Three times as many women are afflicted by migraines as men, according to many large studies. However, 6% of men do suffer from migraines and that means 9 million American men. However, in our clinic, instead of 75%, over 90% of patients are women. Men are often dragged into the office by their wife, girlfriend, or mother.

A new study presented at the recent meeting of the American Headache Society confirms this observation. Dr. Anne Scher and her colleagues established that men are less likely to see a doctor and when they do see one, they are less likely than women to be given the diagnosis of migraine. Only 59% of men with migraines were given the correct diagnosis, while this number was 77% for women. This is probably due to the perception of migraine as a disease of women. The reasons for misdiagnosis in both sexes include the notion that every migraine sufferer has to have a visual aura (it is present only in about 20%), or that the headache has to be one-sided, or the person has to have nausea. In fact, all of the typical migraine features do not have to be present. It is sufficient to have nausea and throbbing pain or light sensitivity and inability to function normally, or light and noise sensitivity and one-sided throbbing pain, etc.

Migraines are often misdiagnosed as sinus headaches because in some people migraine is accompanied by a clear nasal discharge or because the pain is localized in the area of sinuses. True sinus headaches are usually accompanied by yellow or green nasal discharge.

Migraines can be also mistaken for tension-type headaches, but tension-type headaches are milder and never severe, not accompanied by nausea and other symptoms, and typically respond to over-the-counter medications.

One type of headaches that is significantly more common in men, is cluster headache. Cluster headaches are also often misdiagnosed as migraine or sinus headache. The name comes from the fact that these headaches occur in clusters – every day for a month or two and then they go away for a year or longer. The pain is extremely intense, always one-sided and localized around the eye, usually accompanied by tearing and runny nose on the side of the headache. These headaches tend to wake the person from sleep, but can occur during the day and last anywhere from half an hour to a few hours. Some of the treatments for cluster headaches are different from those for migraines, so a correct diagnosis is crucial. There are many posts on this blog and an article on our site devoted to cluster headaches, so please do a search if you are interested in learning more.

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Intravenous magnesium relieves acute migraine attacks in patients with magnesium deficiency, which is present in half of migraine sufferers, according to the study we published in 1995 in the journal Clinical Science. Infusions not only treat an acute attack, but also prevent migraines. Oral magnesium supplementation is not as effective and helps less than 50% of patients because some patients do not absorb magnesium. Most people get enough magnesium from food, but some migraine sufferers have a genetic defect which prevents them from absorbing magnesium or a genetic defect that leads to an excessive loss of magnesium through kidneys.

Our experience with thousands of patients suggests that the majority of migraine sufferers who are magnesium deficient do improve with oral supplementation, but about 10% do not. These patients need regular infusions of magnesium and these infusions are often life-changing. Magnesium not only treats and prevents migraines, but also relieves muscle cramps, PMS, palpitations, “brain fog”, and other symptoms.

There are many mentions of magnesium on my blog and on the nyheadache.com website, so what prompted another post on this topic is a couple of patients with an unusal experience. I would occasionally see such patients but in the past few weeks, I saw several. These patients tell me that when we give them an infusion of magnesium by “slow push” over 5 minutes they get excellent relief, but when they end up in an emergency room or another doctor’s office where they receive the same amount of magnesium through an intravenous drip over a half an hour or longer, there is no relief.

A likely explanation is that a push results in a high blood level, which overcomes the blood-brain barrier and delivers magnesium into the brain, while during a drip, magnesium level does not increase to a high enough level to reach the brain. Studies have shown that migraineurs not only have a systemic magnesium deficiency, but specifically in their brains. A similar phenomenon has been described with sumatriptan (Imitrex). Researchers discovered that migraine sufferers who did not respond to sumatriptan had a much slower increase in the drug level compared to responders, even though the total amount of the drug absorbed into the blood was the same.

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Recently, a patient of mine reported that cramp bark has significantly improved her menstrual migraines. Cramp bark is a common shrub with red berries. Its bark has been used for over 100 years for muscle cramps, menstrual cramps, fluid retention, and other symptoms. Fortunately, it appears to be very safe and even though no scientific studies have been performed on it, it may be worth trying. I will start recommending it to women with menstrual migraines, menstrual cramping and patients with muscle spasms in their neck and upper back.

The two top herbs I recommend to my migraine patients are feverfew and boswellia. Feverfew has been subjected to scientific studies and seems to help some patients while causing almost no side effects. Boswellia has been reported to help even patients with cluster headaches, but no rigorous studies have been done. However, it is safe and because of its anti-inflammatory properties it can also help joint and muscle aches (see my blog post on Boswellia).

Butterbur, on the other hand is not always safe, so I haven’t been recommending it. Here is one of my blog posts on it.

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Vagus nerve stimulation (VNS) with an electrode implanted in the neck is an FDA-approved treatment for depression and epilepsy, when these conditions do not respond to medications. Since antidepressant and anti-epilepsy medications help migraines, I had six patients (four with migraines and two with cluster headaches) treated with VNS. Two of the four chronic migraine patients and both cluster patients had good relief – results that were published in the journal Cephalagia in 2005. This publication led to the development of gammaCore, a device to stimulate the vagus nerve through the skin, without the need for surgical implantation of an electrode. The New York Headache Center participated in one of the earliest studies of this device and the results were encouraging.

An article published in the current issue of Neurology presents the results of another study of gammaCore. In this first double-blind study 59 adults with chronic migraines (15 or more headache days each month) were given either real VNS or sham treatment for two months. After two months they were all given the real treatment for 6 months. The main goal of the study was to examine the safety and tolerability of this treatment, but the researchers also looked at the efficacy by measuring the change in the number of headache days per 28 days and acute medication use.

Both sham and real treatment were well tolerated with most adverse events being mild or moderate and transient. The number of headache days were reduced by 1.4 days in the real and 0.2 days in the sham group. Twenty-seven participants completed the open-label 6-month phase, which suggests that this treatment might work for half of the patients. However, larger sham-controlled studies are needed to prove that this treatment really works. GammaCore is also being tested for the treatment of cluster headaches. Although it has not been definitively proven to be effective, it is already being sold in some European countries.
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Menopause often brings relief to female migraine sufferers. However, many women have worsening of their migraines during the transition. This is thought to be due to the fluctuating levels of estrogen, which is also responsible for menstrual migraines. Steady levels of estrogen during pregnancy and in menopause lead to a dramatic relief of migraines in two out of three women.

A study published in a recent issue of the journal Headache examined the relationship of headache frequency to the stages of menopause. The study looked at 3446 women with migraines with a mean age of 46. Among women who were premenopausal, 8% had high frequency of headaches (10 or more headache days each month), while during perimenopause as well as menopause, 12% of women had high frequency of migraines. This does not contradict the fact that many women stop having migraines in menopause, but it suggests that among those women who continue having migraines, there are more with high frequency of attacks.

By publishing these findings, the authors wanted to draw attention to the fact that many women may need a more aggressive approach to treatment. In women with high frequency of attacks preventive therapies tend to be more effective than abortive ones. These may include magnesium, CoQ10, Boswellia, and other supplements, as well as preventive medications and Botox injections. At the same time, most women may also need to take abortive therapies, such as triptans.

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Several of my patients with trigeminal neuralgia (TN) responded to Botox injection (although some have not). My previous post on this topic four years ago discussed a study involving 40 patients with TN, of whom 68% responded to Botox. Recently, two new cases of TN successfully treated with Botox have been reported and in the past month I’ve treated three additional patients. Two of my patients had excellent relief and one had none.

One of the case reports was presented at the recent meeting of the American Headache Society in San Diego. This was a 65-year-old woman who suffered from very severe electric shock-like pain typical of TN. She did not respond to a variety of medications, including carbamazepine (Tegretol), but did respond to Botox injections. Botox did not eliminate her pain, but the severity of it was reduced by 50% and this significantly improved the quality of her life.

The current issue of Headache contains a report of a 60-year-old man with severe TN who also did not respond to any medications. He did obtain complete relief from Botox injections and Botox has remained effective for over 2 years.

With any new treatment we usually hope to see large double-blind controlled clinical trials and eventually an FDA approval. FDA approval usually compels insurance companies pay for the treatment. Botox injections have received approval for chronic migraines, excessive sweating, twitching of muscles around the eyes (blepharospasm), and several other conditions. Unfortunately, it is not likely that Botox will receive approval for the treatment of TN because it is a relatively rare condition, which will make it difficult to conduct a large blinded trial. Fortunately, the amount of Botox needed to treat TN is much smaller than what is used for migraines, making a little more affordable. We use 100 to 200 units of Botox for chronic migraines (the FDA-approved protocol calls for 155 units injected over 31 sites) and only 20 to 50 units for TN.

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An ENT colleague recently referred to me a patient with very persistent sensation of pressure in her sinuses. She’d had sinus surgery which relieved pain in one of her sinuses, but the pressure sensation persisted. She did not experience much pain, but the pressure was present constantly and was very distracting and upsetting. First we tried intravenous magnesium because her blood test showed a mild deficiency. This did not help and I gave her several acupuncture treatments, which helped only a little and the effect did not last. When she mentioned that sneezing helped for a brief period, I though that intranasal hot pepper extract, capsaicin could help, and in fact it did.

There are several over-the-counter nasal sprays containing capsaicin, but she found that only Ausanil brand was helpful. Other brands include Sinol and SInus Buster. Ausanil is being advertised for both sinus and migraine headaches. There only small studies showing that capsaicin applied into the nostril can relieve migraines and even cluster headaches. A small Italian study showed that if capsaicin is applied into the nostril on the side of the headache it helped, but when applied on the opposite side, it did not.

This is not an easy treatment because it causes severe burning and some people tolerate it well, while other do not. It is certainly safe and inexpensive.

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If you are interested in learning to meditate, but don’t know how to get started, go to Dr. Tara Brach’s website for help. It offers her free weekly podcasts that will guide you through the process. Tara Brach is a psychologist and a buddhist, who after college spent 10 years in an ashram studying yoga and meditation. She has a pleasant voice and her podcasts are full of stories, funny anecdotes and short poems that are sure to inspire you.

My wife and I recently attended Tara Brach’s workshop on “Radical Acceptance” at the Omega Institute in Rhinebeck, NY. There were frequent sessions of guided meditation as well as exercises and Q & A sessions. Many participants had listened to her podcasts for years and came to hear her in person. One of the questions was, how do you maintain a regular meditation practice? Tara’s answer was to meditate daily. If you do not have time for a 20 or 30-minute session, do it for a minute or two. I would also recommend reading books such as Living Fully by Shyalpa Tenzin Rinpoche, Mindfulness by Joseph Goldstein, Peace is Every Step by Thich Nhat Hanh, and Tara’s two excellent books, Radical Acceptance and True Refuge.

Meditation can bring you relief of anxiety, migraine headaches, and many medical conditions that are made worse by stress. It can also make your life more enjoyable.

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It was a great privilege to know Elie Wiesel, survivor of Auschwitz, Nobel Peace Prize winner, author of 40 books, university professor, and most importantly, a tireless campaigner for human rights.

Mr. Wiesel suffered from severe daily migraines. Both of his parents and many members of his extended family suffered from headaches. The only year in his life without headaches was when he was in Auschwitz. He was highly functional with a very busy schedule despite his chronic migraines. I invited him to speak about his headaches at the First International Headache Summit held in Tel-Aviv, Israel, on November 16, 2008 and he generously agreed (here is a photo from the event). This is an excerpt from his presentation which was published in the journal Headache:

“Thank you very much, Dr. Mauskop. I’ve been thinking a lot about this topic, and when I consider a topic I tend to return to my primary source: do we find headaches in Scripture? Perhaps you remember the prophet Elishah, a very special man, the disciple of Elijah. The woman who was his host in a certain village was barren, and she was embarrassed to tell him this. Elishah’s servant knew of her distress, however, and he so informed the prophet whom he served. Elishah blessed her with a son. The son grew, and one day when he was in the fields with his father, he cried out, “My head, my head. I have a headache.” Thus, for the first time, headache enters old religious texts. The father asked his servants to bring the boy home, where he suddenly died. His mother ran to the prophet, to Elisha, and said, “I asked you for a living son . . . not for a dead one.” At that point we first bear literary witness to the act of mouth-to-mouth resuscitation. The prophet administered it resuscitation, and the boy lived once again.
When one poses a question, the Talmud may offer what amounts to advice. What happens if a person has a headache? What should he do? You or I would answer, Go to a doctor, but the Talmud advises, Go study Torah. Now, why should a person who has a headache go and study? Is it because when he or she studies, they forget their headache? or maybe they get a different headache. Everything is possible.
Now, I must tell you, Dr. Mauskop, you kindly asked me to come and see you for my headaches. I didn’t come because I did not want to embarrass you, to cause you to have to admit failure, because nothing has ever helped me. I began having headaches—I’m speaking to you as a patient—at age 7. At age 7, I already was taking pills for headache; everybody in my family was! My mother had headaches; my father had headaches; my grandfather had headaches. So I lived with headaches from my childhood on.
But then something bizarre happened: the day I entered Auschwitz, the headaches disappeared. I studied what you told me about pressure, about headaches as the result of pressure. But that seemed a contradiction. If ever I had pressure, it was there. In the camp. Every moment was pressure. But the headaches disappeared.
The moment I arrived at the first orphanage in France, after Liberation, they came back. The first doctor I went to I saw for my headaches. They are still with me. And they are not rare; they are still frequent. I get up every day with a headache, and once a week, I have what I call the “deluxe” version, a real headache. My problem is if I have to give a lecture that day—and I teach full time—or that evening, what do I do? If I take strong pills, I’m afraid it could affect my thought processes. I try to cope. I didn’t come to see you. I thought, why should I give you pain by realizing that you cannot help my own?
At my age, and rather suddenly, I’ve developed other kinds of pains that I didn’t have before. Back pains, hand pains. So I’ve been to all kinds of doctors for these various woes, and—I don’t have to tell you—the interesting part is, usually when you have a new pain, the old pain recedes. Not in my case. My headache is so faithful to me; it’s so loyal that it remains present always.
I got up this morning with a very, very bad headache. So, I said to my headache, “You won’t win.” I speak to my headache; I personalize it. I say, “I know who you are, and I know what you want, and it won’t work.” And the pain says to me, “Let’s see, Wiesel.” And so we fight.
Through my studies, I’ve discovered that many writers and artists and painters have suffered from headaches, and they have had their own distinctive methods of coping. Dumas used to place a wet cloth on his forehead. Hemingway used to do write standing, because this seemed to afford some relief. Many of the great writers had headaches. Perhaps writers have headaches because they are afraid of critics.
And to this day I have not found a way of handling my own headache except in my own fashion, which is to live with it. It hasn’t slowed down my work. I teach full-time, and I am a very obsessive professor. In some 40 years, I don’t think I’ve ever given the same course twice. I want to be the best student in the class. That’s how I learn and grow with the students. And all that with my constant companion, this headache.
Now maybe once I’ve finished, you will have a session and say, “Now what can we do for Elie Wiesel’s headaches?” But don’t bother; even if you were to try, I don’t think you could help. But perhaps you can use my example to encourage your patients. Patients will come to you and say, “Why can’t you help me?” And you can say, “Look. He couldn’t get cured, and nevertheless he works. He goes on, functioning, studying, teaching.”
Maybe psychologically I need the headaches to work? I’m sure some of you have had that idea in mind. Maybe he needs the added challenge . . . this extra burden. In that case, why did I have headaches at age 7? And 8 . . . 9 . . . 10? Hereditary? Sure. Pressure? No. What pressure? School pressure? I was a good student.
So do I need these headaches? Personally, I think not. I think I could work as well without them. Are they part of me? Are they part of my psyche? Is my headache part of who I am? If so, what a terrible analysis . . . what a terrible definition of self! Am I my own pain?
You know Descartes, the philosopher. As a young man I admired him because he was one of the great thinkers of the Middle Ages, helping us emerge from the darkness. He came out with the formula, and I’m sure most of you recall it from school, cogito ergo sum: I think, therefore I am. And later I discovered about Descartes things I didn’t admire that much. He had written a book on science. When he read about the tragic fate of Galileo, he was so afraid of the Inquisition that he didn’t publish his book. Hey, Descartes, that’s no way to behave. You, the philosopher, should be afraid of the tormentor? But he was. So I began reanalyzing, reevaluating Descartes, and concluding that maybe he’s wrong even with his cogito ergo sum! I’m a student of the Talmud. I encourage students to ask questions . . . even to question the questions. And so I thought, Maybe he’s wrong.
I think he is. I would say, “I think, therefore you are.” My thought must involve you. My life must involve you. I am who I am, not because of myself, but because of my attitude towards you. One also could say, “You think, therefore I am.” Your thought challenges mine. Your existence is a challenge to mine. Your life is maybe a question . . . and an answer in relation to my own. Alone, who are we? Nobody is alone.
So, how might I use even the pain of headache for the benefit of someone else? How can I do that? By doing my work, sure. So I go on; I’m a writer; I’m a teacher; I go around the world trying to do my best to improve some conditions here and there, always failing—but it doesn’t matter . . . I will go on trying.
One last thing to add, something perhaps to tell your patients: when a person says, Leave me alone, I have a headache, it’s wrong. Never leave me alone. Never think that you bother me. I may have the worst headache in my life, but if someone needs me, I have no right to say, “But I have a headache.” That is not a sufficient excuse.”

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Tremor of the hands is usually a benign condition. It is even called, benign essential tremor or, if it runs in the family, benign familial tremor. Patients with tremor are twice as likely to have migraines, so this is why I am writing about it. Tremor is also a symptom of Parkinson’s disease, but these two types of tremor can be easily differentiated. Parkinsonian tremor is a resting tremor, which means that hands shake at rest, while essential tremor occurs in action, like when trying to drink from a cup.

Even though it is benign, essential tremor can be incapacitating and socially embarrassing. Fortunately, in most people it responds to treatment. We usually start with propranolol (Inderal), a drug that belongs to the beta-blocker family, which is used for the treatment of high blood pressure and migraines. If propranolol or another beta-blocker is ineffective or causes side effects (due to low blood pressure or slow pulse), tremor can be treated with epilepsy drugs such as primidone (Mysoline), gabapentin (Neurontin), zonisamide (Zonegran), or an alpha-2 agonist such as clonidine (Catapres), which is a different type of blood pressure medicine.

In rare cases, tremor affects not hands but the voice. I recently treated such a patient. He tried some medications, but when they did not help, he was given Botox injections into the vocal cords. This reduced the tremulousness of his voice, but only partially. Botox can also help with hand tremor, but because there are so many small muscles involved, the results are not very good. Taking careful history revealed that this patient tried only 10 mg of propranolol and when it did not help, he stopped it. I decided to give it another try and built up the dose to 30 mg, which provided complete relief without any side effects. For migraines, we usually go up to 60 to 120 mg of propranolol, but some patients need and tolerate even higher doses.

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A new report presented at the last annual scientific meeting of the American Headache Society in San Diego showed that post-concussion symptoms can be helped by an intravenous infusion of magnesium.

Doctors at the department of neurology at UCLA described six patients with a post-concussion syndrome, who were given an infusion of 2 grams of magnesium sulfate. Three out of six had a significant improvement of their headaches and all had improvement in at least one of the following symptoms: concentration, mood, insomnia, memory, and dizziness.

This was a small study, but it is consistent with other studies that show a drop in the magnesium level following a concussion and also studies in animals that show beneficial effects of magnesium following a head trauma.

Our studies have shown that intravenous magnesium can relieve migraine and cluster headaches in a significant proportion of patients.

Considering how safe intravenous magnesium is and how devastating the effect of a concussion can be, it makes sense to give all patients with a post-concussion syndrome if not an intravenous infusion, at least an oral supplement. I usually recommend 400 mg of magnesium glycinate, which should be taken with food. For faster and more reliable effect, we routinely give patients with migraines, cluster, and post-concussion headaches an infusion of magnesium. Patients who do not absorb or do not tolerate (it can cause diarrhea) oral magnesium, come in to for monthly infusions.

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Should you sleep on the right or on the left side? Researchers led by Dr. Helene Benveniste of Stony Brook University discovered that sleeping on the right side provides better drainage of toxins out of the brain, at least in rats. She presented their findings at the meeting of the American Headache Society in San Diego earlier this month.

The lymphatic system, which has been long known to exist throughout the body, was only recently discovered in the brain. It is called a glymphatic system because brain’s glial cells form this network of draining channels. According to the latest studies, our brain does housekeeping by removing waste products when we are asleep. Insomnia has been associated not only with more frequent migraine headaches, but also with an increased risk for Alzheimer’s disease, which is thought to be at least in part due to accumulation of waste products in brain cells.

When you google sleep positions, many sites recommend sleeping on the left side, but no scientific studies have been done to see which position is more beneficial. The rat study mentioned above suggests that sleeping on either side is better than sleeping on your back or on the stomach. Hopefully, Dr. Benveniste and her colleagues will conduct studies in humans, so that we know how to sleep. For now, whatever position you sleep in, try to get enough sleep every night.

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