Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other).

Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts.

Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS:

“It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month”.

And then she posed a question: How many are being harmed vs helped by this advice?

While Dr. Lipton quoted scientific articles supporting the existence of MOH, Dr. Scher’s conclusions reflected my clinical experience that MOH is not a proven entity as it relates to triptans and NSAIDs. I see it only in those who overuse caffeine or caffeine-containing drugs (Excedrin, Fioricet, etc) or narcotic pain killers (Percocet or oxycodone, Vicodin or hydrocodone, and other).

Dr. Scher concluded that, “Since the existence of MOH has not been proven (and may be non-provable for practical purposes), one is obligated to remain agnostic about this entity. And the corollary is that there is no evidence that undertreating will prevent headache frequency progression and may harm more people than help”.

In fact, the same headache experts who limit abortive therapies to twice a week, recommend aggressive abortive therapy for migraines because undertreatment of episodic migraine can lead to its transformation into chronic migraine.

She also indicated that “Quality of evidence for medication withdrawal alone as treatment for MOH is poor” and “Medication withdrawal alone is not clearly better than doing nothing and may be worse”. Meaning that in addition to withdrawal of the acute medication, patients should be given prophylactic treatment.

Studies indicate that after one year, 60% and after two years, 70% of those with chronic migraines (15 or more headache days in a month) revert to episodic ones (less than 15 headache days a month) regardless of treatment. In 15% headaches decrease to less than one a week. This is because fortunately, migraines often improve with time on their own.

We have evidence that Botox injections and some preventive medications can make discontinuation of acute medications easier. We always try to stop Fioricet (butalbital, acetaminophen, and caffeine), Fiorinal (butalbital, aspirin, and caffeine), Excedrin (caffeine, acetaminophen, aspirin) with the help of regular aerobic exercise, biofeedback or meditation, magnesium and other supplements, Botox injections, and sometimes preventive medications.

However, we do have several dozen patients whose headaches are controlled by the daily intake of triptans. These patients have tried given prophylactic medications, Botox injections and other treatments, but find that only triptans provide good relief and eliminate migraine-related disability. The most commented on post on this blog (with 175 comments to date) is one on the daily use of triptans.

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Chronic migraine afflicts more than 4 million Americans, but shockingly less than 5% of them receive appropriate care, according to a new study just published in the journal Headache.

Chronic migraine sufferers experience headaches on more than half of the days and some, every day. These headaches are much more disabling than episodic migraines (those occurring on less than half of the days).

The study established three barriers to an effective treatment of this very common and very disabling condition. The first barrier was being able to see a specialist for a consultation. Those patients who were more likely to get a consultation were older, had more severe migraine symptoms, more disability, and had health insurance.

The second barrier is getting a correct diagnosis. Consulting a specialist rather than a primary care provider, being a female and having more severe migraines increased the odds of a correct diagnosis.

The third barrier was getting proper treatment with preventive medications and Botox injections and acute treatment with triptans and prescription nonsteroidal anti-inflammatory drugs (NSAIDs).

Only 56 (4.5%) out of the 1254 patients evaluated in the study overcame all three barriers and were given appropriate treatment. In a previous study, the same authors found that 26% of patients with episodic migraines traversed all three barriers, which means that only one of of four of more then 30 million Americans with episodic migraines received proper treatment.

The first barrier is possibly the most difficult to eliminate. Despite the fact that the Obamacare provided millions of people with insurance, access to doctors has improved only marginally. A sudden increase in the number of insured was not matched by an increase in the number of doctors. The main bottleneck is not the number of doctors who graduate from medical schools, but the number of residency training positions. Residency training is subsidized by Medicare, which has not increased the number of residencies. We do have a growing number of nurse practitioners and other non-physician healthcare providers who will hopefully make the shortage of doctors less acute. However, this study suggests that migraine sufferers need to see a specialist to receive a correct diagnosis. This does not necessarily mean a physician – we have three nurse practitioners who specialize in treating headaches and who are highly qualified to diagnose and treat various headache disorders.

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Zecuity, a transdermal sumatriptan patch has been reported to cause skin burns and scarring, according to the FDA. The FDA has started an investigation, but the manufacturer, Teva Pharmaceuticals has decided to pull the product off the market.

This is not a major loss for migraine sufferers since we now have four other ways to deliver sumatriptan (Imitrex) – tablet, injection, nasal spray, and nasal powder.

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Hemiplegic and basilar migraine are rare types of migraine. Hemiplegic migraine is accompanied by a paralysis of one side of the body. Basilar migraine derives its name from the basilar artery, which supplies blood to the brainstem. Symptoms of brainstem dysfunction (double vision, unsteady gait, vertigo, difficulty speaking) made doctors think that ischemia or lack of blood flow in that artery caused these symptoms. We now know that this is not the case and basilar migraine may be just another form of migraine with aura.

The FDA ruled that sumatriptan (Imitrex), other triptans, and ergotamines (DHE-45, Cafergot) are contraindicated in patients with basilar and hemiplegic migraine because of the unsubstantiated fear that these drugs may cause constriction of blood vessels that might be already constricted resulting in a stroke. There is little evidence that symptoms of hemiplegic and basilar migraine are caused by the constriction of blood vessels. It is most likely due to the dysfunction of the brain cells. In addition, constriction of blood vessels by the triptans is very mild.

A study just published in the journal Headache examined 67 patients with basilar and 13 with hemiplegic migraines who were treated with triptans and dihydroergotamine (DHE-45). None of these patients suffered a stroke or a heart attack.

This is not the first report of the safe use of triptans in the treatment of basilar and hemiplegic migraines. Although the total number of patients reported is small, it appears that triptans and ergots are probably safe in these types of migraines. Some doctors are afraid to prescribe triptans to such patients out of fear of litigation. There is a good chance that the next edition of the classification of headache disorders will no longer include basilar migraine because it is recognized as being just a form of migraine with aura. Ergots and triptans are not contraindicated in migraine with aura.

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Post-concussion symptoms have long been thought to be more severe and prolonged in people who have pre-existing psychological problems. This has been shown to be the case in the military personnel. A new study confirmed this observation in the first prospective study. Over 2,000 high school and college athletes in Wisconsin were asked to answer 18 questions (Brief Symptom Inventory-18, or BSI-18) and then were followed for three years. The 18 questions, which are listed below, addressed the presence of anxiety, panic attacks, depression, and somatization (excessive bodily sensations). In the ensuing three years, 127 athletes sustained a concussion. The concussion had to be diagnosed by a licensed athletic trainer according to the Department of Defence definition, which includes alteration of mental status with associated headache, nausea, vomiting, balance difficulties, dizziness, cognitive difficulties, and other. These athletes were again evaluated two and six weeks later. Eighty percent of concussed athletes were men. The mean duration of symptoms was five days. Ninety five percent of them recovered completely within a month. High somatization score on the BSI-18 questionnaire predicted prolonged duration of symptoms, while no correlation was found with the years of playing a sport, the type of sport (most played football), number of prior concussions, migraines, ADHD, or the grade point average. Another factor that delayed recovery was the initial symptom severity after the concussion. Most of the concussions were mild with less than 10% of athletes losing consciousness.

An interesting and unexplained fact, not examined in this study, is that milder concussions tend to cause more severe symptoms than severe ones.

This was a very thorough study, but it was relatively small, so it is possible that other pre-concussion factors may also delay recovery. One such factor is pre-existing migraines. I see many patients, adults and children, who suffered from migraines and after a concussion have worsening of their migraines or new daily persistent headaches. If they themselves have never suffered from migraines, often their mother or siblings have a history of migraines, suggesting genetic predisposition to migraines.

Treatment of post-concussion symptoms, include typical therapies employed in migraine sufferers, including aerobic exercise, biofeedback, magnesium supplementation, Botox injections, and a variety of medications.

Brief Symptom Inventory-18

The Somatization dimension
01. Faintness or dizziness
04. Pains in heart or chest
07. Nausea or upset stomach
10. Trouble getting your breath
13. Numbness or tingling in parts of your body
16. Feeling weak in parts of your body
The depression dimension
02. Feeling no interest in things
05. Feeling lonely
08. Feeling blue
11. Feeling of worthlessness
14. Feeling hopeless about the future
17. Thoughts of ending your life
General anxiety
03. Nervousness or shakiness inside
06. Feeling tense or keyed up
15. Feeling so restless you couldn’t sit still
Panic
09. Suddenly scared for no reason
12. Spells of terror or panic
18. Feeling fearful

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Intravenous magnesium infusions may not be as safe in pregnant women as it has been always thought. The FDA recently moved intravenous magnesium from category A into category D (see category definitions below). This came about after the FDA reviewed 18 cases of babies who were born with serious problems after their mothers received intravenous infusions of large amounts of magnesium for 5 to 7 days in order to stop premature labor. The FDA strongly discourages this practice and states that “Administration of magnesium sulfate injection to pregnant women longer than 5-7 days may lead to low calcium levels and bone problems in the developing baby or fetus, including thin bones, called osteopenia, and bone breaks, called fractures.”

However, treatment of choice for eclampsia remains intravenous magnesium. Eclampsia, one of the most serious complications of pregnancy can be treated only with high doses of intravenous magnesium. Without intravenous magnesium eclampsia can lead to epileptic seizures, very high blood pressure, kidney failure and death.

The FDA also recommends that “Magnesium sulfate injection should only be used during pregnancy if clearly needed. If the drug is used during pregnancy, the health care professional should inform the patient of potential harm to the fetus.”

We do treat many patients, including pregnant women, with intravenous infusions of magnesium if they are deficient in magnesium and if their migraines respond to such infusions. Typically, these infusions are given monthly and the amount is only 1 gram, while for preterm labor the dose is 4-6 grams to start and then 2-4 grams an hour as needed. This monthly dose of 1 gram is extremely unlikely to cause any adverse effects. We find that migraines triggered by magnesium deficiency do not respond well to any other treatments and considering the risk of drugs, it is much safer to administer 1 gram of magnesium. This amount of magnesium just corrects the deficiency and does not cause very high magnesium levels, which can be detrimental.

Several other drugs routinely used in pregnancy may also not be as safe as we thought. Acetaminophen (Tylenol) has been considered one of the safest choices. However, recent evidence suggests possible link to attention deficit disorder with hyperactivity (ADHD).

Butalbital, which is an ingredient in the popular headache drugs such as Esgic, Fioricet and Fiorinal is associated with an increased risk of congenital heart defects. Fioricet also contains caffeine, which has negative effects on the fetus and which can cause rebound (medication overuse) headaches.

FDA drug categories in pregnancy

Category A
Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
Example drugs or substances: levothyroxine, folic acid, liothyronine

Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
Example drugs: metformin, hydrochlorothiazide, cyclobenzaprine, amoxicillin, pantoprazole

Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Example drugs: tramadol, gabapentin, amlodipine, trazodone, prednisone

Category D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Example drugs: topiramate (Topamax), divalproex sodium (Depakote), lisinopril, alprazolam, losartan, clonazepam, lorazepam

Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

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Dr. Leo Galland, whom I’ve known professionally for many years, has written (with his son) another outstanding book, The Allergy Solution. Sometimes I see a patient, who in addition to migraine headaches, suffers from a variety of other ailments. These patients usually see an allergist, an ENT doctor, an infectious disease specialist, and several other physicians, all without answers or relief. In most cases, Dr. Galland is the one who can figure out what’s wrong and how to fix it.

Dr. Galland’s new book, which I just read cover-to-cover, presents scientific research that explains hidden causes of unexplained symptoms such as migraines, fatigue, weight gain, chronic pain, poor sleep, allergies, and reflux. The book describes the role of immune function, stress, nutrition, inflammation, environmental health, leaky gut, and the microbiome.

Most importantly, The Allergy Solution gives people practical solutions to relieve their symptoms, which are very often caused by allergies. Dr. Galland convincingly shows that allergies are aggravated by stress, abnormal gut bacteria, specific vitamin and mineral deficiencies, and other factors. He writes about scientific studies that show the effect of meditation on inflammation and how taking probiotics can improve not only your digestive problems but also migraines and many other symptoms. From this book you will learn the role of vitamin D, zinc, magnesium and a variety of other minerals and vitamins in returning you to health. One of the things I learned is that a combination of vitamin B12 and a mineral called molybdenum can reduce the amount of sulfites in your body. Sulfites, which often trigger migraines are used as a preservative and also occur naturally in wine.

To tell you more about what’s in the book, here is a series of questions answered by Dr. Galland:

Q: What have you discovered about the surprising hidden truths behind chronic symptoms?
A: You may not think of yourself as allergic. Your nose may not run, and your skin doesn’t itch. But you have common complaints that just won’t go away.
Do you suffer from:
•Weight gain?
•Stomachaches?
•Insomnia?
•Headaches?
•Fatigue?
•Depression or anxiety?
•Brain fog?

A hidden allergy is often the culprit. Chronic conditions that were previously diagnosed as autoimmune diseases, psychiatric disorders, or many others, wind up being allergic in origin.

Our search for answers to common mystery conditions, and the source of the allergy epidemic inspired us to write our new book, The Allergy Solution: Unlock the Surprising, Hidden Truth about Why You Are Sick and How to Get Well.

We reveal the proven role of allergy in causing weight gain, fatigue, headache, joint and muscle pain, a range of digestive symptoms from heartburn to diarrhea, mood problems, poor mental focus, and more. A step-by-step method for determining if you have hidden allergies is provided. And if you suffer from classic allergies like rhinitis, eczema or have asthma, our program addresses these issues from a nutritional and lifestyle perspective.

Q: Why are we seeing an epidemic of allergy today?
A: Allergies were once rare. Today they affect over a billion people. Environmental toxicity, depletion of beneficial intestinal bacteria and fast food all contribute to allergies.
Pollen counts are going up and up. A big cause? Air pollution, the kind generated by cars, buses and trucks. Scientists at the US Department of Agriculture investigated how air pollution affects ragweed. They discovered that pollution makes the plants grow twice as large and produce 5 times as much pollen. Many types of pollen, especially ragweed, are actually toxic. They contain an enzyme that damages the lining of your nose and lungs when you breathe them in. This sets the stage for rising allergies.

Driving While Allergic: Dutch scientists tested driving skills in people with allergies and discovered that Pollen exposure impaired the operation of an automobile to the same extent as drinking two cocktails.
Air fresheners increase the risk of allergies and asthma, mostly because of the chemical fragrances they contain, reports a study from the University of California. So what’s alternative? We can’t think of a better way to freshen your air than with ventilation. If the air outside your home is actually worse than the air inside, then try a commercial air purifier.

Cleaning sprays are also hazardous to your health. Using a household cleaning spray just once a week elevates your risk of developing asthma by 30 to 50 per cent, reports a study from Europe. But true clean doesn’t come from a cleaning spray. The Allergy Solution contains a program for freeing your home from these toxins. We call it Mission Detoxable. Step one is easy: ditch the chemical sprays and use water and baking soda for most cleaning jobs. Vinegar in water is great for glass and tile.
Q: How does nutrition impact allergies?
A: Research shows that people with allergies often suffer from nutritional deficiencies and may need nutritional enrichment of protective factors like selenium, magnesium, vitamins C and D, and omega-3 fats. In The Allergy Solution we provide a nutritional approach to overcoming allergy through food and supplements.
All of us need concentrated nutritional support for T-regs, which comes from natural folates found in vegetables such as leafy greens; carotenoids found in orange and yellow vegetables; the bioflavonoids found in things like parsley, strawberries and oolong tea; and detoxifying compounds found in broccoli.

Q: What are the most important nutritional factors for reversing allergy?
A: It is vital that the food you eat supply the nutrients you need to help your body remove toxins and establish healthy immune balance. To accomplish this, we include a simple program in The Allergy Solution called the Power Wash. It’s like hitting the re-set button on your computer. You can get started over a 3-day weekend.
With the Power Wash you eliminate the major problem foods like wheat, dairy, soy, corn, yeast, eggs and you nourish your body with a specially designed combination of vegetables, fruits, spices, herbs, and teas. They’ve been chosen because they support the function of a critical part of your immune system: regulatory T-lymphocytes. We call them T-regs. Their role is to turn off the unwanted immune reactions that create allergies. If you have allergies, you suffer from defective function of T-regs.
Q: How does allergy cause weight gain and prevent weight loss?
A: What happens is a vicious cycle driven by the effects of allergy on your metabolism. Clinical research reveals a strong link between allergy and weight gain. People with allergies are more likely to become overweight. People who are overweight are more likely to develop allergies.
Laboratory research shows that allergic reactions actually make fat cells grow larger and larger. Fat cells create a type of inflammation that unleashes stronger allergic reactions. Balancing immunity is essential for healthy weight loss.

Q: How does your program affect the skin?
A: Your skin is your most visible barrier against a toxic environment and a key target for allergic reactions. Allergy rapidly ages the skin and reversing allergy is essential to restoring its vitality.
The nutrients that nourish your immune cells are also essential for nourishing your skin. In addition, Mission Detoxable helps you decrease the stress placed on your skin by avoiding toxins in your home.

Q: What’s the role of your gut in creating or defending against allergy?
A: Two-thirds of your immune system is located in your intestinal tract. The gut is like a boot camp for training your immune cells. The drill sergeants are the bacteria living in your intestines. Biodiversity of these bacteria is essential for immune health and protects against allergy.
Antibiotics, pesticides, herbicides, disinfectants and the modern diet all destroy this diversity and contribute to the allergy epidemic. Our book contains a program for overcoming allergies by healing your gut. It’s called ARC, for Avoidance, Reflorastation and Cultivation.

Q: How does your book address the environmental challenges facing the world?
A: We wrote The Allergy Solution to change how the world thinks about allergy, health, and our relationship with the environment. We reveal the science that says allergies are not just annoying symptoms to be covered over by medications, and the environment is not just a convenient place to put our car exhaust, toss our garbage, and spray our pesticides. In the chapter “How Did We Get So Sick” we bring to light the astonishing research that connects pollution, global warming and toxins to rising allergies and asthma.

The environment is all around us and within us, inside our digestive tract, respiratory system, and whole body. we have exposed the truth that just as the earth’s environment is out of balance, our bodies have become out of balance. Now the environment we all depend on is threatened as never before.

Q: Can We Be Part of the Solution?
A: Absolutely. A community effort is needed to protect the environment and our health. Let’s all work together to turn around air pollution, giving those with asthma—and those without—a better chance to breathe free? Reductions in air pollution could also curb the rising levels of pollen, helping those with hay fever feel more comfortable. Using fewer toxic chemicals would reduce the burden on the environment.

Allergies are connected to the food we eat, the air we breathe, and the environment we live in. Join us and be part of the solution. Learn more about natural health by joining our community at drgalland.com Follow Dr. Galland on facebook.com/leogallandmd and Twitter (@leogallandmd), and follow Jonathan Galland at facebook.com/jonathangallandjd and on Twitter @JonathanGalland.

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Sumatriptan (Imitrex) and similar drugs (so called triptans) are “designer” drugs that were specifically developed for the treatment of migraine headaches. They are very effective, but do not help all migraine sufferers. Anti-inflammatory pain killers, such as aspirin and ibuprofen work well for some people and sometimes these drugs are combined with triptans to achieve better relief.

Many migraineurs experience nausea and sometimes vomiting as part of their migraine, which prevents or delays the absorption of medicine, making it ineffective or less effective. To address this problem, two of the triptans, sumatriptan and zolmitriptan (Zomig) are available in a nasal spray form. Sumatriptan can be also self-administered as an injection and recently a skin patch of sumatriptan (Zecuity) became available. An anti-inflammatory pain medicine, ketorolac is also available as a nasal spray, as does a narcotic pain killer, Stadol (butorphanol). While Stadol is addictive and has other serious side effects, intranasal ketorolac (Sprix) is a very good pain medication. Sprix works much better than the ketorolac tablet, but not as well as an injection of ketorolac (Toradol).

Intranasal ketorolac was compared with intranasal sumatriptan in a study that was recently published in the journal Headache. The study showed that ketorolac and sumatriptan nasal sprays were equally effective and both were better than placebo spray. Both drugs caused nasal irritation and unpleasant taste in some patients, but these were not severe.

The main problem with intranasal ketorolac is its cost. On GoodRx.com the price of 5 vials of Sprix (with a coupon) is about $1,000. Each vial is good for one day of use; it contains 8 sprays (15 mg each) and the usual dose is one spray into each nostril, repeated every 6 hours as needed. However, there is a way around the cost of this medication. Ten 30 mg vials of generic ketorolac for injections cost $15. You just need to buy a nasal spray bottle, empty the contents of the vial into it and use it as needed.

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The FDA approved Botox injections for the treatment of chronic migraine headaches more than five years ago. I just discovered that in this period of time only 100,000 chronic migraine sufferers received this treatment. According to the Migraine Research Foundation, 14 million Americans suffer from chronic migraines, so less than 1% of them have recieved this potentially life-changing treatment.

There are several possible explanations.
1. Botox is expensive and many insurance companies make it difficult for patients to get it. They require that the patient first try 2 or 3 preventive drugs, such as a blood pressure medicine, (propranolol, atenolol, etc.), an epilepsy drug (gabapentin, Depakote, Topamax), or an antidepressant (amitriptyline, nortriptyline, Cymbalta). Patients also have to have 15 or more headache days (not all of them have to be migraines) in each of the three preceding months. If these requirements are met, the doctor has to submit a request for prior authorization. Once this prior authorization is granted, the insurer will usually send Botox to the doctor’s office. After the procedure is done, the doctor has to submit a bill to get paid for administering Botox. This bill does not always automatically get paid, even if a prior authorization was properly obtained. The insurer can ask for a copy of office notes that show that the procedure was indeed performed. All this obviously serves as a deterrent for many doctors. Some of them find that the amount of paperwork is so great and that the payment is so low and uncertain, that they actually lose money doing it.

2. There are not enough doctors trained in administering Botox. This is becoming less of a problem as more and more neurologists join large groups or hospitals where at least one of the neurologists is trained to give Botox and gets patients referred to him or her. However, doctors in solo practices or small groups without a trained injector can be reluctant to refer their patients out for the fear of losing a patient. They may suggest that this treatment is not really that effective or that it can cause serious side effects.
The majority of doctors who inject Botox are neurologists, but there are only 15,000 neurologists in the US and many specialize in the treatment of strokes, Alzheimer’s, epilepsy, MS, and other conditions. This leaves only a couple of thousand who treat headache patients. Considering that there are 14 million chronic migraine sufferers, primary care doctors will hopefully begin to provide this service.

3. Chronic migraine patients are underdiagnosed. Many patients will tell the doctor that they have 2 migraines a week and will not mention that they also have a mild headache every day. The mild headaches they can live with and sometimes my patients will even call them “normal headaches”, which they don’t think are worth mentioning. Good history taking on the part of the doctor solves this problem. However, once doctors join a large group or a hospital, they are pressured to see more patients in shorter periods of time, making it difficult to obtain a thorough history.

4. Some patients are afraid of Botox because it is a poison. In fact, by weight it is the deadliest poison known to man. However, it is safer than Tylenol (acetaminophen) because it all depends on the amount and too much of almost any drug can kill you. Fifty 500 mg tablets of Tylenol kills most people by causing irreversible liver damage. Hundreds of people die every year because of an accidental Tylenol poisoning, while it is extremely rare for someone to die from Botox. Tens of millions of people have been exposed to Botox since its introduction in 1989. It is mostly young children who have gotten into trouble from Botox because the dose was not properly calculated. Kids get Botox injected into their leg muscles for spasticity due to cerebral palsy, although children with chronic migraines also receive it (the youngest child with chronic migraines I treated with Botox was 8).

In summary, if you have headaches on more than half of the days (not necessarily all migraines) and you’ve tried two or three preventive drugs (and exercise, meditation, magnesium, CoQ10, etc), try to find a doctor who will give you Botox injections. Botox is more effective and safer than preventive medications because it does not affect your liver, kidneys, brain, or any other organ.

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Yoga is the most impactful import from India to the US. Yoga has many documented health benefits, including relief of headaches. I have been practicing Bikram yoga about twice a week for nearly 12 years. About a year ago I started having some neck and left upper back pain. I thought that strengthening neck exercises, meditation, occasional massage, which is what I recommend my patients, would eliminate the pain (I probably should have also gone for physical therapy). The pain was never severe and would temporarily improve with massage, but because it persisted and became annoying, I decided to try chiropractic.

Many doctors’ attitude towards chiropractors is dismissive, disdainful or worse. When I tried to google the number of chiropractic manipulations done in the US, the first item that popped up was Medscape’s Deaths After Chiropractic: A Review of Published Cases (there were 26 cases in that report). I have personally treated an elderly patient who developed a subdural hematoma (bleeding inside the head) after chiropractic manipulation. My usual advice to patients has been to go for physical therapy and massage instead of chiropractic. If a patient really wants to see a chiropractor, I advise asking not have any high velocity adjustments. This adjustment is done by suddenly turning and lifting your head to one side and it is responsible for most of the complications. I also tell patients that a good chiropractor will always give you exercises to do, while those who don’t, just want you to keep coming for adjustments for years. Many people feel immediate relief from chiropractic, but it lasts only a few days and they have to go back for another treatment. In fact, regular stretching done by a chiropractor can loosen the ligaments around the cervical spine and cause habitual subluxation of the joints. Subluxation is a partial joint misalignment, which a chiropractor can fix, but repeated adjustments stretches the ligaments and make it easier for the joint to misalign again.

So, why did I take a chance with my neck if not life? First, I wanted to experience what a chiropractic manipulation is like (I’ve also tried Botox, intravenous magnesium, TMS stimulation, and other treatments I offer my patients). Second, I ran into (or rather gave a TV interview to) Lou Bisogni, a chiropractor who is the chiropractor for the New York Yankees. If Joe Torre, Yogi Berra, Wade Boggs, Derek Jeter, and other top Yankee players (dozens of their signed photos are on the office walls) have been entrusting their bodies to him, then obviously he must be very good.

Because my pain has lasted for almost a year, Bisogni first X-rayed my neck. I was not surprised to see that my C5-6 cervical disc was mildly degenerated and the C5 vertebra slipped slightly forward over the C6. This misalignment was what must have prevented my pain from going away. Treatment of such mild misalignments is what chiropractors are probably best at. I did tell him that I did not want high velocity adjustments and he reassured me that he wasn’t going to do any. Many chiropractors are fully aware of the risks and do avoid this type of adjustment. Instead, Bisogni would first apply TENS (transcutaneous electric nerve stimulation – an old technique often used by physical therapists as well), ultrasound, or massage, followed by a brief and gentle adjustment. The adjustment was so gentle and brief (5 minutes or so) that I was a bit skeptical about its efficacy. But to my surprise, after 5 – 6 sessions my pain dramatically improved. It is not completely gone, so I will go for a few more sessions.

I did cut back on Bikram yoga to once a week (but added some weight training instead) and modified my routine when I do it. It is possible that extreme flexion and extension of my neck, which is part of some yoga positions (rabbit, camel, pranayama breathing), might have caused my neck problem. So, I avoid flexing and extending my neck all the way as far as I can. Many yoga instructors push their students to achieve a full expression of the pose, but if your neck hurts or feels uncomfortable, tell the instructor that you’d rather not take a chance with your neck. You should definitely avoid head stands (unless you can do them without putting any pressure on your head and support yourself on the forearms) and shoulder stands, which put excessive pressure on your cervical spine. Also, the high heat in Bikram studios can be a headache trigger for some migraine sufferers and I usually recommend to my patients doing yoga at room temperature.

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I have not been aware of any research indicating a link between salt intake and migraines. A study just published in the journal Headache by researchers at Stanford and UCLA looked at this possible connection.
This was a national nutritional study that examined sodium intake in people with a history of migraine or severe headaches.

The study included 8819 adults with reliable data on diet and headache history. The researchers classified respondents who reported a history of migraine or severe headaches as having probable history of migraine. They excluded patients with medication overuse headache, that is people who were taking pain medications very frequently. Dietary sodium intake was measured using estimates that have been proven to be reliable in previous studies.

Surprisingly, higher dietary intake of sodium was associated with a lower chance of migraines or severe headaches. This relationship was not affected by age or sex. In women, this inverse relationship was limited to those with lower weight (as measured by body mass index, or BMI), while in men the relationship did not differ by BMI.

This study offered the first scientific evidence of an inverse relationship between migraines and severe headaches and dietary sodium intake.

It is very premature to recommend increased sodium intake to all people who suffer from migraines and severe headaches. However, considering that this is a relatively safe intervention, it may make sense to try increased salt intake. I would suggest adding table salt to a healthy and balanced diet, rather than eating salty foods such as smoked fish, potato chips, processed deli meats, or pickles. These foods contain sulfites, nitrites, and other preservatives which can trigger a migraine attack.

People with high blood pressure and kidney or heart disease need to consult their doctor before increasing their salt intake.

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Caffeine is a well-know trigger of migraine headaches and I regularly write on this topic (my last post on this topic – caffeine causing headaches in adolescents – was three years ago). Caffeine can help migraines and other headaches, but in large amounts it worsens them due to caffeine withdrawal, which can occur in as little as 3 hours after the last cup of coffee. One of my patients was an extreme case. He told me that he figured out that his early morning migraines were due to caffeine withdrawal and he would set his alarm clock for 4 AM, so that he could wake up, drink some coffee and go back to sleep without the fear of a morning headache. A continuous intravenous drip of caffeine would also solve his problem. Most people opt for stopping caffeine, albeit it can be a difficult process. Going cold turkey is often easier than a gradual reduction in caffeine intake. To avoid severe withdrawal, prescription migraine drugs, such as sumatriptan (Imitrex), intravenous magnesium, nerve blocks and other interventions may be necessary in a small percentage of patients.

This post was prompted by a just published study that showed a higher risk of miscarriages in couples where either partner, male or female consumed more than 2 caffeinated beverages prior to conception. Caffeine has been long suspected but not definitively proven to increase the risk of miscarriages in women who drink large amounts of caffeine during pregnancy, but what is surprising is that consumption of caffeine by the male partner also increases the risk.

At the same time, recent studies widely publicized in the press have shown beneficial effects of consuming large amounts of caffeine. Caffeine supposedly lowers the risk of certain cancers, strokes, diabetes, and other conditions. However, if you suffer from headaches, heart burn due to reflux, or are trying to conceive, caffeine should be avoided.

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