The annual course, “The Shifting Migraine Paradigm 2024” will be held February 15-17, 2024 at the Plaza San Antonio Hotel & Spa. This three-day conference offers an excellent update on the treatment of migraine and other headaches.
It is always an honor to be invited to speak at this event. The topic of my presentation is Supplements and Medical Foods.
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Homocysteine, an amino acid crucial for cellular metabolism and protein synthesis, is naturally produced by the body. However, either too low or too high levels in the body can lead to significant health issues.
Insufficient homocysteine levels impair the production of glutathione, a vital substance for detoxifying the liver and the entire body. In some cases, patients are given glutathione infusions for its additional benefits.
Having too much homocysteine is also a problem. High homocysteine levels are associated with an increased risk of cardiovascular disease, cancer, and migraine with aura. High homocysteine levels may also mean you have a vitamin deficiency. Vitamins B12, B6 and folate break down homocysteine to create other chemicals your body needs. Replacing these vitamins often helps return the homocysteine level to normal.
Some drugs may lead to increased homocysteine levels. These include cholestyramine, metformin, methotrexate, nicotinic acid (niacin), and fibric acid derivatives (drugs that are used to lower lipids).
Besides migraine with aura, other symptoms of high homocysteine and low vitamin B12 levels may include memory difficulties, weakness, fatigue, tingling sensations in the hands, arms, legs, or feet, dizziness, mouth sores, and mood changes.
White matter lesions seen on the MRI scans of migraine patients are more common in those with high homocysteine levels. High homocysteine levels may be responsible for the increased risk of strokes in migraine patients.
The good news is that taking vitamins B12, folate, and B6 (pyridoxine) can lower homocysteine levels. Methylated forms of vitamin B12 and folate, methylcobalamin and methylfolate are better absorbed than cyanocobalamin or folic acid.
If you suffer from migraines, especially migraine auras (with or without headaches) you may want to have your homocysteine levels checked. In all of our migraine patients, we also check vitamin B12, folate, RBC magnesium, vitamin D, TSH (thyroid), and routine tests – CBC and CMP.
Read MoreLack of sleep is a common migraine trigger. A less common trigger is getting too much sleep. I always recommend that patients try to go to sleep at the same time and get up at the same time. Even on weekends. Instead of sleeping in on the weekend, take a 30-minute nap in the afternoon.
A new study by Australian researchers published in Neurology reports another important reason for sleep regularity. This was a large and rigorous study involving 88,094 UK subjects. All subjects wore an accelerometer that detected their sleep patterns. The researchers controlled for variables that are known to predispose to dementia – age, sex, ethnicity, material deprivation, retirement status, current shift work status, household income, highest level of education, smoking status, use of sedative, antidepressant, or antipsychotic medication, and genetics (APOE ?4 carrier status).
They “identified a nonlinear relationship between day-to-day sleep regularity and dementia risk such that dementia rates were highest in those with the most irregular sleep, dipped as sleep regularity approached the median, and then marginally increased at the highest estimates of sleep regularity.” In subjects who underwent brain MRI (n = 15,263), gray matter and hippocampal volume (area of the brain critical to memory) similarly tended to be lowest at the extremes of the sleep regularity index. This was surprising – subjects whose sleep patterns were extremely chaotic did slightly better than those with moderately irregular sleep.
Other sleep disorders that can contribute to migraines and increase the risk of dementia are restless leg syndrome, sleep apnea, and sleeping too much or not enough.
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My recent blog post on supplement combinations mentioned one that contains magnesium, riboflavin, and feverfew. I did not mention its name to avoid the appearance of a conflict of interest. I am a paid consultant to the manufacturer. However, many readers of this blog want to know the name of this mystery product. It is called MigreLief.
Akeso, the manufacturer, also makes several related products. One is MigreLief NOW, which contains magnesium, feverfew, ginger, and boswellia. Both ginger and boswellia have proven anti-inflammatory properties.
Another product is a daily MigreLief supplement for children. It also contains magnesium, riboflavin and feverfew but at a lower dose and in smaller caplets.
Read MoreNeurologists diagnose migraine by the description of symptoms provided by the patient. We have not had an objective test to confirm that a person suffers from migraines.
A group of researchers led by Dr. Yiheng Tu in the department of psychiatry at Harvard Medical School developed an AI program that can diagnose migraine using fMRI (functional MRI) scanning. The AI program was first fed information on fMRIs of 116 individuals with migraines and then had this data compared to healthy controls.
The AI program had 93% sensitivity and 89% specificity. This means that it missed the diagnosis of migraine in only 7 out of 1oo patients and diagnosed migraine in 11% of patients who did not have it. These are very good numbers, but clearly, the method is not error-proof.
When they compared people with migraines to those with other types of pain, the sensitivity dropped to 78% and specificity, to 76%. This can be explained by the fact that similar functional changes in the brain probably occur with any type of pain.
A major obstacle to the wide use of fMRI scans is the cost. They are more expensive to perform than a regular MRI. Insurance companies are not likely to cover it since this is an experimental procedure. Another potential difficulty is that fMRI takes much longer to do than a regular MRI – an hour vs 20 minutes. During this time you have to lie inside a tube while trying not to move and hearing loud banging noises.
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I tell most of my patients that after physical exercise, meditation is the second-best preventive treatment for migraine headaches.
It turns out that meditation is not an unalloyed good. In a recent podcast, Tim Ferris interviews a psychologist, Dr. Willoughby Britton whose research is devoted to the negative effects of meditation. Tim Ferris describes his experience of going on a week-long silent meditation retreat, while also fasting and taking psychedelic mushrooms. It is not too surprising that Tim Ferris ended up needing professional help. However, even meditation alone, if taken to an extreme can cause psychological problems. In California, the joke is that meditation is a competitive sport.
Dr. Britton and her colleagues identified a staggering 59 different symptoms that can be triggered by meditation. Cheetah House, an organization led by Dr. Britton, is dedicated to assisting individuals who have experienced negative effects from meditation. According to one study, the most common adverse effects are anxiety, traumatic re-experiencing, and heightened emotional sensitivity. Those with a history of adverse childhood experiences are at a higher risk. But surprisingly, even individuals with adverse effects reported being glad they had meditated.
Dr. Britton suggests that meditating for less than 30 minutes is not likely to result in negative effects.
I have been meditating for years, and it was only when I extended my meditation time to 45 minutes about a year ago that my migraines completely stopped. Fortunately, I have not encountered any side effects.
Read MoreEvery patient visiting our clinic undergoes a routine blood test, which includes an assessment for magnesium and vitamin deficiencies. We know that close to 50% of patients with migraines are deficient in magnesium and many are deficient in riboflavin and other nutrients.
In addition to vitamins and magnesium, we often recommend herbal supplements. One of the herbal remedies that has been used for centuries, is feverfew. It is helpful not only for migraines but also for fever, arthritis, and other conditions. Often referred to as “medieval aspirin”. Most importantly, it has proven to be safe, that is if it is manufactured by a reputable company or you grow your own.
Many patients find it daunting to have to take multiple tablets every day. There are several products on the market that combine various supplements in one tablet. One such supplement that has been on the market the longest, includes magnesium, riboflavin (vitamin B2), and feverfew. I’ve helped develop and promote this combination, so I may be biased. However, it has high-quality ingredients and the same experienced and knowledgeable team that developed it still stands behind it.
Some products also include CoQ10. One-third of migraine sufferers are deficient in this supplement. Because CoQ10 is relatively expensive, many combination products contain insufficient amounts of it. I usually check CoQ10 levels in the blood and if a patient is deficient, I recommend that she takes it separately, 200-300 mg a day.
An important consideration is that you may have a vitamin or RBC magnesium level within the normal range, but if your level is at the bottom of this range, you are likely to be deficient. RBC magnesium level should be above 5, CoQ10 level, above 0.7, vitamin D level, above 45, and vitamin B12 level, above 500.
Read MoreCluster headaches arguably cause the worst imaginable pain, hence the moniker, suicide headaches. Fortunately, there are many treatments for this condition, including two FDA-approved drugs. One is sumatriptan injections taken as needed to stop an attack. The other is a preventive monthly injection of galcanezumab (Emgality). We also use Botox injections, oxygen and a variety of medications. Nevertheless, some people do not respond to these treatments.
A report by Japanese neurologists from Tokyo suggests a new treatment. One theory of the origin of cluster headaches is the reactivation of the varicella-zoster virus that causes chickenpox and shingles.
The study included over 160 patients with episodic cluster headaches who received a shingles vaccine. The response to the vaccine was measured by the amount of antibodies in the blood. Those patients who had more antibodies had a longer delay to the next cluster episode than those with low antibody counts. They also found that those who had a COVID infection and received multiple COVID vaccines, tended to do worse.
It is premature to recommend shingles vaccine to patients with cluster headaches unless they are over 50, the age when everyone is advised to get it.
Read MoreThere is growing evidence that vitamin D is important in the development and treatment of migraines. In the past 15 years, I have written a dozen posts on the role of vitamin D in migraines.
At the last meeting of the International Headache Society, Maria Papasavva and her Greek colleagues presented a study entitled, Genetic variability in vitamin D receptor and migraine susceptibility: a case-control study.
Their study aimed to investigate an association of three genetic variants of vitamin D receptor with the susceptibility to develop migraine. DNA sample was collected and extracted from 191 patients diagnosed with migraine and 265 headache-free subjects. According to their statistical analysis, a significant association between migraine susceptibility and abnormal variants of vitamin D receptors was found. They also showed a significant association of two variants with migraine without aura. Their conclusion was that there is a clear association between migraine susceptibility and two vitamin D receptor variants. This further supports the role of vitamin D and its receptor in migraine.
Vitamin D is important not only for migraines but also for your immune system. Vitamin D deficiency increases the risk of COVID and other viral infections. Lower levels of vitamin D are associated with a higher risk of attacks of multiple sclerosis even if the level is still within normal range. There are many other reasons to maintain your blood vitamin D level at least in the middle of the normal range. The normal range is 30 to 100, so keep it well above 40. If your doctor tells you that your level is normal, ask for the actual number.
Read MoreSince the legalization of medical marijuana in New York in 2014, I have prescribed it to several hundred patients. My experience suggests that approximately one-third of my patients benefit from its use and continue to rely on it for their medical needs. Some have reported relief from symptoms such as nausea and anxiety, often associated with migraines, while others find it highly effective in aiding sleep. Additionally, there are patients who have reported significant pain relief.
It is possible that the relatively low response rate I see in my patients is due to the fact that I reserve medical marijuana for those patients who do not respond to multiple drugs.
At the recent meeting of the International Headache Society, Dr. Nathaniel Schuster and his colleagues presented a study titled “Vaporized cannabis versus placebo for the acute treatment of migraine: a randomized, double-blind, placebo-controlled, crossover trial.” This study aimed to investigate the potential of medical marijuana in alleviating pain and associated migraine symptoms.
In this study, participants were instructed to treat moderate-to-severe migraine attacks within four hours of onset using vaporized cannabis flower. They were asked to treat up to four separate migraine attacks, using vaporized cannabis with different compositions: 1) THC-dominant (6% THC), 2) CBD-dominant (11% CBD), 3) THC/CBD mix (6% THC/11% CBD), and 4) placebo cannabis, with the order randomized and double-blinded.
Out of the 92 participants enrolled, 71 treated at least one migraine attack. Two hours after vaporization, the THC/CBD mix outperformed the placebo in achieving pain relief (69% vs. 48%), pain freedom (36% vs. 16%), and freedom from the most bothersome symptoms, such as nausea, photophobia, or phonophobia (62% vs. 36%). The THC-dominant option was superior to the placebo for pain relief at 2 hours (71% vs. 48%) but was not significantly different from the placebo regarding pain freedom or freedom from the most bothersome symptoms. The CBD-dominant option did not significantly differ from the placebo in terms of pain relief, pain freedom, or freedom from the most bothersome symptoms. The most common side effects reported were sleepiness, followed by euphoria, with no serious adverse events observed.
In conclusion, the authors of the study found that the acute treatment of migraine with a vaporized THC/CBD mix (6% THC/11% CBD) was superior to the placebo in terms of pain relief, pain freedom, and freedom from the most bothersome symptoms at the 2-hour mark.
This study has significant practical implications. In the past, I would leave the choice of products to the licensed pharmacist at the dispensary, while advising patients that finding the right combination is often a trial-and-error process. However, now, I will be better equipped to advise my patients on the most suitable type of medical marijuana for their specific needs based on the findings of this study.
Read MoreA presentation by Jing Jie Yu, Joshua E. Levine, and others from U. of Florida at the last meeting of the International Headache Society described their analysis of the potential risks of triptans.
Triptans are drugs that were first approved in 1992 and include sumatriptan (Imitrex, Imigran), naratriptan (Amerge, Naramig), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert), and frovatriptan (Frova). Because triptans have the potential to constrict blood vessels they are contraindicated in patients who have coronary artery disease (CAD) or cerebrovascular disease (CVD).
The study was entitled, Association between Triptan Use and Cardiovascular Disease and All-Cause Mortality among Patients with Migraine: A Systematic Review and Meta-analysis
This meta-analysis of several studies showed that triptan use was not associated with increased risk of stroke, TIA, or all-cause death risk but with a decreased CAD risk in migraine patients.
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