Headache NewsBlog

Oxygen for cluster headaches through a demand valve

By: Dr. Mauskop

25-06-2013

Oxygen inhalation is a proven method of treating cluster headaches. The patient usually rents a large oxygen tank and breathes in pure oxygen through a mask whenever he gets an attack (it is usually a he since 5 times as many men suffer from cluster headaches as women). Demand valve oxygen (DVO) is a promising new oxygen delivery system for the acute treatment of cluster headaches, according to a recent report by Dr. Todd Rozen.

DVO delivers oxygen to the user as soon as they inhale from an attached mask and the amount of oxygen is controlled by how fast they are breathing. DVO is capable of delivering much more oxygen than by just breathing it through a regular mask. In the study 3 patients tried both DVO and a regular mask. All patients had chronic cluster headaches. On DVO all 3 subjects became pain free; 2 of 3 became pain free on a regular mask, while the third subject needed 30 minutes to get to mild pain. Patients using DVO became pain free faster than when a regular mask was used. This was a very small sample and bigger studies are needed, but DVO appears to be at least as effective for acute treatment for cluster headaches as inhalation of oxygen through a regular mask.

Infantile colic and pediatric migraine

By: Dr. Mauskop

22-06-2013

Headaches in children

Infantile colic seems to be a precursor or an early manifestation of migraine headaches in children. A new European study published in the journal JAMA supports an earlier American study mentioned in one of my previous blogs. This European study involved 208 children who were diagnosed with migraine at emergency departments found that 73% of them had a history of colic in infancy, compared with 27% of a control group of children. History of being colicky was as common in children and teens who suffered from both migraine with and without aura.

This study suggests that many colicky babies whose colic does not respond to any treatment directed at their digestive system may be suffering from migraine headaches. Some of these children may develop cyclic vomiting as they get older and then go on to have typical migraine headaches.

The researchers at two Italian and one French hospital did a second study involving 120 children with tension-type headaches. Only 35% of these children had a history of infantile colic, confirming that it is not any headache, but specifically migraine that is associated with infantile colic. Migraines are very common in children. Before puberty, about 6% of boys and girls suffer from migraines. After puberty, boys remain at 6% and the incidence of migraines goes upt o 18% in girls.

One of the authors of the study suggested that migraine medications might be effective for colicky babies, although this would require a controlled study. Such studies in infants are difficult to perform because of the unknown potential side effects, which understandably will lead to parent anxiety. However, the colic is painful and we know that pain even in infancy leads to harmful changes in brain chemicals and brain structure. A colicky baby also causes high stress for the parents.

In my practice, I’ve encountered many children with episodic and chronic migraines whose parents report infantile colic that gradually transformed into a typical migraine. So, unfortunately, migraine can start even before a child can begin to speak.

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Frequent migraines are not different from chronic migraines

By: Dr. Mauskop

19-06-2013

New treatments, Science of Migraine

Botox is approved by the FDA for the prophylactic treatment of chronic migraine headaches. Chronic migraine was arbitrarily defined by headache researchers as headache occurring on more than 14 days each month. Epidemiological research by Dr. Richard Lipton and his colleagues at the Albert Einstein School of Medicine suggests that there is no biological difference between frequent migraines that occur on 10 or more days each month and chronic migraines.

They compared clinical features and the incidence of other chronic medical conditions in three groups of patients with migraine: low frequency (0-9 days/month), high frequency (10-14 d/mo) and chronic migraine (15-30 d/mo). The American Migraine Prevalence and Prevention Study is a US-population-based study with 16,573 people with migraine who responded to a 2005 survey. Of these, 10,609 had low frequency, 640 had high frequency and 655 had chronic migraines. Rates of pulmonary and respiratory conditions including asthma, bronchitis, chronic bronchitis, emphysema/COPD, allergies/hay fever, and sinusitis increased across headache frequency groups and were significantly different for chronic migraine vs. low frequency, but not for chronic migraine vs. high frequency. A similar finding was seen for cardiac conditions and strokes. Depression, nervousness or anxiety, bipolar disorder/mania, and chronic pain were also much more common and similar in those with frequent or chronic migraine compared to those with low frequency migraines (around 30% vs 15%-18%).

These findings suggest that patients with frequent migraines resemble those with chronic migraines much more than they do those with low frequency migraines. One practical implication of this research is that Botox is very likely to be as effective for patients with frequent migraines (those with 10-14 headache days a month) as it is for patients with chronic migraines. And indeed, I’ve observed an excellent response in patients with frequent migraines in my almost 20 years of giving Botox injections for headaches. The response for both patients with frequent migraines and chronic migraines is about 70%, which significantly exceeds the efficacy of any prophylactic drug with no potentially serious side effects seen with most drugs.

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Calcium promotes chronic pain

By: Dr. Mauskop

16-06-2013

Pain Research

Calcium inside the nerve cells (neurons) seems to be crucial in making pain chronic, according to a publication in the journal Neuron by researchers in Heidelberg, Germany. They discovered that in patients with persistent pain, calcium in the spinal cord neurons helps contact other pain-conducting neurons resulting in increased sensitivity to painful stimuli. This may explain how the pain memory is formed.

Chronic pain caused by inflammation, nerve injury, herniated disks, and other causes often leads to a persistent structural change in the nervous system. This pain often persists even after the original cause, such as a herniated disc, is removed. Many chronic pain patients including those with chronic migraine develop allodynia, an increased sensitivity which results in pain from touch and minor pressure. Migraine patients often cannot brush their hair or wear glasses because of such sensitivity. In people with chronic pain, too much calcium inside the neurons that transmit pain makes them react to activation of neurons that normally transmit sensation of touch, heat, and other non-painful sensations. This excess calcium enters the nucleus of the cell where the genetic material is located and it activates certain genes that promote pain. One of the researchers, Prof. Kuner said that “These genes regulated by calcium in the spinal cord are the key to the chronicity of pain, since they can trigger permanent changes.”

Blocking calcium in the cell seems to prevent such increased sensitivity. Mice in which the effect of the calcium in the cell nucleus is blocked did not develop hypersensitivity to painful stimuli or a pain memory despite chronic inflammation.

Interestingly, magnesium is a natural antagonist of calcium and I would speculate that its deficiency may also promote chronic pain.

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Chronic headaches and sexual pain

By: Dr. Mauskop

10-06-2013

Pain, Science of Migraine

Female pelvic/genital pain is more common in women with chronic Headache, according to a study presented by Canadian neurologists.
The study was carried out by researchers and clinicians at the Wasser Pain Management Centre, Mount Sinai Hospital and the Centre for Headache at Womens College Hospital in Toronto, Canada. During the study period, every adult English speaking female patient at the Centre for Headache at WCH was asked if they would consent to complete a specifically devised questionnaire. Of the 72 completed questionnaires, 32 (44%) of patients reported that they had pelvic region or genital pain brought on by sexual activity. Thirteen (18%) admitted to having pelvic pain that prevents them from engaging in sexual activity. 46% of these women had not had treatment, 39% were currently being treated, and 15% said they had received treatment in the past. All but one said that she would be interested in receiving treatment if available. The researchers concluded that it is important to ask women with chronic headache about sexual pain and, if present, be able to offer a management option.

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Leeches are definitely revolting, but can they help migraines?

By: Dr. Mauskop

03-06-2013

Alternative Therapies

Leeches are not pleasant to look at, but they have been used for medicinal purposes for hundreds of years. Growing up in the Ukraine in the 1960s I remember (this is hard to forget) seeing big jars with leeches in a corner pharmacy. Patients would bring in a prescription from the doctor for 4 leeches to be applied daily. The leeches would be placed into a small jar and taken home by the patient to treat swelling, high blood pressure and I don’t know what else. Leeches went out of fashion because of the advances in medicine and just because they are just disgusting. They are being used again in the US for removing extra blood around the scars after cosmetic surgery, arthritic pains, shingles, and other conditions.

British writer Emma Parker Bowles was recently in the news writing about how leeches cured her migraines. She decided on this unusual treatment because her headaches were so severe. She says, “the word headache doesn’t even begin to describe them”. She goes on with a vivid description, “Migraines are miserable with bells on – actually, the idea of listening to the sound of a bell with a migraine brings me out in a sweat. When I am suffering with one, I can’t even stand the sound of my sheets rustling. Apart from the intense throbbing, all-encompassing pain in my head, I also feel extremely nauseous and sensitive to light. I feel as if I am a vampire – a small sliver of daylight and POOF: I will spontaneously combust”.

Leeches do not hurt when they are applied because they first release a numbing substance, which along with a blood thinner and other chemicals released by the leech may be responsible for their beneficial effect. They do not have any known serious side effects. Leeches are used once and then destroyed to avoid transmitting diseases, although there is no reason why a person could not reuse them herself or himself. Several companies sell leeches to the public with instructions on how to use them. Although leeches have been used for the treatment of migraines for many years, there have been no good clinical trials or even reports of large series of cases, but someone should definitely undertake this research. Me? I am not sure I am ready.

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Getting medicine straight from the nose to the brain

By: Dr. Mauskop

01-06-2013

New treatments

Many migraine sufferers suffer from nausea and vomiting and cannot swallow pills or even if they can swallow them, it takes too long for them to work. Injections is one way to overcome this problem, but nasal spray is a much more pleasant alternative. There are several migraine medications available in a nasal spray form, including Zomig (zolmitriptan), Imitrex (sumatriptan), Migranal (dihydroergotamine), Sprix (ketorolac), and Stadol (butorphanol). Unfortunately, they don’t always work or work inconsistently. Having nasal congestion due to allergies, a cold, or migraine itself often makes these medicines ineffective. Stadol is a narcotic, which can be addictive, while Imitrex and Migranal require delivery into the nose a large volume of fluid, which tends to leak out or gets swallowed, thus reducing their efficacy.

Seattle-based Impel Neuropharma has been working for five years to show it can quickly deliver drugs through the nose, directly to the brain, rather than what happens with the currently available sprays – absorption into the blood stream first and then carried to the brain. Impel, a University of Washington spinoff, recently presented a study of seven patients who used the company’s nose-to-brain drug delivery device, which was able to propel a test protein deep into the upper nasal passages and to the brain stem at an “order of magnitude” greater concentration than a conventional nasal spray. Researchers saw it get delivered to the destination within 10 to 20 minutes. Most nasal sprays don’t propel drugs anywhere close to the upper nasal passages, which is the only place in the body where nerve cells (neurons) are possibly accessible to the outside environment. This device delivers a pressurized, rotational flow of aerosol to reach those neurons.

The company stated that a nose-to-brain delivery device could, in theory, get an effective pain reliever to work more quickly for patients in need of something fast, and do it safely by minimizing the amount that gets absorbed into the bloodstream. It also could be convenient for patients, especially when compared with injectable treatment options.

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TENS unit Cefaly is no longer available in the US

By: Dr. Mauskop

28-05-2013

Alternative Therapies

In my previous post I mentioned a TENS unit spcifically designed for the treatment of migraine headaches. It was available for a short time on Amazon.com, but no longer is. It is sold at COSTCO stores in Canada and in Europe. Howere, regular TENS units can be tried and they are less expensive.

Intravenous medications for trigeminal neuralgia

By: Dr. Mauskop

22-05-2013

Trigeminal and other neuralgias

Trigeminal neuralgia is an extremely painful condition that causes electric-like pain in the face. It is often misdiagnosed as a dental problem, sinus headache or another condition. The pain is very brief, just like an electric shock, but it can occur continuously and is often triggered by brushing teeth, chewing, talking, or even by wind. This is a very treatable condition and it usually responds to anti-epilepsy drugs, Botox injections and, if those fail, surgery. Many patients have periods of sudden worsening of pain and until medications or Botox begin to help they need emergency treatment for pain. Narcotics (opioids) are usually ineffective. Dr. Merritt and Cohen of the Beth Israel Hospital in New York recently described the use of intravenous antiepileptic medications for acute exacerbations of trigeminal neuralgia in the emergency department. They described 21 patients, 15 women and 6 men whose aged ranged from 33-88 and the mean age was 69 (trigeminal neuralgia is more common in the elderly). 19 received intravenous fosphenytoin (Cerebyx, a drug related to an oral drug Dilantin) 2 received levetiracetam (Keppra) with excellent relief. Side effects included double vision, dizziness, sleepiness, and itchiness with fosphenytoin and no side effects were observed in 2 who received levetiracetam. Unfortunately, the most commonly used oral drugs for trigeminal neuralgia, carbamazepine (Tegretol) and oxcarbazepine (Trileptal) are not available in an injectable form. Another epilepsy drug, divalproex sodium (Depakote) can be given intravenously (Depakene) but it does not appear to be very effective for trigeminal neuralgia.

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Another triptan is going generic

By: Dr. Mauskop

17-05-2013

Headache medications

Zomig (zolmitriptan) is the fourth triptan (out of seven) to become available in a generic form. This spells big relief for migraine sufferers who rely on this drug. Only tablets and orally disintegrating tablets (ZMT) will become available, not the nasal spray. Nasal spray offers faster relief and for some patients it is as fast as sumatriptan injection (Imitrex, Sumavel, Alsuma). It may take another 6 months for the price to drop significantly from the current $30 to $45 a pill because at this point only four companies are coming out with a generic version. There are about 10 manufacturers making generic Imitrex. Generic sumatriptan (Imitrex) is now available for $3 a pill, while the other two generics, Maxalt (rizatriptan) and Amerge (naratriptan) are still more expensive.

One caveat with the generics is that the quality sometimes is not as good as that of the brand. Of approximately 10 generic sumatriptan versions, my patients have found that 2 are very ineffective. One of these two manufacturers which is based in India (Ranbaxy), recently paid $500 million fine to the FDA for improper manufacturing, storing and testing of drugs. Many generic manufacturers are based in India and most of them produce good quality products. One of them is Dr. Reddy’s Laboratories. Of the four generic manufacturers of Zomig two are based in India (Glenmark and Zydus), one in Taiwan (Impax) and one is based in the US (Mylan) but also has many manufacturing plants in India. An Israeli company Teva, the largest manufacturer of generics in the world is known for their high quality products and it also has plants in many countries, including India.

Once you find a product that works, stick with that generic manufacturer even if you have to switch pharmacy chains since the entire chain usually carries the same generic. The law requires that the name of the manufacturer is printed on the medicine bottle your receive from the pharmacy, so it is easy to find out who the manufacturer is.

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Triptans are the first line migraine drugs in pregnant women

By: Dr. Mauskop

15-05-2013

Headache medications

Pregnant women are admonished not to take any medications while pregnant. Fortunately, two out of three women stop having migraines during pregnancy, especially during the second and third trimester. Unfortunately, one third of women continue having migraines and in some they get worse. Tylenol (acetaminophen), which is deemed to be the safest pain medicine in pregnancy is also the weakest pain killer and does nothing to relieve the agony of a migraine attack. Many obstetricians say that they are also “comfortable” giving drugs containing butalbital (a barbiturate) and caffeine along with acetaminophen (Fioricet) because these drugs have been around for many years. However, barbiturates are really not good for the developing brain while regular intake of caffeine can cause worsening of migraine headaches. Narcotic (opioid) analgesics are not exactly healthy either. Not taking any medications is also harmful to the mother and the fetus because severe pain causes serious distress to both and vomiting, which often accompanies migraines, can cause dehydration. Not treating migraine attacks may also lead to chronic migraines with pain present continuously. So, what is a pregnant woman to do?
At the recent annual meeting of the American Congress of Obstetricians and Gynecologists several doctors expressed their preference for the use of triptans in pregnant women. Sumatriptan (Imitrex) was first introduced 20 years ago and a registry of women who took sumatriptan during pregnancy suggests that this is a safe drug. Pregnancy registry for rizatriptan (Maxalt), which is the second triptan to come to the market 15 years ago, also suggests that it is a safe drug. Of course, it cannot be said that these drugs are proven to be safe for pregnant women because some yet undetected risk may still be present. However, compared to the alternatives and considering that triptans are much more effective, it is logical to recommend their use in pregnancy.
Besides treating an acute attack with triptans we always recommend preventive measures, such as magnesium supplementation (400 mg, on top of what is in a prenatal vitamin, which is usually only 100 mg), biofeedback, regular sleep, and exercise.
Preventive drugs that can cause major problems in the fetus and are contraindicated in pregnancy include divalproex (Depakote) and topiramate (Topamax). On the other hand, Botox is probably a safe preventive treatment in pregnant women suffering from chronic migraine headaches.

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Botox helps post-traumatic headaches in soldiers

By: Dr. Mauskop

13-05-2013

New treatments

Botox appears to be effective for the treatment of chronic post-traumatic headaches in service Members with a history of mild traumatic brain injury according to a recent report by Dr. Juanita Yerry and her colleagues at Ft. Bragg, NC. The researchers assessed the safety of onabotulinum toxin type A (Botox) in the preventive care of post traumatic headache. Headache is a common complication of mild traumatic brain injury in active duty service members. Migraine and chronic migraine type are the most common headache types. The approved use of Botox in chronic migraine made the doctors think that Botox might be safe and possibly effective in post-traumatic headaches with features of chronic migraines. They examined records of all patients treated with Botox for post-traumatic headache in the Concussion Care Clinic at Womack Army Medical Center, Ft. Bragg, NC between 2008 and 2012. They recorded patient demographics, prior history of headache, injury type, current headache type, time from injury to first injection, treatment techniques, number of treatments/treatment interval, side effects, reasons for discontinuation and Patient Global Evaluation of Change (PGEC). Out of 67 patients (66 male) who were treated 10% had prior history of headaches. Most common injuries were blast (46.3%), parachute jumps (14.9%) and motor vehicle accidents (11.9%). About 56% reported more than one headache type. Headache types included: chronic migraine (22.4%), episodic migraine (7.5%), chronic tension type (7.5%), hemicrania continua (7.5%), nummular (1.5%); mixed tension/chronic migraine (41.8%), and tension/migraine (7.5%). A very large percentage (75%) had a continuous headache. Reasons for discontinuing Botox treatment included ineffectiveness (44.8%), side effects (2.9%), or reinjury (1.5%). They were not able to follow-up with 22% patients of whom 73.3% reported being “much better”. Overall, 60% were better or much better, 4.5% were worse or much worse, and 33% reported no change. The researchers concluded that Botox appears to be safe and well tolerated in active duty service members treated for post-traumatic headaches.

Art credit: JulieMauskop.com