Vertigo and dizziness are more common in migraine sufferers than in people without migraines. A patient I am treating for migraines emailed me a few days ago complaining of vertigo. Dizziness is a term which can mean unsteadiness, lightheadedness, or vertigo. Vertigo is a sensation of spinning, which is most often caused by a disturbance of the inner ear. One type of vertigo is called benign positional vertigo (BPV). BPV usually causes very severe vertigo. One patients told me that while lying on the floor he felt as if he was falling off the floor. BPV is caused by a loose crystal in the inner ear. As the name implies, this type of vertigo occurs only when turning to one side, but not the other. If turning in bed to the right causes vertigo, then the problem is in the right inner ear. A simple (Epley) maneuver can quickly cure this problem by stopping this loose crystal from rolling around and causing havoc. I emailed my patient a link to a YouTube video showing how to do the Epley maneuver and half an hour later she emailed back saying that the vertigo was gone. Sometimes this maneuver needs to be repeated a few times before vertigo completely disappears. Here is the link to the Epley maneuver https://www.youtube.com/watch?v=llvUbxEoadQ&authuser=0
Read MoreA report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk of Bell’s palsy.
Several medical conditions, such as asthma, anxiety, depression, irritable bowel syndrome, epilepsy, and other occur with higher frequency in migraineurs, but until now, no one suspected an association between migraines and Bell’s palsy.
The researchers compared two groups of 136,704 people aged 18 years and older – one group with migraine and the other without. They followed these two groups for an average of 3 years.
During that time, 671 people in the migraine group and 365 of the non-migraine group developed Bell’s palsy.
This association persisted even after other factors such as sex, high blood pressure, and diabetes were taken into account.
The authors speculated that the inflammation and the blood vessel problems seen in both conditions may explain this association.
This study appears to be of purely academic interest since we do not know how to prevent Bell’s palsy. However, I decided to write about it because a couple of my colleagues (one in our office and at least one other on a doctors’ discussion board) reported seeing Bell’s palsy soon after administering Botox injections for chronic migraines. This report by Taiwanese doctors suggests that Bell’s palsy might have been not due to Botox, but rather a coincidence since Bell’s palsy is more common in migraine sufferers.
Read MoreTrigeminal neuralgia is a very painful and debilitating condition (Here is a review article I wrote for physicians). Fortunately, it is relatively infrequent – affecting 0.3% of the population, compared to 12% afflicted by migraines. This explains relative paucity of studies of this condition. A group of neurologists at the Danish Headache Center studied 158 consecutive patients with trigeminal neuralgia (TN) seen at their center over a period of one year. They published their findings in the journal Headache.
Average age of onset of pain was 53 years. TN was more common in women than men (60% vs 40%) and more common on the right side (56%). When only one of the three branches of the trigeminal nerve were affected, the first and the second were involved in 69% of cases and the third branch (lower third of the face) alone was involved in only 7% of sufferers.
The pain of trigeminal neuralgia is described the same way by almost all sufferers – it feels like a strong electric shock. It can be triggered by chewing, brushing teeth, speaking, air movement from wind or air conditioner, and at times it occurs without any provoking factor. In this study, half of the patients reported having a more persistent but milder pain in addition to the typical stabbing, electric-like pain. One fifth of patients reported to have some tearing on the side of pain and in 17% there was some loss of sensation over the area of pain.
Treatment of TN usually begins with epilepsy drugs,such as carbamazepine (Tegretol) or oxcarbazepine (Trileptal). Although 89% of patient in this study reported some improvement, only 56% of them were taking these medications because in others they caused unacceptable side effects. Other drugs that can be helpful for TN include baclofen (a muscle relaxant) and Botox injections. I’ve treated a handful of patients with TN with Botox
and about half of them responded. Botox is injected into the area of pain, which tends to be small and only a very small amount of Botox needs to be injected. Injections of Botox are safer than any oral medication, but depending on the area injected, they can cause cosmetic side effects – asymmetric appearance of the face. Botox is approved by the FDA for chronic migraines but not TN, which means that insurance companies are not likely to pay for it. However, only about one tenth of the amount of Botox used for migraine is needed to treat TN, the cost is much lower.
The authors plan to provide additional information about this group of patients in future publications.
Read MoreCost is the only major issue with Botox injections, which is the only FDA-approved treatment for chronic migraines and which is now covered by almost all insurance companies. It is very safe and highly effective, relieving headaches in 70% of migraine sufferers. A study just published in the journal Headache suggests that Botox may be not only clinically effective, but also cost-effective.
Researchers from the Renown Neurosciences Institute in Reno, Nevada analyzed data from 230 chronic migraine sufferers who did not respond to two or more prophylactic drugs and were given Botox injections. Botox was given twice, three months apart. Compared with the 6 months before Botox, there were 55% fewer emergency room visits, 59% fewer urgent care visits, and 57% fewer admissions to the hospital. In those 6 months the savings amounted to half of the cost of Botox treatments. Considering that improvement tends to get more pronounced with each subsequent Botox treatment, it is very likely that the costs savings would grow with additional treatments.
Obviously, besides saving money, Botox provides a significant improvement in the quality of people’s lives, which is much harder to measure. At our Center we give Botox to more than a quarter of our patients and see a dramatic improvement in the majority. Botox is not only much more effective for chronic migraines, but it is also much safer than any oral medication.
Read MoreCyclic vomiting syndrome (CVS) is usually seen in children. The attacks of vomiting often stop as the child gets older, but then they usually go on to develop migraine headaches. A recent report in Headache describes three adults with CVS. The article also mentions a previous report which described another 17 adults with this syndrome.
CVS typically consists of recurrent stereotypical attacks of incapacitating nausea and vomiting, separated by symptom-free periods. Supporting evidence that helps diagnose this condition include personal or family history of migraine and other symptoms, such as headaches, motion sickness, and sensitivity to light.
Just like in children, CVS in adults is a diagnosis of exclusion, meaning that other causes of vomiting must be considered and ruled out. I mentioned in a previous post that one out of three children with CVS turned out to have another medical problem rather than migraine.
CVS in adults seems to respond well to an injection of sumatriptan (Imitrex). This allows for a quick relief of symptoms and makes this debilitating condition very manageable. Besides Imitrex injections, Zomig (zolmitriptan) nasal spray can sometimes be effective as well.
Read MorePlacebo effect is a well-documented phenomenon, which is particularly pronounced when treating migraine headaches. Intravenous (IV) infusion of saline water is a placebo commonly used in studies where placebo is compared to a medication also given IV.
It is baffling why a group of Canadian physicians decided to test the effect of (IV) fluids on migraines in children and adolescents seen in an emergency room (the study was just published in Headache). They compared a group of children who were told that they will get only IV fluids with another group who was told that they might also get a medication with the IV fluids. The second group actually watched a nurse add something to the bag of IV fluid, but the children were not told that it was just more of the saline water. The researchers thought that the expectation of getting a medicine will help relieve their migraine headache. In fact neither group, the one who received IV fluids without expecting any medicine and the group who thought that they may be getting medicine had much relief. Strangely, the doctors concluded that additional studies using larger volumes of IV fluids are warranted. As if there is a chance that giving more fluids will stop a severe migraine. Sadly, intravenous fluids are often used in emergency rooms as a treatment for migraines in adults and children and we did not need this study to show that it is an ineffective approach. Doing more such studies seems unethical. Imagine a parent getting up in the middle of the night, taking a sick child to an emergency room where the child receives only intravenous fluids and is sent home with the child still in pain.
Emergency rooms, even in the medical mecca of New York City, are notorious for using ineffective treatments for migraine headaches. If not intravenous fluids, patients often get narcotic (opioid) pain killers, tranquilizers, or antihistamines, such as Benadryl. Some patients are just given a tablet of ibuprofen and are sent home after waiting for hours to be seen and treated. Here is a previous post on what to ask for if you end up in an emergency room with a severe migraine. Obviously, some doctors will not comply with your request, but it is worth asking.
Read MoreConsidering that meditation can literally change your brain, it is not at all surprising that it can also prevent migraine headaches. A study by doctors at Wake Forest School of Medicine and Harvard Medical School published in the journal Headache confirmed that meditation can prevent migraine headaches.
I’ve written before about studies showing that meditation reduces negative perception of pain and that even three daily 20-minute meditation sessions reduce pain.
Stress is one of the most common triggers for migraine headaches. Many studies of various mind/body interventions have been shown to be helpful for migraine. The researchers in the latest study used a standardized 8-week mindfulness-based stress reduction program that teaches mindfulness meditation and yoga. This approach has been shown to be effective for chronic pain syndromes, but this was the first time it was tested for migraines.
The study included 9 adults who received their usual care and 10 who were enrolled in the meditation program. The program consisted of 8 weekly 2-hour sessions, plus one mindfulness retreat day (6 hours) led by a trained instructor.
All 10 patients completed the program. The program participants had on average 1.4 fewer migraines per month. The reduction ranged from 3.5 to 1.0 migraines, while in the control group the improvement ranged from 1.2 to 0 migraines per month. Headaches were less severe and shorter in those who meditated compared to those who did not. Disability also improved (measured by Migraine Disability Assessment and Headache Impact Test-6) in the active group, compared to controls.
The authors concluded that mindfulness-based stress reduction is safe and feasible for adults with migraines. Although the study included a small number of patients this intervention had a beneficial effect on headache duration, disability, self-efficacy, and mindfulness. The authors feel that there is a clear need for studies with larger numbers of patients. I, on the other hand, feel that every patient with migraines should try meditation even before larger studies are completed. If meditation can increase the thickness of your brain and prevent age-related brain atrophy, it is very likely to have many other health benefits, including prevention of migraine headaches.
How do you start meditating? Meditation classes are widely available and you can start by reading a book or taking an on-line course. I can recommend a book by BH Gunaratana, Mindfulness in Plain English and a website, www.headspace.com, but there are many other good resources available.
Read MoreGermany was just voted world’s favorite country, according to a report in the USA Today. It also may be the most advanced country in the area of medical rehabilitation. I just came back from Germany where I was invited to give lectures at two prominent clinics. Doctors from both institutions had visited our New York Headache Center to learn about our approach to the treatment of migraines and to learn Botox injection techniques.
My first stop was at the Berolina Klinik, a 280-bed rehabilitation hospital located 80 miles west of Hanover. This hospital provides rehabilitation for a variety of conditions, including orthopedic problems, depression, and chronic headaches. Patients are admitted for a period of 4 to 5 weeks. Treatments available at this institution include physical therapy, biofeedback, individual and group psychotherapy, art therapy, and other. All patient rooms are private. There is a 25-meter (82 feet) swimming pool, gym, inviting dining rooms (with excellent food – I sampled it), green lawns with reclining chairs, and all of it immaculately clean and well-maintained. Staying in such a facility for 4 to 5 weeks is a luxury not available to most Americans. The hospital welcomes patients from abroad and the cost is surprisingly low – about $9,000 for a month of stay, which is less than a third of the cost in the US. They will even pick you up at the Frankfurt airport (third busiest in Europe), which is only 3 hours’ drive. Most of the German patients treated at the Berolina Klinik are covered by insurance, mostly by the German pension fund. The pension fund annually evaluates every facility using strict outcome measures, including the percentage of patients employed two years after being treated at a rehabilitation facility. Berolina Klinik consistently rates among the top German rehabilitation clinics. Dr. Zoltan Medgyessy is the main headache specialist at the clinic and is considered to be one of the leading headache experts in Germany.
The second stop was in Kiel at one of the best German headache and pain clinics, Schmerzklinik Kiel, which is directed by Dr. Hartmut Göbel. This clinic is also an in-patient facility (unlike in the US, where the word clinic implies an office setting). Approximately 70% of patients treated at the Schmerzklinik suffer from headaches and 30% from chronic pain. The clinic is housed in a beautiful building located on the Kiel fjord. Dr. Göbel is one of the top headache researchers and he and I have collaborated on the study of butterbur for the treatment of migraines, which was published in 2004. On this trip I had the honor of speaking in Dr. Göbel’s Master Class – an annual training course for German headache specialists. While I would refer patients who need longer-term rehabilitation (or detox from opioid and other headache drugs) to the Berolina Klinik, Schmerzklinik is where I refer European patients with complicated headache problems and those needing shorter hospital stays.
Read MoreA new report by Drs. Gfrerer, Maman and their colleagues at the Massachusetts General Hospital in Boston entitled Non-Endoscopic Deactivation of Nerve Triggers in Migraine Headache Patients: Surgical Technique and Outcomes was recently published in the journal Plastic & Reconstructive Surgery. Surgery for refractory migraine headaches was developed by Dr. Bahman Guyuron and others and was reported to benefit between 68 and 95% patients. This surgery involves cutting or freeing up nerves in the scalp that appear to be responsible for triggering migraines. Some surgeons use a laparascopic technique, which involves making only a few small incisions while others do this surgery through conventional incisions. The authors of this new study argue that endoscopic techniques may not be appropriate in many cases since some surgeons have little experience or limited access to the endoscope and in some patients this technique is not practical because the nerves could run in an unusual pattern, which would make them hard to find through a small incision.
This study involved 43 consecutive procedures in 35 patients. All patients completed questionnaires before and 12 months after surgery. The overall positive response rate was 91%. Total elimination of migraine headaches was reported in 51%, greater than 80% resolution of symptoms in 21%, and 28% had resolution between 50-80%. No improvement was reported after 9% of procedures. There were no major adverse events.
The authors concluded that non-endoscopic surgery was safe and effective treatment in select migraine headache patients.
Most headache experts agree that until proven effective in large controlled studies, surgery should be done only as a part of such a large controlled trial. Just like with previous studies of surgery for migraines, this was a small and not a rigorously controlled trial. Placebo response to surgical procedures is usually very high, however it is rarely 90% and the effect rarely lasts 12 months, as it did in this study. Considering these facts, as well as that this study was done at a reputable institution and that this group consisted of refractory patients (those who did not respond to conventional therapy, including Botox), surgery may in fact offer some real benefits to a small group of patients. We need larger and better controlled trials to figure out if that is indeed the case and what type of patients are the best candidates for surgery.
Read MoreFish oil, or rather omega-3 fatty acids, seem to reduce the risk of Lou Gehrig disease or ALS (amyotrophic lateral sclerosis). An article in JAMA Neurology by Dr. Fitzgerald and her colleagues analyzed 1,002,082 participants in 5 different large-scale studies. A total of 995 ALS cases were documented. A greater omega-3 intake was associated with a reduced risk for ALS. Consumption of both linolenic acid and marine (fish oil-derived) omega-3s contributed to this inverse association. The researchers concluded that consumption of foods high in omega-3s may help prevent or delay the onset of ALS.
Omega-3s may also relieve migraine headaches, help cope better with stress, prevent damage to nerve endings by chemotherapy, prevent mental decline, and provide other benefits.
I usually recommend (and take it myself) Omax3 brand, which is very pure and concentrated.
Read MoreCluster headaches usually occur once or twice a year for a period lasting from a few weeks to a few months. During those periods, they occur daily or more than once a day. Interestingly, these episodes of cluster headaches tend to occur at the same time of year in many patients, but not always at the same time of year. Looking at our data, we have found that in some years many cluster patients developed their attacks in August, another year, in November, and this year, it has been September – October. This year, we are also seeing many patients whose cluster headaches are not responding to usual treatments.
It does not appear that barometric pressure or allergies are responsible for triggering cluster headaches. One unsubstantiated theory is that the solar activity is responsible for bringing on cluster headaches. This report in the Wall Street Journal indicates that we are currently going through a period of an unusually intense solar activity. Perhaps this is why some of our cluster patients are having unusually severe headaches.
Read MoreThe first time I heard of the potential benefit of stem cells for migraine headaches was last year from one of my patients. This 55-year-old woman had been having some improvement from intravenous magnesium and nerve blocks, while Botox was ineffective. However, she reported a dramatic improvement in her headaches after receiving an intravenous infusion of stem cells in Panama. The stem cells were obtained from a donated umbilical cord.
Stem cell research has been controversial because most of the early research used stem cells obtained from an aborted fetus. Since then, stem cells have been obtained from the bone marrow, umbilical cord, placenta, and artificial fertilization. Another rich source of stem cells is body’s fat tissue. Most of the stem cell procedures are not yet approved in the US. The main concern is that when you obtain stem cells from another person’s umbilical cord or placenta, there is a risk of transmitting an infection. There are relatively few stem cells in the bone marrow, placenta or the umbilical cord, which means that after isolating them, they need to be grown in a petri dish. This process involves adding various chemicals, which may not be safe, according to the FDA.
A group of doctors in Australia recently reported relief of migraines using stem cells from patients’ own fat. These doctors did not grow these cells, but infused them intravenously right after separating them from fat. The infused cells were not only stem cells, but so called stromal vascular fraction, which also includes cells that surround blood vessels. These four patients were given stem cell treatment for osteoarthritis and not migraines, but they noticed that their migraines and tension-type headaches improved.
Four women with long histories of chronic migraine or chronic tension-type headaches were given an infusion of cells isolated from fat, which was obtained by liposuction. Two of the four patients, aged 40 and 36 years, stopped having migraines after 1 month, for a period of 12 to 18 months. The third patient, aged 43 years, had a significant decrease in the frequency and severity of migraines with only seven migraines over 18 months. The fourth patient, aged 44 years, obtained a temporary decrease for a period of a month and was retreated 18 months later and was still free of migraines at the time the report was submitted one month later.
This case series is the first published evidence of the possible efficacy of stromal vascular fraction in the treatment of migraine and tension-type headaches.
It is not very surprising that stem cells can improve migraine headaches because stem cells are tested as a treatment for a variety of inflammatory diseases, such as multiple sclerosis, arthritis, and colitis. Inflammation is proven to be present during a migraine attack and this inflammation may attract stem cells. Many experts believe that stem cells may work for MS or other neurological disorders not by becoming brain cells, but by stimulating body’s own repair mechanisms.
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