Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from Turin. They reported on 194 consecutive patients who had migraine with aura and who were placed on a prophylactic medication. Ninety of these patients were on 300 mg of aspirin daily and the rest were given propranolol (Inderal), topiramate (Topamax), and other daily medications. At the end of 32 weeks of observation 86% of those on aspirin had at least a 50% reduction in the frequency of attacks of migraine with aura compared with their baseline frequency, while 41% had even better results – at least a 75% reduction. In contrast, only 46% of patients on other drugs had a 50% improvement in frequency. The probability of success with aspirin was six times greater than with any other prophylactic medication, according to the lead author, Dr. Lidia Savi.
Aspirin is not only effective for the prevention of migraines with aura but also for acute therapy of migraine attacks. In previous posts I mentioned that a rigorous analysis of large numbers of patients showed that 1,000 mg of aspirin is better than 500 mg of naproxen (2 tablets of Aleve) and that 1,000 mg of aspirin was as good as 100 mg of sumatriptan (Imitrex) with fewer side effects.
Many health benefits of aspirin, which was originally derived from the willow bark, are becoming widely known. In addition to helping prevent heart attacks and strokes, aspirin has cancer-fighting properties. You may want to read a very interesting article about aspirin, The 2,000-Year-Old Wonder Drug, just published in the New York Times.
The use of acute anti-migraine medications in patients with episodic migraine (migraine occurring on less than 14 days a month) prevents progression of episodic migraine into its chronic form, according to Dr. Zaza Katsarava and his colleagues in Essen, Germany. They followed 1,601 patients with episodic migraine headaches for two years. None of these patients were taking prophylactic medications and 151 patients took no acute anti-migraine medications. Overall, during the two years of observation, 6.2% of 1,601 patients developed chronic migraines (defined as headaches occurring on 15 or more days each month). However, those who took triptans (sumatriptan and other) had a 66% reduction of risk of headaches becoming chronic, those who took a single pain medicine had a 61% lower risk of chronification, and those who took a combination pain killer, like Excedrin, had a 40% reduction of this risk. This analysis took into account patients’ age, sex, body mass, education level and baseline migraine frequency. A possible explanation for why combination drugs were less protective is that most of them contain caffeine, which is known to make headaches worse. Another very important lesson that can be drawn from this study is that it is important to treat migraine attacks with effective medications because if left untreated these intermittent attacks may become more frequent and even daily. At least two million Americans suffer from chronic migraines and it is likely that in many this debilitating condition could have been prevented by more aggressive and effective treatment of acute attacks.
Read MoreA new treatment developed by Belgian neurologists was reported to help patients with chronic refractory cluster headaches. The name cluster headaches originates from the fact that headaches occur in clusters, typically once a year for a period of a month or two, during which headaches occur daily. Unfortunately, in some patients cluster headaches are chronic and occur continuously. Some of these chronic cluster patients respond to medications, such as verapamil, topiramate, lithium or Botox injections. A small number of patients fails to respond to any of the usual therapies and are considered refractory to treatment. Because the pain of cluster headaches is extremely severe and because headaches occur daily and often more than once a day these patients often become despondent. Out of desperation, doctors have tried different unproven and at times risky treatments, such as deep brain stimulators with electric probes implanted deep into the brain. This is obviously a very invasive procedure that has resulted in strokes and deaths. I have treated two patients with a much less invasive Vagus Nerve Stimulator and these two responded well.
Dr. Jean Schoenen and his colleagues implanted 28 patients with chronic refractory cluster headaches with a miniature neurostimulator implanted in the back of the nasal cavity, near the sphenopalatine ganglion. This ganglion has been injected and anesthetized (with lidocaine and cocaine) in an attempt to relieve various pains for many years. The stimulator was implanted by a neurosurgeon in an out-patient visit and the procedure leaves no visible scar. Once implanted, the device can be activated by a remote controller which the patient holds near the face. The study was blinded in that some patient were given either very mild or no stimulation at all. The researchers hoped that by stimulating sphenopalatine ganglion for 90 seconds patients would be able to stop a cluster attack. The results showed that only 7 (25%) of patients were able to abort an attack, but surprisingly another 10 (36%) reported that after trying to treat 30 attacks (over 3 – 8 week period) the frequency of their attacks dropped by more than 50%. Headache-related disability improved in 64% of patients. Patients were allowed to use acute medications to stop individual attacks and only 31% of those who received real stimulation used them, while these drugs were used by 78% of those given mild or no stimulation. The most common side effect was an unpleasant sensation in the face, experienced by 81% of patients but these symptoms resolved within 3 months. Two patients had infections and another two had their stimulator drift out of place and had to have it removed. The stimulator is known as ATI Neurostimulator System and it does not preclude having MRI scans done in these patients. The manufacturer of this device launched a large multi-center trial of this device in Europe, both for chronic cluster and disabling migraine headaches.
Exercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is to exercise regularly, starting with low intensity and short duration exercise sessions. If headache occurs with minimal exertion, I suggest taking Advil (ibuprofen), Aleve (naproxen), Migralex (aspirin/magnesium) an hour before exercise for several weeks. However, it appears that even experienced athletes suffer from what is officially known as a primary exertional headache. Dutch researchers are reporting on the incidence of exercise-related headaches among cyclists in the latest issue of journal Headache. They performed an online survey of 4,000 participants of a very challenging cycling race. Thirty seven percent of them suffered from such headaches at least once a month and 10% had them at least once a week. Women were more likely to have these headaches – 54% vs 44% in men. Older cyclists were significantly less likely to have these headaches. Tension-type and migraine headaches were most common. Headache medications were used by 37% of participants. Extreme exertion was the most commonly reported contributing factor (50%), while some reported that low fluid intake (39%) and warm weather (39%) contributed to their headaches; 26% could not identify their trigger. Another possible trigger not reported in the article is neck strain. Riding sports bikes with low handlebars makes riders strain their neck and trigger a cervicogenic headache.
The authors concluded that these headaches are widely underestimated and may cause many people quit their sports. They also called for research into causes and treatment of exercise-related headaches.
Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw another woman who had both erythromelalgia and migraines. My observation of several patients who had both diseases does not mean that these conditions are connected since migraines are very common in the general population. However, magnesium is known to help both conditions, so it is possible that there are common underlying causes. In fact, a sodium channel mutation which is responsible for erythromelalgia was also found in a family with familial hemiplegic migraine. Magnesium is involved in the regulation of sodium channels (as well as calcium and potassium channels) in all cells of the body. Most people who are deficient in magnesium and suffer from erythromelalgia and/or migraines respond well to oral magnesium supplementation, but a small percentage requires monthly intravenous infusions. We give intravenous infusions to those patients who do not tolerate oral magnesium (get diarrhea or stomach pains), those who do not absorb it (as evidenced by persistently low RBC magnesium levels) and those who prefer a monthly infusion to taking a daily supplement.
Many women are denied therapy with combined (estrogen with progesterone) hormonal contraceptives because published guidelines by doctor organizations recommend against their use in migraine with aura. The concern is that these products might further increase the risk of a stroke that accompanies aura. Stroke risk has been reported to vary directly with aura frequency, and aura frequency in turn has been shown to have a direct relationship to estrogen concentration. With the introduction of increasingly lower dosed hormonal contraceptives it is not clear if these risks are as high as with high-dose contraceptives. These formulations are expected to result in a lower frequency of migraine aura. In addition, continuous therapy eliminates monthly estrogen drops which can be expected to prevent menstrual migraines.
Dr. Anne Calhoun and her colleagues in North Carolina examined a database of 830 women seen in a menstrual migraine clinic and identified 23 women who had current history of migraine with aura, had a confirmed diagnosis of menstrually-related migraines, and were receiving extended-cycle (continuous) dosing of a vaginal ring contraceptive. At baseline, subjects averaged 3.23 migraine auras per month. With extended dosing of the vaginal ring contraceptive, median frequency was reduced to 0.23 auras per month after a mean observation of 7.8 months. No at a single woman reported an increase in aura frequency. On this regimen, menstrual migraine was eliminated in 91.3% of women.
The authors concluded that continuous use of vaginal ring contraceptive was associated with a reduced frequency of migraine aura and with resolution of menstrual migraines.
The risk of stroke in an otherwise healthy woman who does not smoke and has migraine auras is higher than in women without aura, but it still extremely small. It is possible that continuous use of very low dose contraceptives, particularly vaginal ring, may not increase the risk of strokes and may even prevent it.
Celiac disease and gluten sensitivity is known to cause or at least increase the frequency of migraine headaches. The recently published study in journal Headache by doctors from Columbia University and Mt. Sinai School of Medicine in New York City examined records of 502 individuals in an attempt to find out the frequency of headaches in these conditions. They looked at records of 188 patients with celiac disease, 111 with inflammatory bowel disease (such as Crohn’s and ulcerative colitis, 25 with gluten sensitivity and compared these to 178 healthy controls. Chronic headaches were reported by 30% of celiac disease, 56% of gluten sensitivity, 23% of inflammatory bowel disease, and 14% of control subjects. Migraine headaches were more common in women and those with anxiety and depression. The severity of the impact of migraine headaches was worst in celiac patients – 72% reported it to be severe, while this number was 60% in those with gluten sensitivity and 30 % with inflammatory bowel disease.
This study confirms previous observations that celiac disease and gluten sensitivity are associated with increased frequency of migraine headaches. The difference between celiac disease and gluten sensitivity was well described in this WSJ aritcle.
Children suffering from migraine headaches are more likely to have difficulty performing well in school, according to a new report published in Neurology. The doctors studied 5,671 children between ages 5 and 12 from 87 Brazilian cities and found that episodic migraine was present in 9% of children (9.6% of girls and 8.4% of boys), probable migraine, in 17.6% (17.3% of girls and 17.8% of boys) while chronic migraine in 0.6% (equally in boys and girls). Headaches were more common between ages 9 and 12 than 5 to 9. Chronic migraine was more common in poor children. Poor performance at school was significantly more likely in children with migraine and chronic migraine, compared to probable migraine and tension-type headaches.
These are not very surprising results, although they cannot be generalized to all children with migraines. It is very common for me to see children who do exceptionally well in school despite having many migraine attacks and missing many days of school. It is possible that those hard-working and driven kids get headaches because of stress, but despite their severe headaches are able to perform well. Because they are high achievers and like doing everything well, they often excel at biofeedback, which helps them learn how to control their stress and reduce their headaches. Regular meals, exercise, and sleep are also very important. We try magnesium, COQ10 and other supplements next, and if headaches are very frequent, Botox injections followed by preventive medications.
I see many patients who tell me that “I’ve tried every migraine drug” and seek me out to explore non-drug approaches, such as herbs, supplements, Botox, acupuncture and other. I always try to avoid using medications (and have written books on non-drug approaches), but some patients do best with a combination of medications and non-drug approaches. So, when someone tells me that they’ve tried “every drug”, I tell them that I’ve never seen such a person because there are so many drugs that we use to treat headaches. For example, they might’ve tried a blood pressure medication, but we have many different anti-hypertensive drugs and they work in different ways. One type of blood pressure medication may work when another does not. Also, if one drug caused side effects, another in the same or different category may not.
Here is a brief description of blood pressure medications that are used for the prophylactic treatment of headaches. The first medication approved by the FDA for the prevention of migraine headaches was propranolol (inderal) (methysergide or Sansert was approved earlier, but it is no longer available in the US). Propranolol was originally developed for the treatment of hypertension and then accidentally was found to help migraine headaches as well. A second beta blocker, timolol (Blocadren) was also tested, was found to work well and it also received FDA approval. Other beta blockers, such as atenolol (Tenormin), labetalol (Normodyne), and nebivolol (Bystolic) were also shown to be effective. Nebivolol tends to have fewer side effect, but it is not yet available in a generic form, so it can be relatively expensive. Propranolol is available in a slow release form (Inderal LA) which can be taken once a day, while regular propranolol goes in and out of the body quickly and needs to be taken two or three times a day. Atenolol and nebivolol produce effect that lasts all day, so they can be taken once a day. Atenolol is very inexpensive and I always remind patients to ask the pharmacist about the price without insurance because the insurance co-pay can be higher than the out-of-pocket cost of the drug. Most pharmacists will not volunteer this information.
Because beta blockers worked for migraines other blood pressure medications were also tested. Calcium channel blockers, such as verapamil (Calan), amlodipine (Norvasc), diltiazem (Cardizem), and other do not seem to be as effective as beta blockers. High doses of verapamil are very effective for the prevention of cluster headaches.
Another category of blood pressure medications, ACE (angiotensin converting enzyme) inhibitors, such as lisinopril (Zestril, Prinivil), enalapril (Vasotec) and other do help probably as well as beta blockers. These medications sometimes cause cough or other side effects and can be substituted by similar drugs in the category of ACE receptor blockers (ARBs). ARBs do not cause cough and may have fewer other side effects. Drugs in this group that were studied for the prevention of migraine headaches include olmesartan (Benicar), losartan (Cozaar), and candesartan (Atacand).
Pituitary adenoma is a benign tumor of an endocrine gland that is situated underneath the brain. Pituitary gland is connected to the brain and it produces several hormones. The most common type of pituitary tumor is one that secretes prolactin, hormone responsible for breast milk production. Women with this tumor usually have irregular periods and breast discharge. Pituitary adenoma usually does not cause headaches, unless it becomes large and compresses the brain. Most of the tumors are small and are called microadenomas and only rarely become large macroadenomas. A group of German researchers just published a study in Cephalalgia that looked at possible causes of headaches induced by pituitary adenoma. Fifty-eight patients with pituitary adenoma were analyzed. Twenty-four patients (41%) had tumor-attributed headache with seven having migraine-like headaches, 11 tension-type headaches, and three having both. Cluster headache-like headache was found once, and two headaches remained unclassified. Tumor-attributed headache was associated with a positive prior history of headaches, nicotine abuse, and a faster tumor growth. Whenever a woman with headaches has irregular periods or a milky discharge from her breast an MRI scan of her brain and a blood test for prolactin level must be obtained. If the tumor is allowed to grow large it can cause impairment and even loss of vision because of the compression of optic nerves. The treatment is usually with medication that shrinks the tumor and only rarely surgery is needed. This surgery can often be performed transnasally – through the nose with faster recovery than when it has to be done by opening the skull.
Occipital nerve stimulation (ONS) has been reported to relieve refractory (difficult to treat) migraine headaches. Results of a clinical trial of ONS for patients with refractory migraine was just published in the journal Cephalalgia. This study was sponsored by St. Jude Medical, company that manufactures occipital nerve stimulators. This was a large (157 patients) and very scientific (randomized, controlled) study.?Patients were considered refractory if they failed two prophylactic migraine medications, such as blood pressure medications, anti-epilepsy drugs, or anti-depressants. Of the 157 patients, 105 patients had real stimulation and 52 had sham stimulation. The primary endpoint was a difference in the percentage of responders (defined as patients that achieved a ?50% reduction in pain scores after 12 weeks). The researchers found no significant difference in the percentage of responders in the Active compared with the Control group. The authors of the report suggest that had they used different measures of efficacy, the results would have been positive and they are calling for more studies. The most common adverse event was persistent implant site pain, which occurred in 15% of patients. The editorial by Hans-Christoph Diener, one of the leading headache experts suggested that the efficacy of this treatment appears to be very low, while side effects and costs are quite significant. The cost of the stimulator and of the surgery to implant it ranges from $20,000 to $40,000. Another problem with the study is that it did not require that patients fail Botox injections before they were enrolled in this trial. Botox is known to be effective for the treatment of migraine headaches in many patients who fail prophylactic medications. Botox is not only very effective, but is also significantly cheaper and much safer.
Steroid injections are routinely used at our Center for the treatment of cluster headaches and occipital neuralgia. I just received a call from a concerned patient with cluster headaches who recently received an occipital nerve block with methylprednisolone acetate (Depo-Medrol), the same drug that caused fungal meningitis in almost 200 patients, of whom 14 died. His cluster headaches stopped after the injection and he had no symptoms of meningitis, but understandably he was still concerned. All of the patients who contracted meningitis were given epidural injections which are given for low back or neck pain with medicine deposited near the meninges or soft covering that envelopes the spinal cord. All of them received a tainted product manufactured by a compounding pharmacy, which was not licensed to mass produce such medications. Their product was significantly cheaper than the same medicine produced by the largest pharmaceutical company in the world, Pfizer. We have never used any other products except for the one made by Pfizer. I an addition to methylprednisolone (Depo-Medrol) some doctors use a different steroid, triamcinolone, which is manufactured by Brystol Myers Squibb under the name Kenalog. Whenever you receive a steroid injection for back pain, joint inflammation, cluster headaches, or any other indication, ask the doctor if the steroid you are going to receive was manufactured by a major pharmaceutical company. In case of epidural steroid injections, you should also question if these injections are really necessary because they have never been proven to be effective in the first place and even pure untainted products have been associated with spinal cord damage and other serious side effects.
Epidural steroid injection:
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