Headache NewsBlog

Cluster headaches are on an upsurge in the past 2 weeks. Is sun to blame?

By: Dr. Mauskop

13-10-2015

Solar activity is high again – NASA’s Solar Dynamics Observatory reported a flare on October 1. And in the past two weeks we’ve been seeing many more patients whose cluster headaches returned. The last time we had a surge in the number of cluster patients was last October, when solar activity was also high (see this post).

Unfortunately, there is not a lot we can do about the solar activity, but we do have many treatment options for cluster headaches. These include intravenous magnesium (40% of cluster headache sufferers are deficient), occipital nerve blocks, steroids, daily prevention with verapamil, Botox injections, oxygen inhallation, nasal spray of zolmitriptan (Zomig NS), and sumatriptan (Imitrex) injections. For most cluster patients one more often several of these treatments provide good relief. If these are ineffective, we also use drugs such as lithium, topiramate, and even an herbal supplement, Boswellia.

You can’t get magnesium through the skin

By: Dr. Mauskop

11-10-2015

Alternative Therapies, Migraine

A report describing delivery of magnesium through the skin for the treatment of fibromyalgia has just appeared in the Journal of Integrative Medicine. The title of the report is, Effects of transdermal magnesium chloride on quality of life for patients with fibromyalgia: a feasibility study. It was conducted by doctors at the Mayo Clinic, which carries a certain amount of legitimacy. However, close reading of this report shows shockingly poor quality of this study.

It is true that magnesium deficiency has been found in patients with fibromyalgia (especially if levels other than serum or plasma are measured, i.e. ionized or RBC) Fibromyalgia is a syndrome of unknown cause, which is characterized by chronic pain, fatigue, depression, and sleep disturbances. Some studies have found that the lower the level of magnesium, the more symptoms patients were having. There is an association between fibromyalgia and migraine headaches and those of our patients who have both conditions often report relief of both migraines and fibromyalgia with oral magnesium supplementation or intravenous infusions.

Several companies promote products that promise to deliver magnesium into the body through the skin. The oldest one is Epsom salts, which is magnesium sulfate. Taking a warm bath with Epsom salts surely feels relaxing, but there is no evidence that magnesium penetrates through the skin.

The Mayo clinic study enrolled forty postmenopausal female patients with the diagnosis of fibromyalgia. Each was given a spray bottle containing a 31% solution of magnesium chloride (and “a proprietary blend of trace elements”) and asked to apply 4 sprays per limb twice daily for 4 weeks. They were also asked to complete various questionnaires. Only twenty-four patients completed the study, with 4 dropping out because of skin irritation. At week 2 and week 4 most were significantly improved.
The authors concluded that their study “suggests that transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia”. This was a very small and unblinded study with many dropouts, which means that no conclusions can be made. It is very surprising why the authors did not measure magnesium levels before and after the treatment, which would make the study much more valuable.

The company that sponsored the study has a product they’d like to sell to the unsuspecting public and it will certainly use this “study” and the Mayo Clinic name to sell their miracle spray. The Mayo Clinic is a highly respected institution and I hope they will not allow its name to be associated with such poor quality marketing studies.

Zecuity, a transdermal migraine patch is now available

By: Dr. Mauskop

05-10-2015

Headache medications, New treatments

Zecuity, a skin patch containing a migraine drug sumatriptan was approved by the FDA almost two years ago, but it became available (by prescription) only last month (see my previous post about Zecuity). The product is not available in retail pharmacies, only from a specialty pharmacy. The doctor who prescribes the patch will usually provide information on where to get it. Otherwise, go to zecuity.com, where you can find a section entitled Migraine Support Solutions. At this site you can verify that your insurance covers this product, get it shipped to you, and then get information on how to apply the patch. A discount coupon is also available on the site and it promises that the copay will be as low as $15. That is a good thing, because it looks like (on GoodRx.com) each patch costs $300. Yes, not $30, but $300 a piece, or $1,200 for a box of 4. I don’t think too many people will be buying this patch if their insurance does not cover it.

So, who is the best candidate for Zecuity? Half of migraine sufferers experience nausea and/or vomiting with their attacks. This makes the absorption of oral drugs, such as triptans (Imitrex, Maxalt, Zomig, etc) so slow as to make them ineffective. In such patients we try to bypass the stomach, which until now was possible to do with a nasal spray, suppository, or an injection. Sumatriptan (Imitrex) is available in the US in tablets, nasal spray and self-administered injections. Nasal spray of sumatriptan is not very effective, but injections work better than tablets. Relief from an injection can occur in as quickly as 10 minutes, but injections can cause more side effects, which are mostly unpleasant rather than dangerous. Obviously, most people would rather not get a shot. One form of injectable sumatriptan delivers the medicine through the skin without a needle (Sumavel), but not without pain see this post.

One other triptan, zolmitriptan (Zomig) is available in a nasal spray and it is more effective than sumatriptan nasal spray, but it is not available in a generic form, making it less accessible because of the high cost and restricted insurance coverage.

The perfect patient for Zecuity is someone who experiences nausea and/or vomiting with their migraine attacks and who does not respond to tablets and has side effects from or aversion to injections. Zecuity provides good relief for such patients with the main side effect being skin irritation from the patch. The patch is fairly large, the size of a palm. It uses a miniature battery to generate an electric current, which helps drive the medicine through the skin. Iontopheresis is the name of this process. Iontopheresis has been known for decades, but Zecuity is the first product approved by the FDA to utilize this technology.

Disclosure – Teva Pharmaceuticals, manufacturer of Zecuity pays me to give lectures about Zecuity to doctors.

Meditation improves quality of life in drug-resistant epilepsy, reduces seizures

By: Dr. Mauskop

30-09-2015

Alternative Therapies

Epilepsy and migraines share many features and those with epilepsy have a higher risk of developing migraines, while those with migraines are more likely to develop epilepsy. Anti-epilepsy drugs are commonly used for the preventive treatment of migraines.

A study just published in Neurology by Hong Kong researchers investigated the effectiveness of mindfulness-based therapy and social support in patients with drug-resistant epilepsy.

It was a blinded and randomized trial. Sixty patients with drug-resistant epilepsy were randomly allocated to mindfulness therapy or social support (30 per group). Each group received 4 biweekly intervention sessions. They measured quality of life, as well as seizure frequency, mood symptoms, and neurocognitive functions.

Following intervention, both the mindfulness and social support groups had an improved quality of life, but significantly more patients in the mindfulness group had a clinically important improvement. Significantly greater reduction in depressive and anxiety symptoms, seizure frequency, and improvement in delayed memory was observed in the mindfulness group compared with the social support group.

The authors concluded that even short-term mindfulness therapy in patients with drug-resistant epilepsy provides significant benefits.

It is surprising that even seizure frequency was reduced, although stress and lack of sleep can definitely increase seizure frequency. The study did not evaluate the quality or duration of sleep, but mindfulness meditation is know to improve sleep. It also improves migraine headaches (see my previous post).

To start meditating you can download a very popular app, Headspace or read a book by BH Gunaratana, Mindfulness in Plain English or download free podcasts at TaraBrach.com.

Having migraines and fibromyalgia increases the risk of suicide

By: Dr. Mauskop

28-09-2015

Chronic migraine, Migraine, Pain, Science of Migraine

About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a higher risk than the general population of additional disability related to depression, anxiety, irritable bowel syndrome, fibromyalgia, and other conditions.

Fibromyalgia is a disorder of the central nervous system with increased brain excitability. It often manifests itself not only with muscle pains, but also fatigue, memory problems, and sleep and mood disturbances. Various studies estimate that anywhere from 2% to 8% of the general adult population suffers from fibromyalgia. Just like with migraine, women are more often affected than men. The likelihood of coexisting fibromyalgia increases with increasing frequency and severity of migraine attacks.

Both migraine and fibromyalgia have been individually linked with increased risk of suicide. However, it is not clear that the risk is more than additive.

A study just published in Neurology, reports that patients with migraine and coexisting fibromyalgia have a higher risk of suicidal ideation and suicide attempts compared with migraine patients without fibromyalgia.

The study looked at 1,318 patients who attended a headache clinic. Of these patients, 133 or 10% were found to also have fibromyalgia. Patients with both conditions had more frequent, more severe, and longer-lasting migraine attacks as well as higher use of abortive medications.

Compared with migraine patients who did not have fibromyalgia, those with fibromyalgia were more likely to report suicidal ideation (58% vs 24%) and suicide attempts (18% vs 6%).

This report suggests that migraine and fibromyalgia may magnify the risk of suicide compared with the risk of the individual conditions. However, because this data comes from a specialty headache clinic, many patients were severely affected by their migraines, with more than 35% having chronic migraine. It is likely that the results would be less dramatic among migraine sufferers in the general population. Almost half of the estimated 35 million migraine sufferers in the US do not consult a physician. Most of them suffer from milder migraines than those who do consult a doctor.

This study suggests that patients with migraine should be evaluated for other chronic pain conditions and for their mental health well-being. In particular, patients with chronic migraine should be screened for other painful conditions and mental illness. And patients with fibromyalgia should also be evaluated for migraine and potential suicide ideation. Patients often do not appear depressed, but simple questions can detect depression, which can lead to effective treatment. Our initial evaluation at the New York Headache Center includes two questions which are highly indicative of depression: 1. Have you been bothered a lot in the last month by feeling sad, down, or depressed? 2. Have you been bothered a lot in the last month by a loss of interest or pleasure in your daily activities?

Antidepressants have been proven to be effective for the prevention of migraines even in the absence of depression and are the best choice for people suffering from both conditions. Prozac, Lexapro and other SSRI antidepressants do not help migraines or pain, but SNRIs such as Effexor, Cymbalta, and Savella or tricyclics such as Elavil, Pamelor, and Vivactil do relieve pain and depression.

Magnesium deficiency is common in both migraines and fibromyalgia and we recommend an oral supplement to all patients. Some patients do not absorb magnesium and respond very well to monthly intravenous infusions of magnesium. Both their migraines improve as do fibromyalgia symptoms.

One interesting difference between migraines and fibromyalgia is the response to Botox. Botox is proven to be highly effective for the prevention of migraines and it works very well to relax spastic muscles. However, Botox appears to be ineffective for the treatment of muscle spasm in fibromyalgia. It is possibly explained by the fact that Botox interferes with the function of acetylcholine, a neurotransmitter involved in contracting healthy muscles. In fibromyalgia, studies suggests a deficit in acetylcholine, so further blocking it would be ineffective or even make the muscle pain worse (which I’ve seen in a few patients).

Emergency room treatment of migraines

By: Dr. Mauskop

10-09-2015

Migraine

Narcotic (opioid) drugs are still widely prescribed by doctors in offices and emergency rooms. They are not only potentially addictive, but also are not effective for the treatment of migraine headaches. The guidelines of the American Academy of Neurology call for avoidance of opioids for migraine and headache.

Doctors at the Cleveland Clinic developed a detailed, step-by-step algorithm that has dramatically reduced the use of narcotics for migraine management in the emergency room and prescribing of them upon discharge.

In the three months before the algorithm was implemented 66% of migraine patients had received narcotics in the ER and 44% had discharge prescriptions for these medications. After algorithm implementation, the rates were 19% and 5%, respectively.

The results of this study were presented at the 2015 annual meeting of the American Headache Society.

The first step of the algorithm involves using a three-question screener for diagnosing migraine. The questions elicited the presence of nausea, sensitivity to light and inability to function normally. If two of these three symptoms were present, migraine diagnosis was made, provided no other serious condition was causing the headache. Doctors then evaluated for potential drug-seeking behavior and repeated ER visits without appropriate follow-up with the patient’s primary care provider.

The first step was intravenous or intramuscular injection of a nonsteroidal anti-inflammatory pain medicine ketorolac (Toradol) plus a nausea drug, metoclopramide (Reglan) plus an anti-histamine, diphenhydramine (Benadryl). If the patient did not experience at least 50% pain relief, step 2 was a steroid medication, dexamethasone (Decadron) plus valproate sodium (Depacon) plus magnesium sulfate. Step 3 used in patients who didn’t experience at least 50% pain relief was a subcutaneous injection of sumatriptan, which was repeated in one hour if the headache did not resolve. If the patient failed sumatriptan in the past, dihydroergotamine (DHE-45) was given with a nausea drug prochlorperazine (Compazine), metoclopramide (Reglan) or ondansetron (Zofran).

If patients do not respond to the third step, they are considered for hospital admission and admission did increase from 8% to 25%.

It is a very good algorithm and if you suffer from severe migraines that at times land you in an ER, I would keep this list of injectable drugs, so that you can ask for them. However, I would ask for intravenous magnesium to be given first since it has a 50% chance of helping without side effects, which can occur with every other drug. I would also use sumatriptan after magnesium since it is very effective and is the only migraine-specific drug available in an injection. Studies suggest that diphenhydramine (Benadryl) and valproex sodium (Depacon) are not very effective, so I would avoid those if you have a choice.

Can an MRI scan of the brain diagnose migraine?

By: Dr. Mauskop

05-09-2015

Migraine, Science of Migraine

MRI scans of migraine sufferers are almost always normal. Occasionally we see white spots on the MRI, which can be also found in people with high blood pressure, dementia, and sometimes in perfectly healthy people (see my previous post on this).

However, Mayo Clinic neurologists, led by Dr. Todd Schwedt reported being able to diagnose chronic migraines on the MRI scan. The accuracy of the diagnosis of those who had 15 or more headache days each month was fairly high – 84%. Patients with this frequency of attacks are considered to be suffering from chronic migraines. However, they could diagnose only 67% of those with episodic migraines (less than 15 headache days each month). The researchers used sophisticated software (FreeSurfer) that measured the surface area, thickness, and volume of 68 various brain regions and discovered that changes in 6 of these regions were predictive of migraine diagnosis. These 6 regions participate in pain processing in the brain and include the temporal lobe, superior temporal lobe, anterior cingulate cortex, entorhinal cortex, medial orbital frontal gyrus, and the pars triangularis. The software used in the study is freely available, but using it is time consuming and it is utilized only by researchers and not by any hospital or private MRI facilities.

Their findings confirmed what until now was an arbitrary decision by headache experts to divide migraines into episodic and chronic ones with a 15 day cutoff. Ahother study by Dr. Richard Lipton and his colleagues at the Montefiore headache clinic has found that those who have 10 or more headache days each month have many similar features compared to those who have less than 10.

This is not a purely academic question. Insurance companies will pay for Botox only if a patient has 15 or more headache days each month because this type of patients was used in clinical trials of Botox. However in practice we also see very good response to Botox in patients who have fewer than 15 days.

Migraine drug may be highly effective for ovarian cancer by reducing stress effects

By: Dr. Mauskop

24-08-2015

Headache medications

Propranolol was first introduced as a blood pressure drug 50 years ago and about 40 years ago it was discovered to be effective for the prevention of migraines. This is quite a remarkable drug because it is also used for rapid heart beat, heart attacks, tremor, and performance anxiety. Public speakers, musicians, and others take a small dose before performances and the drug reduces the physical stress responses such as sweating, tremulousness, weakness, and other. Blinded studies showed that musicians perform better when given a beta blocker compared to musicians who are given a placebo pill.

Since the introduction of propranolol, another two dozen beta blockers have been developed. The newer, so called selective beta blockers (they attach to only one type of stress receptor) tend to have fewer side effects than propranolol and other non-selective beta blockers. Selective beta blockers can be given to patients with well-controlled asthma, while non-selective ones can cause an asthma attack.

Recent studies have shown that chronic stress promotes the growth and spread of cancers. Researchers at MD Anderson Cancer Center decided to review the records of 1,425 patients who were treated for ovarian cancer at four hospitals between 2000 and 2010. Of these, 268 had been treated with a beta blocker while receiving chemotherapy for their ovarian cancer. The average survival of those who were on a beta blocker was 48 months compared to 42 months for those who were not. A more dramatic difference was found between those who were taking a non-selective beta blocker (propranolol in almost all cases): they lived 95 months – twice as long as women not on a beta blocker.

Considering these findings, if I decide to prescribe a beta blocker, I may start prescribing propranolol as the first-line drug for the prevention of migraines. And only if the patient has side effects, will I switch them to a selective beta blocker, such as atenolol or nebivolol (Bystolic). Common side effects of beta blockers are fatigue and dizziness from a drop in blood pressure and difficulty exercising because the heart rate cannot increase high enough to provide for the increase in demand for oxygen. Because regular aerobic exercise is my first recommendation for the prevention of migraines, I tend to reserve beta blockers for patients whose blood pressure is high or at the high end of normal range, whose pulse is fast, and for those who fail other preventive drugs and Botox (however, most insurers approve Botox for chronic migraines only if the patient fails 2 or 3 preventive drugs, including a beta blocker).

Headaches in pregnancy – when to worry

By: Dr. Mauskop

23-08-2015

Headaches, Migraine

New onset of headaches is always worrisome, but even more so in a pregnant woman. Neurologists at the Montefiore Headache clinic in the Bronx conducted a 5-year retrospective study of pregnant women who presented with an acute headache, were hospitalized, and received a neurologic consultation. The study was published in Neurology.

The researchers identified 140 women with a mean age of 29 years. About 56% of these women presented in the third trimester. Primary headaches was present in 65% and secondary (due to an underlying disease) was found in 35% of women. The most common primary headache disorder was migraine and it was found in 91%, while the most common secondary headache disorder present in 51% was high blood pressure.

Primary headaches included migraine without aura, seen in 37%, migraine with aura, in 24%, chronic migraine, in 6%, episodic tension-type headache, in 3%, chronic tension-type headache, in 1%, and primary stabbing headache, in 2% (this adds up to more than 65% because some had more than one type of headaches). Besides hypertensive disorders such as preeclampsia and eclampsia (18%), secondary headache diagnoses included pituitary adenoma or apoplexy in 4%, infections in 2%, stroke in 3%. Pregnant women with secondary headaches were less likely to have had headaches in the past (37% in secondary vs 13% in primary) and were more likely to have seizures (12% vs 0%), elevated blood pressure (55% vs 9%), fever (8% vs 0%), and an abnormal neurologic examination (35% vs 17%). Psychiatric comorbidity (presence of depression, anxiety, bipolar, etc) and phonophobia (sensitivity to light) were less likely with secondary headache.

The authors concluded that among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache. Doctors should be particularly vigilant in the absence of a headache history and if seizures, hypertension, or fever are present. On the other hand, specific headache features such as location of the pain, throbbing character, sensitivity to light and noise are less helpful in distinguish primary vs secondary headaches. The neurologists who conducted this review recommend low thresholds for neuroimaging (CT or MRI scan) and monitoring for preeclampsia and eclampsia. Preeclampsia and eclampsia are complications of pregnancy with elevated blood pressure, sometimes seizures, and kidney problems, which can be life-threatening and which are treated with intravenous infusions of magnesium.

Smoking increases the risk of strokes in those with migraines

By: Dr. Mauskop

12-08-2015

Brain disorders, Migraine

Migraine with aura is believed to increase the risk of strokes and possibly heart attacks, although the risk estimates vary from study to study.

A recent study demonstrated no increase in the risk of strokes in people who suffered from migraine with and without aura, unless they were active smokers. The findings were published last month in the journal Neurology. Among the 1292 participants with an average age of 68 years there were 262 with migraine. There was no relationship between migraine (with or without aura) and stroke or heart attacks during the 11 year follow up period. However, among the 198 current smokers, there was a 3-fold increased risk for stroke.

The lack of relationship between migraine with aura and stroke seen in previous studies is probably due to a relatively small sample size.

I personally have seen two young women with migraine with aura who suffered a stroke. Both of them were smokers and were taking oral contraceptives. Estrogen contraceptives (even newer ones with lower estrogen content) further increase the risk of strokes in women who have migraine with aura. Progesterone-only pill does not increase the risk of strokes. Some women with severe endometriosis, heavy menstrual blood loss, and severe PMS sometimes have to accept a slight increase in the risk of strokes and take an estrogen-based contraceptive. However, if they smoke, they must stop smoking and also try to reduce other risk factors for strokes, if they are present. These include keeping hypertension and diabetes under control, lower high cholesterol, maintain normal weight and exercise regularly.

Testosterone and headaches

By: Dr. Mauskop

07-08-2015

Chronic migraine, Cluster headaches, New treatments

Fluctuations in the female hormone estrogen have been proven to be involved in triggering menstrual and perimenopausal migraine headaches. Testosterone levels have been reported to be low in men and women with cluster headaches. Testosterone replacement therapy seems to help these patients, when other standard treatments for cluster headaches do not.

A study presented at the recent annual meeting of the American Headache Society reported on testosterone levels in men with chronic migraine headaches. A significant percentage of men with chronic migraines also have low testosterone levels. This study did not look at the effect of testosterone replacement therapy, but it is possible that it may help chronic migraine sufferers as it does those with cluster headaches. It seems prudent to check testosterone level in men with chronic migraine headaches who do not respond to standard approaches such as medications, Botox injections, magnesium, and other treatments. And if the level is low, replacement therapy should be tried.

The dangers of Ayurvedic medicine

By: Dr. Mauskop

03-08-2015

Alternative Therapies, Headache medications

Ayurvedic medicine has many healthy aspects. However, a recent story on NPR described the risks involved with the traditional Ayurvedic medicines from India. A very high percentage of Ayurvedic supplements in the category called bhasmas sold in the US contains large amounts of lead and other toxic elements. There is a lot more to Ayurvedic medicine than these supplements, so it is important to separate dangerous parts from things like healthy diet, yoga, and other.

Unfortunately, the US government does not regulate supplements, so there is always a question of safety of these products, especially those made outside the US. The one exception is products made in Germany, where supplements are as strictly regulated as drugs (please note that Petadolex, a butterbur product is made in Germany, but is not allowed for sale there). Many patients ask me about not only Indian but also Chinese herbal medicines, which are often combined with acupuncture and other treatment methods. As a rule, I recommend avoiding products made in China or India, where quality controls are very poor. Instead, you should buy products made by major US manufacturers, although they do not make many traditional Chinese and Indian products. However, you cannot always count on products sold in major US store chains either – recently, herbal products sold at Walgreens, WalMart, Target and GNC were found to have no active ingredients. Thankfully, there were no toxic ingredients in those products.

The largest mass poisoning with a Chinese herbal dietary weight loss product occurred in Europe where 18 patients developed kidney failure and urinary cancer.

In summary, no matter how promising a Chinese or an Indian herbal product may sound, it is not worth the risk.