Headache NewsBlog

Magnificent Magnesium and Movement Disorders

By: Dr. Mauskop

15-10-2023

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine

Magnificent Magnesium is the title of a book my colleague and friend, cardiologist Dr. Dennis Goodman wrote about this underappreciated mineral. Magnesium produces magical results, albeit only in those who are deficient. And millions of Americans are deficient. Our research has shown that close to half of migraine sufferers are. Magnesium saves lives in cardiac care units by reducing the risk of arrhythmias. It is given intravenously for acute asthma attacks and treats eclampsia and pre-eclampsia in pregnancy. The list goes on.

A report by Canadian neurologists just published in a leading neurology journal, Neurology, describes magnesium’s role in the treatment of movement disorders. Sixty patients with low magnesium levels who had a movement disorder were identified in medical journals. Movement disorders observed were postural tremor (14 patients), resting tremor (5), intention tremor (6), ataxia involving the trunk (29) or limbs (15) and dysarthria (13), athetosis (5), myoclonus (4), and chorea (1). Some patients also had downbeat nystagmus, tetany (muscle cramping), drowsiness, vertigo, and proximal muscle weakness.

The most common culprit in these patients was a class of drugs called proton pump inhibitors (PPIs). These are drugs like omeprazole (Prilosec), pantoprazole (Protonix), esomeprazole (Nexium), and dexlansoprazole (Dexilant). They are known to interfere with the absorption of not only magnesium but also other vitamins. Long-term users of these drugs are at a higher risk of dementia, most likely because they prevent absorption of vitamin B12. I try to get all of my patients off PPIs. This is not easy because stopping the drug causes a rebound in acid production. Some people have worse heartburn than when they started the PPI. One strategy is to replace these drugs with famotidine (Pepcid) and Rolaids (better than Tums since Rolaids have calcium and magnesium while Tums have only calcium). After a period of time, patients are able to stop famotidine and take only Rolaids and then, stop Rolaids as well. A healthy low-acid diet, stress management, weight loss, and sleeping on the left side can also help.

#magnesium #migraine #ataxia #dysarthria #tremor #PPIs

New Daily Persistent Headache is very treatable

By: Dr. Mauskop

09-10-2023

Alternative Therapies, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, injections, Migraine, New treatments, Psychology of headaches, Science of Migraine

New daily persistent headache (NDPH) is condition that is defined solely by the fact that the headache begins suddenly one day and does not go away. There are no scientific studies to suggest possible underlying mechanisms or treatments. Some patients develop it after a viral infection while others, after a period of stress and many with no apparent trigger.

In my latest book, I mentioned how a seemingly benign idea of classifying medical conditions can cause harm. In case of NDPH, many anecdotal reports in medical journals indicate that this condition is not responsive to treatment. However, there are no controlled double-blind studies, only anecdotal reports. Many patients with this condition will look up this literature and conclude that there is no hope of getting better. I have seen many such devastated people. But this bleak picture is clearly wrong.

I have seen many patients with NDPH who responded to various treatments. In my 30 years of using Botox, I have found it to be one of the safest and most effective treatments for NDPH as well as migraine and other types of headaches.

At the recent meeting of the International Headache Society held in Seoul, two presentations described good responses of NDPH to Botox injections.

The first report was by S. Cheema and colleagues of Queen Square Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK. They compared patients with NDPH (58) and those with chronic migraine (CM) with daily attacks (153) and chronic migraines without daily attacks (85). There was a 30% reduction in mean moderate and severe headache days in 33% of patients with NDPH, 43% with daily CM and 55% with non-daily CM.

The second report was by Shuu-Jiun Wang and colleagues of the Neurological Institute, Taipei Veterans General Hospital. They looked at the response of patients with NDPH who had predominately migraine features and those who had predominantly features of tension-type headaches. Of 228 patients diagnosed with NDPH, 199 patients (87%) had migrainous features and 29 patients (13%) had tension-type features. Their conclusion: “Through a mean follow-up duration of 2.5 years, around 40% patients with NDPH showed a favorable outcome at our headache center. Our results suggest NDPH might not be as grave as previously reported.”

Yes, these were also anecdotal reports rather than controlled trials, but they clearly show what I have also observed in my practice – NDPH is a very treatable condition. Hopefully, the next, fourth edition of the International Classification of Headache Disorders will no longer list NDPH as a diagnosis since it has no scientific basis.

Gut bacteria and migraine

By: Dr. Mauskop

18-09-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, New treatments, Science of Migraine

Most people have heard about the gut-brain connection. Research published in The Journal of Headache and Pain examined this connection in relation to migraine headaches. The researchers looked at whether the collection of microorganisms living in our guts (called the gut microbiome) could be linked to the development of migraine headaches and its different types – migraine with and without aura.

To do this, the scientists used information from a big genetic study that looked at the genes related to the gut microbiome. They also used data from studies that explored the genetics of migraine headaches. They employed sophisticated methods to analyze this data, and they also checked for other factors that could affect the results.

In the analysis, they found that certain types of bacteria in the gut were connected to migraine headaches, including ones with and without aura. They also found that some specific types of bacteria were more likely to be associated with certain types of migraines. Even after doing some statistical adjustments, these connections still held up.

So, this study suggests that the mix of bacteria in our guts might actually influence whether we get migraines and what kind they are. It shows that there might be a link between our gut and our brain when it comes to migraines.

They found that while some bacteria seemed to contribute to migraines, one type appeared to be protective. This protective effect was linked to the Bifidobacterium family. You can find Bifidobacterium in many probiotics, including a well-known brand called Align. Additionally, various fermented foods like milk kefir, sourdough bread, sauerkraut, kimchi, and other fermented vegetables contain Bifidobacterium.

However, it’s important to note that this research doesn’t mean other types of bacteria aren’t helpful too. A healthy human gut microbiome consists of many different types of bacteria. When there is an imbalance of these healthy bacteria, it can lead to various health problems, not just migraines. This imbalance can come in many different forms and may require different probiotics to correct it. That is why I recommend that patients try different types of probiotics for a few months at a time. Besides Bifidobacteria, some patients respond well to Saccharomyces, Lactobacillus, or other types, or even a combination of several.

Anxiety may facilitate transformation of pain from acute to chronic

By: Dr. Mauskop

07-09-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Pain, Pain Research, Psychology of headaches, Science of Migraine

Our thoughts and emotions can impact the development of chronic pain. However, there haven’t been many studies exploring what causes pain to transition from being short-term (acute) to long-lasting (chronic).

Australian researchers conducted a study to investigate how our thought patterns, anxiety related to pain, and the tendency to avoid pain affect both acute and chronic pain. They conducted two studies for this purpose. In the first study, they interviewed 85 individuals experiencing long-term pain to understand their thoughts and emotions. In the second study, they observed 254 individuals who had recently started experiencing acute pain and followed up with them three months later.

In both studies, they examined interpretation bias using a word association task and assessed pain-related anxiety, pain avoidance, pain intensity, and how pain interfered with daily life. In both cases, they discovered that the way people think about pain was linked to how much it disrupted their daily lives. In the second study, they also found that people’s thought patterns about pain were connected to increased anxiety about pain. This heightened anxiety, in turn, made the pain more severe and disruptive after three months. While anxiety about pain also led people to try to avoid it, this avoidance behavior didn’t seem to affect the level of pain they experienced later on.

This research provides valuable insights into how pain can transition from acute to chronic. It suggests that our initial thoughts about pain might trigger anxiety related to pain, which can contribute to the pain persisting and becoming more troublesome over time. This finding could be crucial in developing strategies to prevent chronification of pain by addressing how people perceive and manage their anxiety about pain during its early stages. Cognitive-behavioral therapy, meditation, and other mind-body techniques could be some of such strategies.

A better fix for Benign Paroxysmal Positional Vertigo

By: Dr. Mauskop

21-08-2023

Brain disorders, Chronic migraine, Migraine, New treatments, Science of Migraine

People who suffer from migraines are twice as likely to develop benign paroxysmal positional vertigo (BPPV) than individuals without a history of migraines. BPPV, though benign, can be a terrifying experience, especially for those experiencing it for the first time. It has a sudden onset and is often accompanied by nausea and vomiting. The first thought that enters people’s mind is a stroke or a brain tumor.

The cause of BPPV is a loose crystal in one of the semicircular canals of the inner ear. Epley maneuver usually succeeds in trapping and immobilizing this crystal. I’ve had a patient who emailed me with a typical description of BPPV. I emailed her this link to a YouTube video with the instructions on how to perform the Epley maneuver. She emailed back 30 minutes later reporting that her vertigo stopped.

A new study by Dr. Michael Strup, a neurologist at the Hospital of the Ludwig-Maximilians University in Munich and his European colleagues compared two different maneuvers to relieve BPPV. They showed that Semont-Plus maneuver is more effective than the Epley maneuver.

Of the 195 participants 64% were women and the mean age was 63. Initially, the procedure was administered by a physician. Subsequently, patients were instructed to perform the maneuver independently—three times each in the morning, noon, and evening. The Epley group stopped having vertigo after an average of 3.3 days, while the Semont-Plus group, after an average of 2 days.

The role of a physical therapist in treating migraines

By: Dr. Mauskop

14-08-2023

Alternative Therapies, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Because migraine is fundamentally a brain disorder, the involvement of physical therapists in its treatment might seem unnecessary. However, their contribution can be profoundly impactful, provided they have a keen interest in the nuances of migraine care.

One such physical therapist to whom I refer patients, Pete Schultz, just co-wrote an article, A Multimodal Conservative Approach to Treating Migraine: A Physical Therapist’s Perspective.

This article shows how experienced physical therapists approach migraine patients. They usually perform a very thorough examination and they can sometimes detect a serious problem that was missed by a physician.

The physical therapist often discovers general weakness, muscle tension, poor posture, diminished endurance, neck pain, teeth clenching, visual symptoms, dizziness, poor balance and coordination and high stress levels.

The interventions may include exercise directed at strengthening neck and upper back muscles, manual therapy, general conditioning exercise, biofeedback and mindfulness techniques, and vestibular therapy.

There is a wealth of data on the therapeutic effect of exercise in migraine patients. Interestingly, weight training seems to be more effective in the prevention of migraines than aerobic exercise.

Vestibular symptoms, such as dizziness and unsteadiness, are very common and are highly responsive to vestibular therapy.

Biofeedback is typically done by mental health professionals, but also by physical therapists. Over 100 clinical trials have been performed utilizing biofeedback in the treatment of headaches. The consensus is that this is a very effective technique.

An additional benefit that physical therapists can provide is what psychologist call a shift in locus of control, from internal to external. This means that instead of feeling like a victim of external uncontrollable circumstances, people acquire agency and cam actively do things to help themselves. This shift has been consistently shown to increase the efficacy of headache and pain treatment.

Depakote, oral and infusion, for migraines in children

By: Dr. Mauskop

10-08-2023

Chronic migraine, Headache medications, Headaches in children, Migraine, Migraine in pregnancy

A recently published study suggests that valproic acid (Depakene) given intravenously in an emergency room can relieve migraine headaches in children. The researchers also showed that giving these children an oral version of this drug, divalproex sodium (Depakote), does not reduce the frequency of future migraine attacks.

Divalproex sodium was first approved by the FDA in 1983 for the treatment of epilepsy. Subsequently, it was also approved for the treatment of mania and for the prevention of migraine headaches. Notably, the FDA-approved label does not place any age limit on the use of this drug. It took years to discover all the risks associated with this medication. In rare instances, the drug may lead to liver failure and severe pancreatitis, both of which can be fatal. Moreover, divalproex sodium can result in significant congenital malformations, as well as diminished IQ scores and neurodevelopmental disorders when the fetus is exposed to the drug in utero. It is strictly contraindicated in pregnant women. Women of childbearing age must use effective contraception. Divalproex can also cause many other less dangerous but unpleasant side effects.

With all this in mind, why would anyone want to take this drug? It is certainly not on the list of my top 20 or 30 drugs for the prevention of migraines. I do, however, have several patients whose migraines did not respond to many drugs but are significantly improved with divalproex sodium. Such patients must have proper monitoring with regular blood tests.

We do occasionally give intravenous valproic acid in the office but only if 5 or 6 other acute treatments fail to stop a severe persistent migraine. It works in about half of our patients. I am even more reluctant to give this drug to children.

Botox in pregnancy

By: Dr. Mauskop

24-07-2023

Alternative Therapies, Botox, Chronic migraine, Headaches, Migraine, Migraine in pregnancy

Botox injections is arguably the safest and most effective preventive treatment for migraine headaches. There have been cases of pregnant women receiving Botox for various medical and cosmetic reasons, and no evidence suggests that the fetus gets harmed during this treatment. The botulinum toxin molecule is too large to cross the placenta and enter the circulation of the fetus, which further supports its safety during pregnancy.

An analysis of pregnancy outcomes after onabotulinumtoxinA exposure over a 29-year period was conducted to gain more insights into the safety of the treatment during pregnancy. The researchers examined data from the Allergan Global Safety Database from 1990 to 2018, focusing on pregnant women or those who became pregnant within three months of receiving onabotulinumtoxinA treatment. They analyzed the outcomes of these pregnancies to estimate the prevalence of birth defects in live births.

Out of 913 pregnancies, the study considered 397 with known outcomes. The majority of the mothers were 35 years or older, and most of the onabotulinumtoxinA exposures occurred before conception or during the first trimester of pregnancy. Among the 197 fetuses from 195 pregnancies, there were 152 live births and 45 fetal losses (including spontaneous and elective abortions). Four of the 152 live births had abnormal outcomes, with one major birth defect, two minor fetal defects, and one birth complication. The overall prevalence of fetal defects in live births was 2.6%, with a prevalence of 0.7% for major defects, similar to the rates seen in the general population. Among the cases with known exposure times, one birth defect occurred with preconception exposure and two with first-trimester exposure.

While the study has some limitations due to the nature of the data collected, the results indicate that the rate of major birth defects in live births exposed to onabotulinumtoxinA is consistent with the rates seen in the general population. However, it is important to note that there is limited data available for exposure during the second and third trimesters of pregnancy. Nevertheless, this updated and expanded analysis provides valuable real-world evidence for healthcare providers and their patients when considering Botox treatment during pregnancy.

I’ve treated more than a dozen pregnant women in my 30 years of using Botox for migraines. Some of them received Botox during more than one pregnancy. Some pregnant women sought Botox treatment specifically because they preferred to avoid taking any medications during pregnancy. Their decision was justified. When it comes to migraine drugs, including over-the-counter pain medications, they carry a higher likelihood of causing harm during pregnancy.

Controlled trial of meditation for migraines

By: Dr. Mauskop

17-07-2023

Alternative Therapies, Brain disorders, Chronic migraine, Headaches, Migraine, Psychology of headaches

Meditation had a dramatic effect on my migraine headaches, especially when I increased my daily meditation time from 20 to 45 minutes. I have found that sumatriptan has always been very effective and migraines have never disrupted my daily life, even when I experienced prolonged periods of daily headaches. Because of meditation I hardly ever need to take sumatriptan. My personal experience and that of many of my patients align with the viewpoint of a small group of headache specialists who believe that triptans do not cause medication overuse headaches.

Mindfulness has been gaining a lot of attention as a potential way to manage migraines, but there haven’t been many scientific studies to support this. A group of Italian researchers investigated whether a specific mindfulness-based treatment, consisting of six sessions of mindfulness practice and daily self-practice, would be effective when added to the usual treatment for patients with chronic migraine and medication overuse headaches.

They conducted a study with 177 patients. Half of the participants received the usual treatment alone, which included withdrawing from overused medications, education on proper medication use and lifestyle, and tailored prevention. The other half received the usual treatment plus the mindfulness-based intervention.

They looked at various factors to assess the effectiveness of the mindfulness-based treatment, including headache frequency, medication intake, quality of life, disability, depression and anxiety, sensitivity to touch, awareness of inner states, work-related difficulties, and disease-related costs.

After analyzing the data, they found that the patients who received the mindfulness-based treatment in addition to the usual treatment had better outcomes. They were more likely to achieve a significant reduction in headache frequency compared to their baseline (at least 50% reduction), and they also showed improvements in other areas such as quality of life, disability, headache impact, productivity loss due to headaches, medication intake, and healthcare costs.

They concluded that adding a six-session mindfulness-based treatment, along with daily self-practice, to the usual treatment is more effective than the usual treatment alone for patients with chronic migraine and medication overuse headaches.

Zavegepant, a new abortive migraine drug, is now available

By: Dr. Mauskop

05-07-2023

Chronic migraine, Cluster headaches, Headache medications, New treatments

Zavegepant (Zavzpret), the first CGRP nasal spray for the treatment of acute migraine attacks, was approved by the FDA in March and is now readily available in all US pharmacies..

Zavegepant belongs to the family of CGRP antagonists, which work by blocking excessive amounts of the neurotransmitter CGRP. Elevated levels of CGRP are known to contribute to the development of migraines. By inhibiting its action, zavegepant can effectively stop an ongoing migraine attack. While there are already two oral CGRP medications for the acute treatment of migraines (Nurtec and Ubrelvy), zavegepant is the first nasal spray option. Nasal sprays offer several advantages, including faster onset of action compared to tablets and the ability to bypass the stomach. These benefits are particularly valuable for individuals experiencing migraines accompanied by nausea and vomiting.

Clinical studies have demonstrated that zavegepant is superior to placebo in promptly eliminating all pain and the most bothersome symptom within two hours of administration. The most commonly reported bothersome symptoms associated with migraines are nausea, sensitivity to light (photophobia), and sensitivity to noise (phonophobia).

Side effects of zavegepant were generally mild and infrequent. Participants in clinical trials noted an unpleasant taste in 18% of cases, compared to 4% in the placebo group. Additional side effects included nausea (4% vs. 1%), nasal discomfort (3% vs. 1%), and vomiting (2% vs. 1%). Taste-related issues have been observed with other nasal sprays used for migraines, particularly among patients who experience nausea. However, this can be easily addressed by sucking on a hard candy while using the nasal spray.

Interestingly, even individuals who did not respond to other CGRP drugs may potentially benefit from zavegepant. While these drugs are similar in their mechanism of action, they are not identical, and patients often exhibit strong preferences for a particular medication within the same category. This preference phenomenon is common in other migraine drug categories such as triptans, NSAIDs, and oral CGRP drugs.

Effects of observational learning on placebo responses, or why sham remedies seem to work so well

By: Dr. Mauskop

19-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Pain, Pain Research, Psychology of headaches

Many companies selling ineffective treatments for painful conditions manage to attract a large customer base by showcasing testimonials from satisfied customers. Recent research suggests that these individuals might genuinely benefit from hearing others express positive experiences.

A study published in the journal Pain, titled “Learning pain from others: a systematic review and meta-analysis of studies on placebo hypoalgesia and nocebo hyperalgesia induced by observational learning” explores the impact of observational learning on placebo and nocebo responses.

Placebo hypoalgesia refers to when a fake treatment (placebo) reduces pain, while nocebo hyperalgesia is when the placebo actually increases pain. Learning processes, such as classical conditioning and operant conditioning, have been shown to play a role in these effects. Verbal suggestions and observational learning from others also influence placebo and nocebo responses. However, the magnitude of these effects can vary depending on the specific learning process used.

This meta-analysis of 17 studies showed that observational learning can effectively modulate pain and pain expectancies. However, the magnitude of these effects varies across studies. Observing a model in person resulted in larger effects compared to observing a videotaped model. The analysis also suggested that placebo effects can be induced through observational learning, but nocebo effects were not consistently observed. Empathy, specifically the empathic concern component, was found to be associated with the magnitude of observational learning effects.

The article concludes that observational learning can indeed influence pain experience and pain expectancies. Further studies possibly could lead to methods to enhance the treatment effects of proven therapies.

PTSD biomarkers

By: Dr. Mauskop

12-06-2023

Alternative Therapies, Brain disorders, Chronic migraine, Head trauma, Headaches, post-traumatic headache, Psychology of headaches

Researchers have identified four blood biomarkers that show promise in predicting, diagnosing, and monitoring treatment response for posttraumatic stress disorder (PTSD). These biomarkers could lead to more accurate methods of screening for PTSD, allowing for early intervention and prevention strategies. Additionally, they could help monitor treatment progress, identify different subtypes of PTSD, and enhance our understanding of the underlying mechanisms of the disorder.

The study was conducted by the PTSD Systems Biology Consortium, initiated by the Department of Defense, and involved approximately 45 researchers. The team analyzed blood samples from 1,000 active-duty Army personnel from the Fort Campbell Cohort (FCC), who were assessed before and after deployment to Afghanistan in 2014.

The researchers focused on four biomarkers: glycolytic ratio, arginine, serotonin, and glutamate. They categorized the participants into four groups based on their PTSD symptoms, resilience levels, and clinical assessments. The findings revealed that individuals with PTSD or subthreshold PTSD had higher glycolytic ratios and lower arginine levels compared to those with high resilience. Additionally, participants with PTSD exhibited lower serotonin and higher glutamate levels. These associations were independent of factors such as age, gender, body mass index, smoking, and caffeine consumption.

The study results require further validation. The researchers also aim to determine the optimal time to screen soldiers for PTSD, considering the psychological challenges that arise around 2 to 3 months post-deployment. Moreover, they recognize the need for gender-specific biomarkers to improve the clinical assessment of female soldiers, given the increasing number of women serving in combat roles.

Ultimately, these findings may apply to the civilian population experiencing PTSD.