Headache NewsBlog

Acupuncture provides long-term relief

By: Dr. Mauskop

04-11-2016

Acupuncture for the treatment of migraines has been studied in dozens of clinical trials. A 2012 study mentioned in a previous blog post described a rigorous trial done in 480 patients with highly positive results. The largest, albeit uncontrolled study was done in Germany and involved over 15,000 patients. A well controlled and randomized study of 960 patients comparing acupuncture with sham acupuncture and drug therapy concluded that “…acupuncture is as effective as drug therapy, but …sham acupuncture is as effective as ‘real’ acupuncture.” and “…acupuncture should be offered to patients who do not respond to prophylactic treatment with drugs, terminate drug treatment because of adverse events or have contraindications to drug treatment.”

Most headache specialists recommend acupuncture to their patients even if they believe it works only through the placebo effect. I’ve been a licensed acupuncturist for the past 30 years, but treat a relatively small number of patients with acupuncture. The main reasons are the fact that insurance companies do not pay for it and that it is too time consuming. In the first study mentioned above, which was performed in China, patients were treated five days a week. The minimum frequency of treatments should be once a week. I often recommend that patients find a non-MD acupuncturist (whose rates are usually lower) who is closer to the patient’s home or work place. Another concern with acupuncture is that while it might help during the treatment, the effect might subside once the treatment is stopped.

A study The persistence of the effects of acupuncture after a course of treatment: A meta-analysis of patients with chronic pain, just published in the journal Pain addresses this question.

A group of researchers from the US and Europe examined a large set of information on individual patients from high quality randomized trials of acupuncture for chronic pain. The chronic pain conditions included musculoskeletal pain (low back, neck and shoulder), osteoarthritis of the knee and headache / migraine. Data on longer-term follow-up were available for 20 trials, which included 6,376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), the treatment effect diminished by a very small amount after treatment ended. They estimated that 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham acupuncture, they observed a higher reduction in effect, suggesting about a 50% diminution at 12 months. They concluded that “The effects of a course of acupuncture treatment for patients with chronic pain do not appear to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist.” They also suggested that studies of the cost-effectiveness of acupuncture should take these findings into account when considering the time horizon of acupuncture effects and that further research should measure longer term outcomes of acupuncture.

Do migraine drugs work in kids?

By: Dr. Mauskop

29-10-2016

Chronic migraine, Headaches in children, Migraine

About 6% of young children suffer from migraine headaches. After puberty, this number triples to 18% in girls and remains at 6% in boys. Several abortive drugs (drugs taken as needed), such as rizatriptan (Maxalt) and zolmitriptan (Zomig) are approved for migraines in children. Only topiramate (Topamax) is approved for children (over the age of 12) for the prevention of migraines. We do use preventive drugs approved for adults in children as well. These are divalproex sodium (Depakote), propranolol (Inderal), and botulinum toxin (Botox). Many other drugs, such as amitriptyline (Elavil), gabapentin (Neurontin), candesartan (Atacand) are used “off label”, meaning that they are not FDA-approved for migraines in adults or children. One of the reasons that more drugs are not approved specifically for children is the difficulty in conducting research in kids. Their are migraines are usually shorter in duration and often stop occurring for long periods of time without treatment.

A large multi-center 24-week study just published in the New England Journal of Medicine examined the efficacy of topiramate, amitriptyline and placebo in children between the ages of 8 and 17. It was a double-blind study with neither the children and their parents nor the doctors being aware of who was getting which drug or placebo. The study showed no statistically significant difference among the three groups. The main outcome measure was a 50% or higher reduction of headache days. Placebo achieved this result in 61% of children, while this number was 52% for those on amitriptyline and 55% on topiramate. Not surprisingly, side effects were much more common in children taking medications than placebo. Fatigue and dry mouth were the most common side effects from amitriptyline, while topiramate caused mostly tingling and weight loss. Serious side effects occurred in four – three kids on amitriptyline had a serious mood disorder and one on topiramate attempted suicide.

This study did not prove that amitriptyline and topiramate are ineffective since they did help half of the children they were given to, however the placebo worked at least as well. These findings are not surprising since placebo has a powerful effect, which is often more pronounced in children and because children’s migraines often stop on their own. Even in adults, placebo effect has often made clinical trials, particularly in migraines, very difficult. It took a couple of attempts to prove that Botox prevents migraines better than placebo, again not because Botox was ineffective, but because placebo also worked well.

The initial approach to treating migraines in children and adults should always involve looking for modifiable triggers, such as sleep schedule, regular meals with healthy food, elimination of caffeine and sugar, regular exercise, sleep hygiene, meditation or biofeedback, and so on. Our second step is trying supplements such as magnesium (which sometimes is given intravenously because of poor absorption of pills) and CoQ10, which have been proven to be effective both in children and adults. Other, less proven supplements, such as riboflavin, feverfew, and boswellia are also worth trying before starting a daily preventive medication. At the same time, since migraine often causes severe pain, we often prescribe abortive migraine medications, such as sumatriptan or rizatriptan, which are often more effective than ibuprofen and acetaminophen.

It is considered unethical for doctors to prescribe placebo, although we do sometimes prescribe very mild drugs in a small dose (cyproheptadine is one such drug), which is almost the same as prescribing a placebo.

An interesting study of placebo in patients with low back pain was just published in the journal Pain . One group was given the usual treatment and the other received the usual treatment as well as a placebo pill, but they were told that they are being given a placebo. The group that knowingly took placebo had a significant reduction in pain and disability. After three weeks of this trial, the first group was also given a placebo pill and they also had a significant drop in pain and disability. It is possible that the effect is just due to the act of taking a pill, which subconsciously sends a message to the brain that something is being done to fix the problem.

Guidelines for the use of medical marijuana

By: Dr. Mauskop

24-10-2016

Alternative Therapies, Headaches, Migraine, New treatments, Pain

Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with.

Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments:

“The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.”
Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed.

“The doctor’s office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.”
This one is easy for us.

“The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.”
I’ve never tried it.

“There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.”
I prescribe it only to our established patients.

“The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.”
All of our patients undergo a thorough evaluation.

“The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.”
We use medical marijuana only after other non-drug and drug treatments fail.

“If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.”
Yes, I do that.

“The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.”
This is a standard practice with any treatment.

“Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.”
I typically avoid prescribing medical marijuana to such patients.

Liver damage is often caused by supplements

By: Dr. Mauskop

18-10-2016

Alternative Therapies

We are big proponents of non-drug treatments, including a variety of vitamins, minerals, and herbal supplements. However, potential liver damage by butterbur is why we do not recommend this supplement, even though I was one of the participants in the clinical trial that showed it to be effective in preventing migraines. I also cautioned about risks of some Ayurvedic medications.

A recent report in Hepatology, a journal devoted to liver diseases, suggests that 20% of all cases of liver damage are due to herbal and dietary supplements. The main culprits were anabolic steroids (these are banned in professional sports, but are widely used for muscle building), green tea extract, and supplements with multiple ingredients. Anabolic steroids cause prolonged, but not serious liver injury, which resolves when the supplement is stopped. Green tea extract and many other products cause acute liver damage, similar to that seen in hepatitis. The majority of cases of liver injury are due to products that contain multiple ingredients, which makes it difficult to figure out which of the supplements is responsible. Unfortunately, non-prescription supplements are not regulated by the government. This is mostly because it is a $37 billion dollars a year industry with a powerful lobby in Washington. The authors conclude their report by saying that “the ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety.”

Until these products come under FDA’s supervision, you should buy only products made by reputable American and German companies. Germany tightly regulates their supplement industry, so if a product is sold in Germany (and none of the butterbur products are approved there or in Great Britain), it is probably safe to take. Do not buy products made in China where corruption has led to many scandals related to the quality of supplements, drugs, food, and environmental pollution.

Another option for the treatment of nausea

By: Dr. Mauskop

14-10-2016

Headache medications, Migraine, New treatments

Nausea is a very common symptom that accompanies migraine attacks. Effective treatment of migraine with a drug like sumatriptan often stops the headache, nausea, and other associated symptoms. However, sometimes pain subsides, while nausea does not, or nausea is much more bothersome than the headache. Nausea can also be a side effect of the most effective injectable migraine drug, dihydroergotamine (DHE-45). We often administer this drug in our office after other injectable drugs (magnesium, sumatriptan, ketorolac, dexamethasone, etc) fail. If nausea is already present, we will always give an intravenous injection of a nausea drug such as ondansetron (Zofran) or metoclopramide (Reglan) before giving DHE. Sometimes these drugs are ineffective in preventing nausea and vomiting induced by DHE and we have to look for other options.

Phenothiazine family of drugs, including prochlorperazine (Compazine), chlorpromazine (Thorazine), and promethazine (Phenergan) are very old and effective anti-nausea drugs. However, they have a potential for a rare but devastating side effect, which consists of persistent involuntary movements of the face (grimacing and lip smacking) and body. The onset of this side effect can be delayed, which is why it is called tardive dyskinesia. It is not unusual for these drugs to cause an immediate severe and very unpleasant restlessness (akathisia), which patients sometimes describe as wanting to crawl out of one’s skin. Metoclopramide (Reglan) can also cause these side effects, but less often.

Ondansetron (Zofran) does not cause any such side effects and should be the preferred drug for nausea of migraine, although it is only approved for nausea caused by chemotherapy or radiation and for post-surgical nausea. Since it has become generic and inexpensive, it can be used for other causes of nausea, including migraines. It is available as an injection or as a tablet.

Aprepitant (Emend) is an anti-nausea drug that has a totally different mechanism of action than the medications described above, so it is possible that it can help when other drugs do not or when other drugs cause side effects.

A study just published in Neurology by Dr. Denise Chou and her colleagues describes the use of oral aprepitant in the treatment of DHE-induced nausea in hospitalized patients.

The authors reviewed hourly diary data and clinical notes of patients admitted to the hospital for the treatment of refractory migraine headaches (status migrainosus) with DHE infusions between 2011 and 2015.

They identified 74 such patients, of whom 24 had daily diaries. In 36 of 57 cases in which aprepitant was given, there was a 50% reduction in the number of other anti-nausea medications given to patients. Of 57 patients, 52 reported that the addition of aprepitant improved nausea. Among 21 of 24 patients with hourly diary data, nausea scores were reduced. In all 12 patients with vomiting aprepitant stopped it. Aprepitant was well tolerated and caused no side effects.

The authors concluded that aprepitant can be effective in the treatment of refractory DHE-induced nausea and vomiting. They also suggested that perhaps this drug could be used for nausea of migraine even when DHE is not given. The only problem, and it is a very big problem, is the cost. This drug is not going to be available in a generic form until 2018. A single capsule of Emend costs $105 with a coupon you can get on GoodRx.com. Without a coupon, it is $145. A single vial for injection costs $345, so we are not going to use this drug for nausea due to migraine or DHE for at least two years, when cheaper generic copies become available.

Thyroid disease and headaches

By: Dr. Mauskop

08-10-2016

Headaches, Migraine

Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as Synthroid or Armour Thyroid often improves headaches.

Researchers at the University of Cincinnati College of Medicine tried to determine if having headaches made one more prone to developing hypothyroidism. They examined 8,412 healthy people and checked their thyroid function every 3 years over a 20 year period. They excluded from the group people with past thyroid disease or abnormal thyroid function tests at the first office visit. The diagnosis of a headache disorder was established based on person’s report of “frequent headaches,” by the use of any headache-specific medication, or a physician’s diagnosis of a headache disorder. They also recorded age, sex, body mass index, income, smoking, narcotic use, and medicines that could cause thyroid dysfunction.

Headache disorders were present in about 26% of the population and new onset hypothyroidism developed in 7%. Those who had a headache disorder had a slightly higher risk (1.2 times) of developing hypothyroidism. The researchers concluded that headache disorders may be associated with increased risk for the development of new onset hypothyroidism. These results were published in Headache.

One of my colleagues tells an embarrassing story of his wife’s headaches. She developed them after giving birth to their child, so he attributed them to stress and lack of sleep. When headaches persisted she went to her primary care doctor who discovered that she had an underactive thyroid. The headaches promptly went away with thyroid medicine.

Besides headaches, low thyroid function can cause weight gain, fatigue, constipation, muscle cramps, intolerance of cold, dryness of the skin, memory and concentration difficulties. Many of these symptoms also occur with magnesium deficiency, so both RBC magnesium and thyroid function tests (along with vitamin B12, vitamin D, and routine tests) need to be checked when headaches worsen or new ones develop.

Migraine and blood clots in veins (thrombosis)

By: Dr. Mauskop

04-10-2016

Migraine

Migraine with aura is known to be associated with an increased risk of diseases of arteries, such as strokes, heart attacks and diseases of peripheral blood vessels. This risk is further increased by estrogen-containing contraceptives.

A new study by Taiwanese neurologists suggests that migraine with aura also carries a higher risk of blood clots forming in the veins, so called venous thrombosis or deep vein thrombosis (DVT). Venous thrombosis is more likely to occur in obese, people with cancer, smokers, women on birth control pills, and those who are bedridden or sit for a long time, like on a long airplane ride. According to this new study, having migraines with aura increases the risk of this condition by two and half times.

DVT, which most commonly occurs in a deep vein in a leg, can completely resolve on its own without any residual effects. However, it can also cause long-term swelling and poor circulation in the leg and in about 10% of cases, a piece of the blood clot can break off and be carried into the lung. This is called pulmonary embolus and it is fatal in 10% of patients. DVT requires urgent treatment with blood thinners, which can prevent pulmonary emboli.

So, it is important to recognize symptoms of DVT. These include swelling in a leg or an arm, pain or tenderness in the leg when standing or walking, warmth in the area that is swollen or hurts, redness of the skin, and visible enlargement of the veins in the leg or arm.

Symptoms of pulmonary embolus are sudden shortness of breath or cough, rapid breathing, chest pain, back pain, profuse sweating, lightheadedness, and passing out.

Because blood clot can damage valves inside the vein some people develop a post-thrombotic syndrome, which can consist of pain, persistent swelling, darkened skin color, skin sores and varicose veins (enlarged and tortuous veins that sometimes can be seen under the skin).

To reduce the risk of both arterial and venous complications one needs to stop smoking, exercise regularly, maintain normal weight, blood pressure and blood sugar, avoid estrogen-containing contraceptives and hormone replacement therapy, and avoid sitting for prolonged periods of time. Obviously, these measures apply to everyone, but they are particularly crucial for those with migraine with aura.

Common avoidable problems with Botox injections

By: Dr. Mauskop

28-09-2016

Botox, Headaches, Migraine, Pain, TMJ

One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man.

Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding the remaining 45 units, we usually give additional injections into the areas of pain that may not be included in the standard protocol.

Giving injections every 3 months or even every 12 weeks works well for many patients. However, about a quarter of my migraine patients find that the effect of Botox lasts only 10 weeks and in a small number , even less than 10 weeks. Fortunately, some insurance companies allow Botox to be administered every 10 weeks, but many do not. Some even limit injections to every 3 months, and not a day earlier, even though the clinical trials that led to the FDA approval involved giving injections every 12 weeks. Having a week or two of worsening migraines can eliminate the cumulative effect we see with repeated treatments. That is, each subsequent Botox treatment provides better relief than the previous one. This may not the case if headaches worsen before the next treatment is given.

Cosmetic concerns are not trivial since Botox injections can make you look strange – as if you are always surprised or look sinister with the ends of your eyebrows always lifted. This can be easily avoided by injecting a very small amount of Botox into the appropriate muscles above the ends of the eyebrows or a little beyond them. In some patients this can be predicted before the first treatment by looking at the lines seen with lifting of the eyebrows. In others, it becomes apparent only after the first treatment. If the appearance is very unappealing, we ask the patient to return to get two small additional injections for which we do not charge.

To minimize bruising and pain we use very thin needles. A 30-gauge needle is used most often, however an even thinner, 33-gauge needle is also available, but is rarely used (higher number indicates a thinner needle). We recommend using a 33-gauge needles, at least for the forehead, where injections tend to be more painful and where bruising, if it happens, is very visible.

Many dermatologists and plastic surgeons tell their patients not to bend down or do anything strenuous to avoid movement of Botox which may lead to drooping of the eyelids. There is no theoretical or practical evidence for this restriction. Once injected, Botox does not move around freely but stays in the injected area. In my 22 years of injecting Botox, I’ve treated thousands of headache sufferers and fewer than 1% of patients developed drooping eyelids and none were related to bending or any other activities. Drooping is more common in older patients, is always reversible within days or weeks, and sometimes can be relieved by eye drops (aproclonidine).

Medical marijuana reduces prescription costs

By: Dr. Mauskop

18-09-2016

Alternative Therapies, Migraine

Medical marijuana reduces the number of prescriptions written by doctors, according to a recent study published in Health Affairs. The researchers at the University of Georgia in Athens looked at all prescriptions filled by Medicare participants over a four year period for nine conditions for which medical marijuana is used for. These included anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders and spasticity. They compared 17 states and Washington, DC where medical marijuana was legalized with those where it was not. In states with legalized medical marijuana the number of prescriptions dropped by 0.5% providing estimated savings of $165 million a year. Of all approved indications, relief of pain was by far the most common reason medical marijuana was prescribed for. This was a much more dramatic effect than the researchers anticipated. They expected that the mostly elderly patients on Medicare would be more resistant to the idea of using marijuana than younger people.

In a February post I mentioned that I started prescribing medical marijuana to my patients with migraine headaches who also have neuropathic pain as part of their headache. While medical marijuana is not approved for migraines per se, it is approved for neuropathic (i.e nerve-related pain), which many migraine sufferers do have. Burning or stabbing pain indicates the presence of neuropathic pain. So far, I’ve prescribed medical marijuana to about two dozen patients and as expected, the results are mixed. It works well for some, but not other. Most commonly, patients who’ve had positive experience with recreational marijuana tend to request medical marijuana and they tend to do better than those who’ve never tried it.

Research on medical marijuana is complicated by the fact that there is no standard formulation, which means that there is wide variation in the strains of the plant with varying amounts of active and inactive ingredients. In New York State medical marijuana can be ingested, inhaled through a vaporizer or placed under the tongue. We also have various ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD), which produce different results. Nevertheless, we do plan to do an observational study of 100 migraine sufferers who also have neuropathic pain. We hope to get an indication as to what route of administration and what THC/CBD ratio work best for migraine patients.

CGRP drugs remain highly promising.

By: Dr. Mauskop

11-09-2016

Migraine

CGRP migraine drugs remain on track to get an approval from the FDA within two years. My first post on these drugs appeared in 2007. The first product in this family was tested for the prevention and acute treatment of migraines. It reached the final phase 3 trials and was found to be very effective and safe, but a few patients developed minor liver abnormalities on blood tests. In view of these blood test abnormalities, the manufacturer, Merck decided against completing the trials. A similar medicine, also in a tablet form, is now being developed by Allergan (maker of Botox) and it appears to be free of liver problems.

CGRP (calcitonin gene-related peptide) is a chemical that is released in the brain during a migraine attack. Four companies are targeting the CGRP molecule in a different way. Instead of taking a pill during an attack or daily to prevent migraines, they are developing monoclonal antibodies which bind to the CGRP molecule or its receptor and block its action. These drugs are given by injection. Three of the companies, Amgen, Eli Lily, and Teva are testing intramuscular injection every month, while the fourth one, Alder is testing intravenous administration every three months. Eli Lily is also testing their compound for the treatment of episodic cluster headaches.

To date, there have been several thousand patients exposed to these monoclonal antibodies in clinical trials. What is most surprising to me is their outstanding safety. The side effects have been infrequent and mild. All four companies are conducting large-scale phase 3 trials, which will hopefully confirm their safety. Based on the previous studies, there is little doubt that these studies will show that the drugs are highly effective in preventing migraines. Unfortunately, it will be at least two years before these truly innovative medications become available.

While I am very excited about getting a new and a very different treatment for migraine and cluster headache sufferers, my enthusiasm is tempered by the potential cost of these drugs. Business experts project the cost to be between $12,000 and $18,000 a year. By comparison, the $6,000 yearly cost of Botox injections seems cheap. Only about 100,000 out of several million chronic migraine sufferers have been treated with Botox since it was approved for migraines 6 years ago. This is in large part due to the difficulties in getting approval from the insurance companies. Besides extensive paper work from the doctor, they require that the patient first try and fail two or three preventive drugs. The new CGRP drugs are likely to be the last option in this chain and will require even more paperwork. The result is likely to be a great underutilization of these breakthrough drugs, just as it has been happening with Botox.

I am not suggesting that these drugs should be cheap since literally billions of dollars will have been spent by the time these drugs receive approval. If the companies cannot make a profit, the investment in research will dry up and fewer breakthrough drugs will be developed. This is why most new treatments are developed in the US and not Europe, where drug costs are controlled by the government. Hopefully, in a few years the cost will drop as it has happened with another family of highly effective migraine drugs, the triptans.

Vitamin B12 is in the news

By: Dr. Mauskop

06-09-2016

Alternative Therapies, Migraine

Vitamin B12 was the subject of an article in the New York Times by Jane Brody entitled, Vitamin B12 as Protection for the Aging Brain. However, she mentions that “insufficient absorption of B12 from foods may even be common among adults aged 26 to 49” and that the advice to take a vitamin B12 supplement may apply to young people as well. This is particularly true for vegans and vegetarians, as well as people with stomach problems and those on PPIs – drugs for ulcers and heartburn, such as Prilosec, Nexium, Aciphex, etc.

Vitamin B12 deficiency can cause “fatigue, tingling and numbness in the hands and feet, muscle weakness and loss of reflexes, which may progress to confusion, depression, memory loss and dementia as the deficiency grows more severe”. Severe deficiency leads to peripheral and central nervous system damage (so called subacute combined degeneration), which eventually becomes irreversible and leads to death.

Jane Brody does not mention that besides Alzheimer’s, other chronic diseases, such as multiple sclerosis, diabetes, and cancer are also associated with low vitamin B12 levels. Vitamin B12 with vitamin B6 and folic acid has been shown to help some migraine sufferers

You can ask your doctor to check your vitamin B12 level, but unfortunately it is not reliable. Most laboratories cite as normal blood levels of above 200 or 250, but there are reports of rare cases where severe deficiency is present with a level of 700. I recommend taking a supplement if the level is below 500. In severe cases or in people with stomach problems, a monthly injection is a better choice. Patients can easily self-inject vitamin B12, but it does require a doctor’s prescription. Some of my patients feel the need to inject themselves with vitamin B12 more often than once a month. Whenever they start feeling tired or having other symptoms, they take a shot. Unlike some vitamins, such as B6 and A, vitamin B12 does not cause any negative effects even at high levels. As an oral supplement I usually recommend tablets of methylcobalamin, rather than cyanocobalamin form of vitamin B12 because of better absorption. The usual dose is 1 mg (or 1,000 mcg) daily. If you are deficient and stop taking the supplement, the deficiency can return within a few months.

Fracking and Migraines

By: Dr. Mauskop

01-09-2016

Migraine, Science of Migraine

Living in areas where fracking takes place doubles the risk of having migraines, as well as fatigue and sinus symptoms. Fracking, or hydraulic fracturing, is a water-based method of extracting natural gas from deep under the ground.

Johns Hopkins researchers described these findings in the journal Environmental Health Perspectives. The study was conducted using questionnaires which were completed by 7,785 adults. Among these people, 1,765, or 23% suffered from migraines, 1,930 people or 25% experienced severe fatigue and 1,850 or 24% had symptoms of chronic sinusitis (three or more months of nasal and sinus symptoms). In the general population the incidence of migraines is about 12%.

Previous studies have discovered an association between fracking and increased risk of premature births, asthma attacks and indoor radon concentrations.

It is unclear how fracking results in these health problems. Some possible explanations include air pollution, odors, noise, bright lights, and heavy truck traffic.