines can be prevented with CoQ10 supplementation

By: Dr. Mauskop

08-01-2018

Alternative Therapies, Headaches in children, Migraine

Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of migraine sufferers are deficient in CoQ10, according to a study by Dr. Andrew Hershey and his colleagues published in the journal Headache. They tested 1,550 children and adolescents and a study in such a large population tends to be very reliable. Supplementing these children with 1 to 3 mg/kg of CoQ10 produced significant improvement not only in CoQ10 levels but also in the frequency of attacks (from 19 a month to 12) and the disability (the disability score dropped from 47 to 23).

This deficiency is present in adults as well, as was shown in another study by a Swiss neurologist, Dr. Peter Sandor and his colleagues. They gave 100 mg of CoQ10 three times a day or placebo to 42 adult migraine sufferers and discovered that a 50% drop in migraine attack frequency occurred in 48% of patients on CoQ10 and only 14% of patients on placebo.

The Hershey study was done in a more logical way – determine who is deficient and give them CoQ10. If you give CoQ10 to those who need it and those who don’t, the results of the study and in practice will not be as impressive. Although CoQ10 is not expensive ($7 a month for 200 mg a day) and is very safe, why supplement to someone who does not need it? Although the blood test for CoQ10 is fairly expensive ($158 at Labcorp), it is usually covered by most insurance plans. It is important to ask your doctor what the actual blood level was because the laboratories will report as normal values between 0.37 and 2.2 (Labcorp) or 0.44 and 1.64 (Quest Diagnostics), studies have shown that the level should be at least 0.7.

As far as side effects, a few of my patients developed insomnia, possibly because CoQ10 is involved in energy generation, so I always advise taking it in the morning. While Sandor gave his patients 100 mg three times a day, in Hershey’s study the benefit appeared at lower doses. I usually recommend 100 to 200 mg (depending on body weight and how low the level is), to be taken once, in the morning.

Dementia and magnesium levels

By: Dr. Mauskop

03-01-2018

Alternative Therapies

Magnesium deficiency is found in up to 50% of migraine sufferers, 40% of those with cluster headaches, 45% of the elderly diabetics, and in a high percentages of people with other chronic diseases. Magnesium has been shown to relieve migraine and cluster headaches, post-concussion syndrome, lower blood pressure, prevent irregular heart beats, and improve breathing in asthmatics.

A new study by Dutch researchers published in the leading neurology journal, Neurology reports on an association between magnesium and dementia (Alzheimer’s and other types). Brenda Kieboom and her colleagues measured magnesium levels in almost 10,000 people without any evidence of dementia and followed them for an average of 8 years. The average age at the start of the study was 65. Only 2 subjects had magnesium level above normal and 108 below normal.

The surprising discovery, which was suggested by previous contradictory studies, is that people with both low normal and high normal levels (lowest and highest quintile of the normal range) were at an increased risk of developing dementia.

There are two hypotheses as to why low magnesium levels could predispose to dementia. One is that magnesium blocks NMDA receptor, which is involved in the development of dementia, traumatic brain injury, pain, migraines, and other conditions. The second theory is that magnesium deficiency promotes inflammation, which is found in brains of patients with dementia (and migraines). The authors did not offer any theories as to why high normal magnesium levels were also associated with the development of dementia.

The researchers admit several weaknesses of their study, including poor correlation between serum magnesium levels and the total magnesium in the body and the reliance on a single measurement of magnesium level. The study does have many strengths, including large number of subjects, correction for a variety of confounding factors (education, weight, smoking, alcohol, cholesterol, kidney function, stroke, and other). The fact that this correlation was found as early as 4 years after the initial assessment also suggests a real correlation.

Although, correlation does not mean causation, it is prudent to keep your magnesium level in the middle of normal range. We rarely see high or high normal magnesium levels in our migraine patients and in this study only 2 out of almost 10,000 people had higher than normal levels and 108 had lower than normal levels. Ideally, everyone who suffers from any medical condition or has a family history of dementia, should have their magnesium level checked. The more accurate test is not the serum level, but the RBC magnesium level.

Botox for kids with chronic migraines

By: Dr. Mauskop

27-12-2017

Botox, Chronic migraine, Headaches in children

A new report by doctors at UC Irvine describes successful treatment of 9 children aged 8 to 17 with migraine headaches using Botox injections. It may sound surprising, but unfortunately children also suffer from chronic migraines. Chronic migraine is defined as headaches that occur on 15 or more days each month and on at least 8 of those days headaches have migraine features. In children with episodic and chronic migraines, migraine features, such as throbbing, unilateral location, sensitivity to light and noise are less common than in adults.

There are only 5 treatments that are approved by the FDA for the prevention of migraine attacks. Four are drugs – 2 blood pressure medications, propranolol (Inderal) and timolol (Blocadren) and 2 epilepsy drugs, topiramate (Topamax) and divalproex sodium (Depakote). The fifth treatment is Botox injections. While Botox is not approved for kids with migraines, it is approved to treat eye conditions in children 12 years of age and older. Botox is also widely used to treat younger children with cerebral palsy (CP), although there is no official FDA clearance for such use. For a child with CP, Botox injections can make a difference between being wheelchair-bound and walking unassisted. However, very young children with CP are at the highest risk of serious complications and even death because they have small bodies and very stiff muscles, which require relatively large doses of Botox.

The dose to treat migraines is much smaller and therefore a lot safer. My youngest child with chronic migraines was a boy of 8 who weighed 50 lbs. He had excellent relief of his migraines after receiving 15 units of Botox into his forehead. He underwent a total of five treatments over a period of two years and for the last treatment, I gave him 50 units (forehead and temples). By then his weight was 65 lbs. The standard adult dose for migraines is 155 units. The dose for cerebral palsy in an adult goes up to 400 units.

The main difficulty in using Botox in children with migraines is that insurance companies often deny coverage, which they justify by the lack of FDA approval. However, Botox injections at low doses used to treat migraines in children are safer than drugs for epilepsy, high blood pressure, or depression.

Ignore fearmongering: triptans still do not increase the risk of strokes and heart attacks

By: Dr. Mauskop

18-12-2017

Migraine

A group of highly respected researchers at the Albert Einstein College of Medicine just published their second article in the journal Headache on the cardiovascular disease (CVD) risks in migraine sufferers. Not surprisingly, they have found that there is an increase in the CVD risk factors with increasing age – more people develop diabetes, hypertension, heart attacks, strokes, get stenting and other heart procedures as they get older.

This study concludes that, “Among people with episodic migraine in the US population, the number of women and men with relative contraindications to triptans… includes over 900,000 women and men. This includes more than half a million individuals with episodic migraine who have not had a prior cardiovascular events or procedures.” They also extensively refer to the FDA-approved label for triptans, which says that “It is strongly recommended that sumatriptan not be given to patients in whom unrecognized coronary artery disease is predicted by the presence of risk factors…”. This is because triptans can slightly constrict blood vessels, especially diseased ones (but vasoconstriction is not how triptans relieve migraines).

This is a strange conclusion considering that in the first article devoted to this large and extensive study they admit that “Serious cardiac events following triptan administration are very rare and in claims analysis, triptan use is indeed not associated with increased risk of CVD”. And the triptan label includes this statement (mentioned by the authors): “Considering the extent of use of sumatriptan in patients with migraine, the incidence of these events (drug-associated cardiac events and fatalities) is extremely low.”

The first study reported that there is a decline in the use of triptans in patients with CVD risk factors. The authors note that “It is our impression that this finding reflects a “fear-factor”; doctors may fear the onset of CV events in individuals with migraine and patients may fear the triptan label. Therefore, migraineurs that could theoretically benefit from triptans do not receive them. Nonetheless, it must be emphasized once more that triptans are not associated with the migraine/CVD relationship in populational studies; that no evidence exists to suggest increased risk of CVD in individuals with specific risk factors; and that triptans are not contraindicated in individuals without CVD but with risk factors for it.”

In the second study they inexplicably change their tune and say that “Nonvasoconstrictive acute treatments for migraine may be particularly valuable in persons of both sexes, especially men over the age of 40 and women over the age of 60. In addition, as the population ages, migraine treatments that do not constrict blood vessels may play an increasingly important role.”

What “nonvasoconstrictive acute treatments”? NSAIDs, such as ibuprofen and naproxen? Regular intake of NSAIDs, unlike that of triptans, is proven to increase the risk of CVD. Narcotics? They do not work well for most migraine sufferers and fuel the addiction epidemic. Butalbital/caffeine combination? It does not help most migraine sufferers (and was never approved for migraines) and, unlike triptans, cause medication overuse headaches.

Fortunately, patients with severe coronary artery disease and other strong contraindications for the use of triptans will soon have a safe option in a new category of migraine drugs, CGRP antagonists. They do not have any effect on blood vessels and will not have a warning label about their use in patients with CVD risk factors. However, these are very new drugs and we do not have long-term safety data that we have for triptans. Triptans have been in use for over 25 years and are sold without a prescription in most European countries.

The first group of these CGRP drugs, which will be released next year, will be given by injection for the prevention of migraines. In about 2-3 years we also hope to have CGRP drugs in a tablet form for the treatment of acute attacks. These will be expensive drugs, but their development has cost billions of dollars, so I have no quarrel with that (but insurance companies will). However, even if price was not an issue, a triptan would still be my first choice for most patients.

Breakthrough in the treatment of migraines

By: Dr. Mauskop

08-12-2017

Cluster headaches, injections, Migraine, New treatments

Two landmark studies on an entirely new type of treatment for migraines have been just published in the New England Journal of Medicine.

One of the reports describes a phase 3 trial (final phase that can lead to the FDA approval), which was conducted by Teva Pharmaceuticals using a monoclonal antibody, fremanezumab to treat patients with chronic migraine (patients with 15 or more headache days each month). The study involved 1,130 patients who were divided into three groups: one group received monthly injections (subcutaneously, i.e. under the skin) of the active medicine, another group was given an injection of the real medicine every 3 months and placebo injections monthly in between, and the third group received placebo injections every month. Patients in both groups that received real shots did much better than those given placebo. They had fewer days with headaches, used less of the abortive migraine medications, and had a lower impact of migraines on their lives. The effect of the drug lasted 3 months, which suggests that one injection every three months will be sufficient. We also hope that patients will be able to inject themselves and not have to come to doctors’ offices every month. The side effects were mostly related to the injection itself – pain, swelling, and bruising.

The second study conducted by Amgen and Novartis utilized a similar drug, erenumab (it will have the brand name of Aimovig when it becomes available in the middle of next year) to prevent episodic migraines, that is migraines that occur on fewer than 15 headache days each month. A total of 955 patients participated in this study and they were also divided into three groups: those receiving either 70 or 140 mg of medicine and a group receiving placebo. Injections were given monthly to prevent migraine attacks. Both doses of the drug resulted in significantly fewer migraine attacks and improvement in physical impairment and everyday activities. Side effects were mostly due to the injection site reactions, just like with fremanezumab.

Both fremanezumab and erenumab belong to the family of CGRP monoclonal antibodies, drugs that block a neurotransmitter CGRP which is released during a migraine attack. Two additional companies, Eli Lilly and Alder are developing similar drugs, galcanezumab and eptinezumab, which are also expected to be approved next year. Eli Lilly’s drug is also being tested for the prevention of episodic cluster headaches.

I first wrote about the CGRP drugs in a blog post in 2007, more than 10 years ago. At that point CGRP was the target of research for over 10 years, so in total, it will have taken 20 years to bring these new drugs to the market. It was even longer with triptans, such as sumatriptan (Imitrex) – it took 30 years since the discovery of the potential role of serotonin to the approval of sumatriptan. The drug development process takes not only decades of time, but also billions of dollars, which explains why new drugs are so expensive, at least in the first few years. After years of being on the market, prices of drugs tend to go down and now 90 tablets of sumatriptan can be bought for $70 at Costco, while similar branded triptan drugs used to cost $40 for a single tablet.

Vomiting from too much pot is similar to cyclic vomiting syndrome

By: Dr. Mauskop

02-12-2017

Alternative Therapies, Migraine

Excessive consumption of marijuana can lead to bouts of severe nausea and vomiting, which in medicalese is called cannabinoid hyperemesis syndrome (CHS). With many states legalizing medical and recreational marijuana, there has been an increase in ER visits and admissions to the hospital for severe vomiting. This is often misdiagnosed as cyclic vomiting syndrome (CVS), a condition which is more common in children than adults and is related to migraines. CVS, which is mentioned in a previous post, is often relieved by sumatriptan (Imitrex).

Unfortunately, people who overindulge in pot, do not realize that it is responsible for their symptoms and end up undergoing endoscopies, MRI scans and other procedures. Taking a hot shower is known to relieve pot-related vomiting, but hot shower also works for some patients with CVS, so this does not help in differentiating the two conditions. German researchers tried to find a reliable way to differentiate CHS and CVS and concluded that the only way to tell these apart is to completely stop marijuana. They do note that CHS can develop after years of using marijuana and that after marijuana use is stopped, it may take several days and up to a couple of months for symptoms to subside.

So far, we’ve prescribed medical marijuana to a couple of hundred patients with headaches, migraines, and nerve pain and have not seen such a problem. It is possible that the amount used for medicinal purposes is too small to cause CHS. The cost of medical marijuana is relatively high and could be preventing its overuse.

Psychological factors in chronic migraine

By: Dr. Mauskop

24-11-2017

Alternative Therapies, Chronic migraine, Pain, Pain Research, Psychology of headaches

Psychological factors play a major role in migraines. This is not to say that migraine is a psychological disorder – we have good genetic and brain imaging studies confirming its strong biological underpinnings. The divide between biological and psychological is very artificial since we know that physical illness leads to psychological problems and the other way around. Stress is obviously one of the major triggers of migraines and we know that people with migraines are at least twice as likely to develop anxiety, depression, and other mental disorders. These are not cause-and-effect relationships because anxiety and depression can precede the onset of migraines. The connection is probably due to shared underlying problems with serotonin, dopamine, and other neurotransmitters.

We have strong evidence that addressing psychological factors involved in migraines through biofeedback, meditation, and cognitive therapy can lead to the reduction of migraine frequency, severity, and disability. Studies in chronic pain patients have shown that people with external locus of control (thinking that uncontrollable outside chance events are major contributors to pain) have more disability than people with internal locus of control (those who feel that their actions are contributing to pain and that active involvement in treatment can relieve pain).

Chronic migraine sufferers (defined as those with 15 or more headache days each month) are known to have greater disability than those with episodic migraines. In a recent study by researchers at the Yeshiva University and Albert Einstein College of Medicine, 90 chronic migraine patients were evaluated for psychological symptoms. Of these 90 patients, 85% were women, their mean age was 45, and half reported severe migraine-related disability. They were twice as likely to be depressed and to have external locus of control. The half with severe migraine-related disability were 3.5 times more likely to have anxiety and depression and were twice as likely to have a symptom described as catastrophizing. Catastrophizing is defined as having irrational thoughts about pain being uncontrollable, leading to disability, loss of a job, partner, ruined life, etc.

The good news is that many studies show that with cognitive therapy locus of control can be shifted from external to internal, catastrophizing can be reduced or eliminated, and disability diminished. This may not eliminate migraines or chronic pain, but can make you less anxious and depressed, and much more functional. Cost and access to therapy can be a problem, but studies suggest that even online therapy can be very effective.

Besides psychological approaches, regular aerobic exercise (stationary bike is easiest for migraine sufferers), certain supplements and prescription drugs can also help. Supplements that can relieve anxiety and depression include SAMe, omega-3 fatty acids (fish oil), methylfolate, and other. Some antidepressant medications relieve not only anxiety and depression, but also provide relief of migraines even when psychological factors are absent. These include so called SNRIs (duloxetine or Cymbalta, venlafaxin, or Effexor, and other) and tricyclics (amitriptyline, or Elavil, protriptyline, or Vivactil, and other). The most popular group of antidepressants, the SSRIs (fluoxetine, or Prozac, escitalopram, or Lexapro, and other) do help anxiety and depression, but have no pain or headache-relieving properties. Obviously, all drugs have potential side effects and for most patients it makes sense to try non-drug treatments first.