Headache NewsBlog

Migraine, strokes, and oral contraceptives

By: Dr. Mauskop

22-05-2023

Brain disorders, Headaches, Migraine, Migraine in pregnancy

Researchers at the Cleveland Clinic investigated the risk of stroke associated with different estrogen doses in oral contraceptives (OCP) for individuals with migraines. The results of their study were recently published in the journal of the American Headache Society, Headache.

The overall stroke risk among OCP users in this study was low. Out of the 203,853 women aged 18-55 who used OCPs, 127 were confirmed to have had a stroke. The case group had a higher proportion of individuals diagnosed with migraines (34/127, 26.8%) compared to a control group of 635 women (109/635, 17.2%; p = 0.011). The risk of stroke was higher among those using OCPs with 30 mcg or more of estrogen compared to those using OCPs with less than 30 mcg. Having a personal history of migraines increased the likelihood of stroke compared to those without migraines. There was no significant increase in stroke risk among those with migraine with aura, but migraine without aura did increase the risk.

Interestingly, previous studies have suggested the opposite—that migraine with aura carries a higher stroke risk compared to migraine without aura. The researchers speculate that this discrepancy could be because patients with migraine with aura are rarely prescribed OCPs, and the number of such patients in this study was small.

Traditionally, young and healthy women diagnosed with migraine with aura have been advised against using estrogen contraceptives due to concerns about increased stroke risk compared to those without aura. However, the risk of unintended pregnancies should be weighed against the risk of a stroke. The authors emphasize the need for proper patient education and shared decision-making when it comes to starting contraceptives in women with a history of migraines, including those without aura. OCP formulations with less than 30 mcg of estrogen are preferred to minimize the risk of stroke.

Avoid screen time after a concussion

By: Dr. Mauskop

15-05-2023

Brain disorders, Head trauma, Headaches, Headaches in children, Migraine

A new study published in JAMA Pediatrics found that engaging in screen time within the first 48 hours after concussion may prolong recovery time. The study was conducted by researchers at UCSF. They looked at data from 125 patients aged 12 to 25 who had recently been diagnosed with a concussion. The participants were divided into two groups: one group was allowed to use screens, and the other group was asked to abstain from screen time.

The study found that the group permitted to use screens had a significantly longer median recovery time of 8.0 days compared to 3.5 days in the group that abstained from screens. Additionally, individuals who used screens reported experiencing more symptoms such as headaches, dizziness, and fatigue. The screen time permitted group reported a median screen time of 630 minutes during the intervention period, while the screen time abstinent group reported 130 minutes.

The study’s authors concluded that avoiding screen time in the first 48 hours after concussion may help to shorten the duration of symptoms. However, this was a relatively small study and more research is needed to confirm these findings.

In a recent post, I mentioned a large Canadian study that showed that early return to school after a concussion was associated with better outcomes. These two reports are not contradictory. Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations. Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental.

Magnesium makes your brain bigger, according to a 6,000 person study.

By: Dr. Mauskop

08-05-2023

Alternative Therapies, Brain disorders, Migraine, New treatments

Our research at the New York Headache Center and that of many of our colleagues, as well as the clinical experience of doctors and thousands of patients, have proven the role of magnesium in treating migraine headaches. I’ve written many blog posts on the role of magnesium in a wide variety of other medical conditions.

A new report in the European Journal of Nutrition suggests that dietary intake of magnesium is related to the size of the brain.

This study looked at how the amount of magnesium in people’s diets is related to the size of their brains and the presence of white matter lesions (which are abnormalities in the brain seen on the MRI scan) as they get older. The researchers used data from 6,000 middle-aged to older adults in the UK. They measured magnesium intake through a questionnaire and used statistical models to analyze the data.

The results showed that people who had higher magnesium intake generally had larger brain volumes, including the gray matter and specific areas called the left and right hippocampus. When they looked at different patterns of magnesium intake over time, they found three groups: one with high magnesium intake that decreased over time, one with low magnesium intake that increased, and one with stable and normal magnesium intake. In women, those in the high-decreasing group had larger brain volumes compared to the normal-stable group. On the other hand, women in the low-increasing group had smaller brain volumes and more white matter lesions.

The researchers also looked at the relationship between magnesium intake and blood pressure, but the results were not significant. Additionally, they found that the positive effect of higher magnesium intake on brain health was more pronounced in women who had gone through menopause.

In conclusion, having a higher intake of magnesium in the diet is associated with larger brain volumes.

Omega-3 fatty acids have also been shown to have a positive effect on brain volu me in older adults.

Vitamin B12 is another nutrient that is probably involved in preserving brain volume.

Multiple studies have shown that meditation is associated with larger brain volumes.

Exercise is also a proven way to prevent cognitive decline.

All these interventions have no side effects and I would recommend them to everyone regardles of age.

Antidepressant use during pregnancy

By: Dr. Mauskop

30-04-2023

Brain disorders, Chronic migraine, Headache medications, Headaches, Headaches in children, Migraine, Pain, Psychology of headaches

Antidepressants are commonly prescribed to treat migraines, tension-type headaches, and various types of chronic pain. Migraines primarily affect women of reproductive age, and those who suffer from migraines are more likely to develop anxiety and depression compared to those without migraines. This may be another reason why someone with migraines might be prescribed an antidepressant. Women who are pregnant or planning to become pregnant are understandably cautious about taking any medication.

Antidepressant use during pregnancy does not increase the risk of neurodevelopmental disorders in children, according to a new study published in JAMA Internal Medicine.

Antidepressant use during pregnancy has been associated with neurodevelopmental disorders in children in some studies. However, other factors such as the parent’s mental health status, genetics, and environmental factors may have influenced these results. The objective of this study was to evaluate the association between antidepressant use in pregnancy and neurodevelopmental outcomes in children.

The study looked at data from over 3 million pregnancies, tracking children from birth until outcome diagnosis, disenrollment, death, or the end of the study (maximum 14 years). There were 145,702 antidepressant-exposed pregnancies.

The study found no evidence to suggest that antidepressant use in pregnancy itself increases the risk of neurodevelopmental disorders such as autism spectrum disorder, attention-deficit/hyperactivity disorder, specific learning disorders, developmental speech/language disorders, developmental coordination disorders, intellectual disabilities, or behavioral disorders.

However, given the strong crude associations found in previous studies, antidepressant exposure during pregnancy may be an important marker for the need for early screening and intervention to modify factors that do increase such risk.

How to reduce pain recollection

By: Dr. Mauskop

24-04-2023

Brain disorders, Headaches, Migraine, Pain, Pain Research, Psychology of headaches

A recent study published in the journal Pain showed that adding a non-painful stimulus at the end of a Pap smear can reduce pain recollection. The study, titled “Adding a Nonpainful End to Reduce Pain Recollection of Pap Smear Screening: A Randomized Controlled Trial,” was conducted by Taiwanese researchers and involved 266 women.

The study involved an intervention group that received a modified Pap test, where the operator kept the speculum still in the vagina for an additional 15 seconds after rotating it back, instead of immediately removing it. Participants in the modified Pap test group were unaware of this additional step, as they were behind a privacy curtain.

The outcomes of the study included recalled pain after Pap smear screening, real-time pain, and 1-year willingness to receive further Pap tests. Among 266 subjects, the modified Pap group experienced lower 5-minute recalled pain than the traditional Pap group on a 1 to 5 numeric scale and on a 0 to 10 visual analog scale. Subgroup analyses showed that these results were not affected by predicted pain, demographic, or socioeconomic characteristics, but it was more apparent in postmenopausal women. Additionally, the modified Pap test attenuated 1-year recalled pain on both pain scales and increased the 1-year willingness grade to receive further Pap tests.

This technique could potentially be applied to many other painful procedures, including Botox injections, blood draws, vaccine injections, dental procedures, and more.

Using AI to predict who will respond to placebo

By: Dr. Mauskop

16-04-2023

Headache medications, Headaches, Pain, Pain Research, Psychology of headaches

Placebo response is a bane of clinical trials but it can be very helpful in practice. A team of American and Canadian researchers used AI to help identify predictors of the placebo response. The results were recently published in Pain, under the title, Predicting placebo analgesia in patients with chronic pain using natural language processing: a preliminary validation study.

Since they used AI for their study, I thought it would be fitting to use ChatGPT to edit their abstract for the lay public.

Patients with chronic pain often experience significant pain relief from placebos (inert pills), and this effect can last for days or even weeks. However, it’s still unclear whether we can reliably predict who will respond to placebo and how to do so. Previous research has shown that people who respond well to placebos tend to talk about their pain and their life in a certain way. In this study, the researchers looked at whether these language patterns can predict who will respond to a placebo before they even receive the treatment, and whether we can distinguish between people who will respond to a placebo versus a real drug.

To do this, they analyzed language patterns from patients with chronic back pain who received a placebo in one study and used this information to build a language model that could predict who would respond to a placebo in a separate study. They found that this language model was able to predict, before treatment, which patients would respond well to a placebo in the second study. These patients reported an average of 30% pain relief from the placebo, while those predicted to be non-responders only experienced a 3% reduction in pain. However, the model was not able to predict who would respond to a real pain medication or who would recover without treatment, suggesting that it specifically predicts response to placebos.

Overall, this study suggests that we may be able to use language patterns to predict who will respond to placebos, which could help researchers design better clinical trials and improve patient care.

Functional brain networks in migraine and meditation

By: Dr. Mauskop

09-04-2023

Uncategorized

I’ve previously written about the benefits of meditation and how it has helped alleviate my migraines. I recommend it to all of my patients.

A recent study published in the Journal of Headache and Pain by Chinese researchers examined changes in resting-state functional networks in the brain and their correlation with clinical traits in migraine patients.

The study used EEG and fMRI to compare 24 migraine patients with 26 healthy controls. The subjects were evaluated for migraine-related disability using the MIDAS score, cognitive functioning, anxiety, and depression.

The researchers found that the decrease of functional connectivity within the default mode network (DMN) and between DMN and executive control network (ECN) in migraine patients was negatively correlated with MIDAS score.

They also found differences in various other functional networks, but the difference in DMN connectivity caught my attention because of its association with meditation. Studies using fMRI have shown that engaging in meditation leads to a decrease in DMN activity and an increase in the activation of brain regions responsible for cognitive and emotional regulation.

Altered connectivity in the DMN has been associated with a range of neuropsychiatric conditions such as depression, anxiety, post-traumatic stress disorder, attention deficit hyperactive disorder, and obsessive-compulsive disorder. Psychedelics are also thought to produce their effect, at least in part, by acting on the DMN.

How long to rest after a concussion

By: Dr. Mauskop

03-04-2023

Botox, Brain disorders, Chronic migraine, Head trauma, Headaches, Migraine

The traditional approach for managing concussions has been to recommend rest until post-concussion symptoms resolve. While many neurologists still advocate for this approach, several studies have suggested that an early return to activity after a concussion may lead to better outcomes.

Most pediatric guidelines recommend 24 to 48 hours of physical and cognitive rest, followed by a gradual return to school with support and accommodations.

The latest pediatric study was done in Canada. It examined data for 1630 children aged 5 to 18 with a mean age of 12 and of whom 38% were girls. The primary outcome was symptom burden at 14 days, measured with the Post-Concussion Symptom Inventory. Missing fewer than 3 days after concussion was defined as an early return to school.

An early return to school was associated with a lower symptom burden 14 days postinjury in the 8 to 12-year and 13 to 18-year age groups, but not in the 5 to 7-year age group.

Prolonged periods of complete physical and cognitive rest lasting one to two weeks can be detrimental, as it can be challenging for many people to remain inactive for such an extended period. This approach, which involves refraining from activities such as reading, writing, screen time, and exercise, can lead to depression, increased anxiety, and may even delay recovery.

After a brief period of rest lasting 24 to 48 hours, I typically recommend a gradual return to full activities. The key is to monitor for any exacerbation of post-concussion symptoms such as headaches, dizziness, brain fog, or fatigue. If an activity does not worsen symptoms, patients can continue to increase the level of physical and cognitive activities at a steady pace.

The top 10 non-drug therapies for migraines

By: Dr. Mauskop

27-03-2023

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

Most people are right in not wanting to take medications. They can have serious or just very bothersome side effects, they help only some people and can be expensive. Fortunately, there are many ways to control migraines without drugs. Here are the top 10 non-drug therapies for migraine headaches among several dozen described in my book, The End of Migraines: 150 Ways to Stop Your Pain.

Non-drug therapies

Aerobic exercise
Meditation
Magnesium
CoQ10
Cognitive-behavioral therapy
Acupuncture
Nerivio
Cefaly
Riboflavin
Boswellia

The Top 10 Prophylactic Treatments for Migraines

By: Dr. Mauskop

20-03-2023

Botox, Chronic migraine, Headache medications, Migraine

In a recent post, I listed the top 10 acute treatments for migraine attacks that are mentioned in my book, The End of Migraines: 150 Ways to Stop Your Pain. Here is a list of the top 10 preventive drug therapies for migraines. In the next post, I will list the top 10 non-drug therapies.

The order of choices can vary depending on co-morbidities, potential side effects, cost, and other factors. For example, patients with coexistent anxiety and/or depression would have duloxetine and nortriptyline move higher on this list. Patients with rapid heartbeat, anxiety, or PTSD could start with nebivolol. Those with high blood pressure, could start with candesartan or nebivolol, and so on.

OnabotulinumtoxinA (Botox)
Atogepant (Qulipta)
Rimegepant (Nurtec)
Galcanezumab (Emgality)
Nebivolol (Bystolic)
Propranolol (Inderal)
Candesartan (Atacand)
Duloxetine (Cymbalta)
Nortriptyline (Pamelor)
Fremanezumab (Ajovy)

Thank you for making The End of Migraines #1 Bestseller in Nervous System Diseases

By: Dr. Mauskop

14-03-2023

Alternative Therapies, Blocks, Botox, Brain disorders, Chronic migraine, Headache medications, Headaches, Migraine, Migraine in pregnancy, Psychology of headaches, Science of Migraine

A new migraine drug and my top 10 acute treatments for migraines

By: Dr. Mauskop

13-03-2023

Chronic migraine, Headache medications, Headaches, Migraine

Zavegepant nasal spray (Zavzpret) was just approved by the FDA for the acute treatment of migraines. It belongs to the family of gepants. These drugs abort migraine attacks by blocking the CGRP receptor. CGRP (calcitonin gene-related peptide) is released during a migraine attack. Blocking this molecule or the receptor it attaches to relieves migraines in about 50% of people.

There are four CGRP monoclonal antibodies, or mAbs, that are injected once every one or three months to prevent migraine attacks. Gepants are taken by mouth. Two of them – ubrogepant (Ubrelvy) and rimegepant (Nurtec) – are approved for the acute treatment of migraine attacks. Rimegepant, along with atogepant (Qulipta), is also approved for the prevention of migraines.

Nasal sprays to treat migraines have the advantage of faster onset of action. They are particularly useful for people who have nausea or vomiting and have difficulty absorbing or holding down oral medications. Other migraine drugs in a nasal spray include sumatriptan, zolmitriptan, dihydroergotamine, and ketorolac. For patients for whom these older drugs are ineffective, cause side effects, or are contraindicated, zavegepant could be a very good option.

If there are no contraindications for the use of a triptan (e.g. heart or other vascular diseases), I would use sumatriptan first because of the cost. It is also likely that insurance companies will require that the patient fails sumatriptan before they agree to pay for a new and more expensive drug. This is what they usually require before paying for oral gepants.

Here is a list of what I consider to be the top 10 acute medications to treat migraine from the second edition of my book, The End of Migraines: 150 Ways to Stop Your Pain. I might add zavegepant to the next edition of this book.