Vertigo is a common symptom in patients suffering from migraine headaches. Vestibular migraine is a new category of migraine proposed by German researchers led by Dr. Andrea Radtke. In the current issue of Neurology Dr. Radtke and her colleagues report on the long-term outcomes of 61 patients with this condition. The average follow-up period was 9 years. Unfortunately, 87% of sufferers still had vertigo and in 56% it improved, 29% it worsened and in 16% it remained unchanged. In 21% the impact of vertigo on their lives was severe, in 43% moderate and in 36% mild. Mild hearing loss occurred in 11 or 18% of patients.This report does not mention what kind of treatments were attempted in these patients. It is possible that aggressive therapy with vestibular rehabilitation, possibly acupuncture, magnesium, other supplements and medication can make a difference.
Read MoreProdrome refers to symptoms that precede an actual attack of migraine. Migraine aura also precedes an attack, but it occurs 20 to 60 minutes before the headache and typically consists of visual disturbances or partial visual loss. Prodrome typically is a period of 24 to 48 hours before a migraine attack and it can consist of a wide variety of symptoms. Many people are aware that these symptoms indicate an impending migraine attack, but some are not. Some people tell me that when they feel unusually full of energy, very happy, and creative they realize that they will get a headache the next day. And some realize that what was happening to them was a prodrome only in retrospect, even after having all of the same symptoms repeat themselves many times. Not many people experience prodrome and its features are varied. Here are some of the symptoms reported in the prodrome period:
Depression
Euphoria
Irritability
Restlessness
Hyperactivity
Fatigue
Drowsiness
Difficulty concentrating
Neck or other muscle stiffness
Feeling hot or cold
Increased thirst
Increased urination
Food cravings
Loss of appetite
Yawning
Tearing
Constipation
Diarrhea
Fluid retention
Sensitivity to light and/or sound
If you do experience a prodrome and are aware of it while it is happening, taking an anti-inflammatory medication (Advil, Aleve, Migralex) or, if that does not work, a triptan may prevent an attack or at least make it milder.
Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. 
The aura can sometimes occur without a headache and some people, myself included, always have migraines and auras independently of each other. A typical aura usually lasts 20-30 minutes and consists of partial loss of vision on one side of both eyes, or flashing lights, colored zigzags, or tunnel vision. 
Most headache specialists and neurologists have always believed that most people have an aura first and when it resolves, the headache begins. A study by Dr. Jakob Hansen suggests that this may not be the case. He examined diaries of 201 adults who experienced 861 migraine attacks and discovered that in 61% of attacks the headache was present within 15 minutes of the onset of aura. Nausea was present in 40%, sensitivity to light (photophobia) in 84% and to noise (phonophobia) in 67% within 15 minutes of the onset of visual aura. I have heard from some of my patients similar reports of a headache and aura starting at the same time, but it seemed that those were a small minority. I will have to be more thorough in questioning my patients. One practical application of this finding is that we usually tell patients who use injectable sumatriptan (Imitrex) to treat their migraine attacks to wait for the aura to resolve and then take the injection. The reason for this delay is a perception that the injection will not help if taken during the aura phase. It is speculated that if the medicine gets into the brain circulation before pain starts it may not be able to attach itself to certain receptors. We do recommend taking a tablet as soon as the aura starts because it takes at least 30 minutes for a tablet to be absorbed. If Dr. Hansen’s results are confirmed, then most people should not wait to give themselves an injection of sumatriptan.
Since we are on the subject of injections, I should point out that they are extremely underutilized. Doctors usually prescribe them if the patient has severe nausea or vomiting and cannot hold down the pill. However, an injection may also be very useful for someone who wakes up with a headache without severe nausea, but they know that the tablet may take 2 hours or longer to provide relief. Taking an injection, which can stop the headache within 10 – 15 minutes, can make a difference between being able to go to work or not. I sometimes take an injection even when I have a mild migraine if it happens at night. The tablet will usually work, but I may have to wait for two hours before I can fall asleep, so I take a shot. From left to right 3 types of sumatriptan injectors: Alsuma, Sumavel, Imitrex injections. 
Infant colic appears to be more common in babies whose mothers suffers from migraines, according to a just published study by researchers at UCSF. This study looked at 154 infant-mother pairs and discovered that the risk of colic increases 2.6 times if mother suffers from migraines. Dr. Amy Gelfand, the pediatric neurologist who was the lead author concluded that infant colic could be the earliest manifestation of migraine headaches. We also know that some people who suffer from migraines report being told by their parents that as infants they had brief attacks of vomiting associated with paleness which seemingly were not related to food intake. This study confirms the old suspicion that migraines can begin from infancy. While we have many effective therapies, the true cure of migraines will come from genetic therapies, which unfortunately are decades away.
Read MoreRizatriptan (Maxalt) is the only migraine drug approved by the FDA for children as young as 6. Almotriptan (Axert), another drug in the same family of triptans, is approved for children from age 12 and up. Rizatriptan also has an advantage over almotriptan in that it is available in a “melt” formulation (Maxalt MLT), which is a wafer that melts in the mouth. This is especially important for younger children who may have difficulty swallowing solid tablets, but is also useful for migraine sufferers of any age who have severe nausea that makes swallowing tablets difficult. The study that led to the FDA approval of rizatriptan included over 900 children. Obviously, it was a positive study, however, it showed what many previous studies have also shown – children respond to placebo at a much higher rate than adults. That is after two hours many children will have good relief from taking a sugar pill. This is partly due to the fact that pediatric migraines tend to be much shorter in duration, often only one or two hours. So, regardless of what a child takes, the headache will be gone in two hours. Nasal sprays work a little faster, so they may be a little more effective in children and sumatriptan nasal spray (Imirex NS) is approved for children in Europe. Nasal spray also avoids the need to swallow tablets. Another triptan in a nasal spray form is zolmitriptan (Zomig NS) and anecdotally it is more consistently effective than sumatriptan. Zolmitriptan also doesn’t have a very unpleasant taste of sumatriptan and the amount of fluid that is being sprayed into the nose is much smaller. There have been many studies of various triptans in children and they all showed that these drugs are safe in pediatric population. Cost can be an issue since branded triptans are very expensive. Fortunately, sumatriptan (Imitrex) is now available in a generic form and by the end of 2012 rizatriptan (Maxalt, Maxalt MLT) will also lose it patent protection and become available as a generic.
Despite their safety and efficacy, triptans should not be always the first choice for pediatric migraines. Some children may respond well to ibuprofen (Advil) or acetaminophen Tylenol. Younger children should be given these drugs in a liquid form for ease of swallowing and for faster onset of action. And prophylactic measures should also be never forgotten – regular meals and sleep schedule, avoidance of sugar, exercise, biofeedback, magnesium and CoQ10 supplements, and other.
Marijuana seems to help some patients with migraine and cluster headaches. However a new study suggests that it has more negative effects than previously thought. We know that smoking pot causes lung problems and risks serious damage to various organs due to possible impurities. A recent report in the Proceedings of the National Academy of Sciences shows that regular cannabis use is harmful to health. Adolescents are beginning to use marijuana at younger ages, and more adolescents are using it on a daily basis. This study showed that persistent use of marijuana leads to neuropsychological decline. Researchers from Duke University, England and New Zealand examined records of 1,037 individuals who were followed from birth to age 38. Marijuana use was determined in interviews at ages 18, 21, 26, 32, and 38. Neuropsychological testing was conducted at age 13, before initiation of marijuana use, and again at age 38. Persistent use was associated with neuropsychological decline, including IQ, even after taking into account years of education. Persistent marijuana users reported noticing more cognitive problems. Impairment was strongest among those who started using marijuana in adolescence and the more persistent was the use the greater was the cognitive decline. Stopping marijuana use did not fully restore neuropsychological functioning and IQ among those who started its use in adolescence. This study suggests that cannabis has a toxic an persistent effect on the adolescent brain.
Read MoreCognitive-behavioral therapy (CBT) has been convincingly proven to help pain and headache sufferers. Many people are very skeptical about the value of psychological treatments and tell me, just get rid of my migraines and I will be fine. Unfortunately, sometimes it takes time to relieve chronic headaches and pain. So, while we are trying to find relief, it helps to learn how to function better despite pain, how not to panic and become completely paralyzed by headaches, how to inform and interact better with family, friends, and employers. Research indicates, that people who take charge of their care, get involved in working with the doctor to find relief, learn relaxation techniques, rather than just sit back and wait for doctors to “fix” the problem, do much better. CBT, which usually involves relaxation training, is one way to improve your care and it usually involves 8 to 12 structured sessions. Here is an example of what might take place during these sessions:
1. Three-component CBT model (thoughts, feelings, behaviors), pain monitoring
2. Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery)
3. Migraine trigger avoidance
4. Pain-fatigue cycle, activity pacing, and pleasant event scheduling
5. Identifying and challenging negative thoughts (Activity, Belief, Consequences, Dispute model)
6. Problem-solving skills training and assertive communication
7. Review and practice
8. Review and practice
9. Relapse prevention
Another form of CBT is Acceptance Commitment Therapy (ACT) and this is what a typical schedule of sessions of ACT looks like:
1. The limits of control (short and long-term costs and benefits; finger
traps), focus on experience (body scan)
2. Values (what you care about, how you want to live your
life)
3. Cognitive defusion (observing thoughts without trying to evaluate or
change them)
4. Mindfulness (being in the moment, raisin exercise)
5. Committed action (“road map” connecting values, goals, actions,
obstacles, and strategies)
6. Review and continued action in support of values
7. Review and continued action in support of values
8. Moving forward
CBT usually is conducted by a a social worker or a psychologist and sometimes this treatment is covered by insurance. Group sessions have also been shown to be effective. However, sometimes insurance does nor cover this service or a therapist is not available. Online, web-based CBT seems to work too. Two Australian web sites offer free CBT for anxiety, depression and other problems, although they are not specifically tailored for people with headaches or pain. ThisWayUp.org.au and moodGYM.anu.edu.au are both excellent free resources for people who are looking for help, but cannot find or afford a therapist. The psychologists who developed and run these sites published results of their treatments in scientific journals, showing that self-taught CBT can be very effective. Here is a schedule of lessons for anxiety and depression on ThisWayUp website:
Lesson 1
About anxiety and depression
Learn about your own symptoms of anxiety and/or depression, and learn to tackle the physical symptoms of anxiety/depression.
Lesson 2
Identifying thoughts and tackling low activity
Learn to identify the thought symptoms of anxiety/depression, and learn to tackle the behaviours associated with anxiety/depression.
Lesson 3
Tackling thoughts
Learn to tackle the thought symptoms of anxiety/depression.
Lesson 4
Tackling avoidance
Learn to tackle avoidance behaviours associated with anxiety/depression by facing your fears.
Lesson 5
Mastering your skills
Learn to master your ability to face your fears using graded exposure, and learn to cope with the distressing emotions associated with anxiety/depression.
Lesson 6
Staying well
Learn how to avoid relapses and how to keep getting better!
Spinal tap, or lumbar puncture headache occurs in one out of four people undergoing this procedure. Spinal tap is usually done to examine spinal fluid for infections, bleeding, multiple sclerosis, and other conditions. A small percentage of people undergoing epidural anesthesia, which involves placement of the same kind of needle into the same space between vertebrae, also develop a spinal tap headache. This happens because the needle is accidentally placed too far and it causes a leak of spinal fluid. Spinal tap headache is very easy to diagnose – it stops as soon as the person lies down and begins within minutes of sitting up. Normally, the brain floats in cerebrospinal fluid, but if this fluid is drained away by a spinal tap, the brain sags, pulls on the brain coverings, called meninges, and causes a severe headache. The majority of people do not develop this headache after a spinal tap because as soon as the needle is withdrawn, the hole in the dural sac that covers the spinal cord and the brain closes. In some people, especially if it takes a few sticks to get the fluid flowing and with a larger needle, the hole may not close right away and the fluid keeps leaking inside the spine. In most people the headache stops on its own within a day or two. If it doesn’t, the problem can be fixed by a “blood patch” procedure. It involves taking the patient’s own blood from the vein and injecting it into the same space between vertebrae where the spinal tap was done. Patient’s blood clots and seals the persistent leak of the cerebrospinal fluid, which stops the headache, often within minutes.
A similar headache can rarely occur without a spinal tap or even a trauma to the spine. It is called spontaneous low cerebrospinal fluid headache and it is also very positional, meaning that it gets better when the person is lying down. This headache is more difficult to diagnose, but an MRI scan of the brain sometimes shows inflamed meninges around the brain, which suggests this diagnosis. Finding a leak is more difficult and requires looking at the flow of the spinal fluid and searching for a leak. When a single leak is found, a blood patch procedure can help, but with multiple leaks the treatment becomes more complicated. A single case of using Botox to helps this type of headaches was described here last year.
Autoimmune dysfunction can cause pain according to a study just published in Neurology by a group of Mayo Clinic researchers. Dr. CJ Klein and his colleagues examined 316 patients who had antibodies to a structure involved in various nerve functions (voltage-gated potassium channel, or VGKC) and discovered that 159 of them had pain as the initial symptoms and 45 of those had pain as the only symptom of this autoimmune reaction. In 19 of these patients pain was localized to face and head, suggesting that some of the headache patients may also suffer from this condition.
The antibodies to VGKC are known to cause excessive excitability of the nervous system. Some of the patients in the study were previously thought to have fibromyalgia (a condition known to be associated with excessive excitation of the nervous system) or psychogenic (not real) pain. This is an exciting discovery since treatment with immune therapies (such as drugs and intravenous immune globulin, or IVIG) relieved chronic pain in 81% of the Mayo Clinic patients. Epilepsy drugs can also help some of these patients.
The difficulty at this point is in identifying patients who should be tested for VGKC antibodies. Probably, we should test patients with chronic persistent pain that does not easily respond to standard treatments. Another difficulty is that the immunosuppressive drugs can have serious side effects, while IVIG is very expensive and can also cause side effects. So these therapies should be reserved for patients in whom pain causes significant disability and in whom potential benefits outweigh the potential risks.
There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and other topical products can provide relief of milder headaches. There are no scientific studies proving that these treatments work beyond the placebo effect, although we do have some evidence established by Hartmut Gobel and his colleagues in Germany suggesting that the smell of peppermint can provide some pain relief. So it is possible, that the smell of herbs in Tiger Balm and possibly the cooling effect of these ointments combined with placebo effect is what accounts for the popularity of these products.
I have been using a prescription ointment for some of my patients with headaches and neck pain. This ointment has to be prepared by a compounding pharmacy and typically is not available from big chains, such as CVS or Walmart, although Walgreens does offer compounding services at some of its pharmacies. We do not have any information about the best combination of ingredients to use for the relief of headaches and pain. However, some studies indicate that topical skin application of some products does provide relief. Ketamine, which blocks the so called NMDA pain receptor can relieve pain of complex regional pain syndrome, a very serious and painful condition. Application of clonidine, a blood pressure medication has been shown to relieve pain of diabetic neuropathy – painful nerve damage due to diabetes. We also know that lidocaine is very effective when applied to the skin and it is the active ingredient in a prescription pain patch, Lidoderm. Anti-inflammatory drugs, such as aspirin or similar salicilate drugs (Aspercreme), diclofenac (Flector patch), piroxicam and other also help pain when applied to the skin. There are no studies of topical application of muscle relaxants, such as baclofen and tizanidine or an epilepsy drug gabapentin, but these drugs are often also included in compounded creams.
My usual prescription is to combine ketamine with lidocaine, piroxicam and baclofen. Unfortunately, we do not know what is the most effective combination and it would be very difficult to compare so many available ingredients in a scientific study. However, these creams are safer than oral drugs and for some patients can be as effective. Another drawback of the compounded products is that insurance often will not pay for it.
Children with epilepsy are more likely to suffer from migraine headaches than children without epilepsy, according to a study just published in Neurology by researchers from Johns Hopkins University. Dr. Sarah Kelley and her colleagues studied 400 children who were seen at an epilepsy clinic. They discovered that 25% of children with epilepsy also suffered from migraine headaches. Children aged 10 and older, as well as those with JME (juvenile myoclonic epilepsy) and BECTS (benign epilepsy with centrotemporal spikes) were more likely to have migraines than younger children or those with other types of epilepsy.
Unfortunately, pediatric neurologists who were seeing children who had both epilepsy and migraines (with migraines occurring once a week or more) did not discuss their migraines in half of such cases. Primary care doctors treating adults have also been shown to ignore complaints of migraine headaches in many patients, but in this study doctors were pediatric neurologists and they should know better. The education of all doctors, including adult and pediatric neurologists in the treatment of headaches leaves a lot to be desired. Many prominent neurology programs, including those at Cornell, Yale, NYU, and other medical schools lack a dedicated headache specialist. This is probably due to a combination of factors, including low prominence of headaches as compared to conditions such as epilepsy, Alzheimer’s, strokes, and MS, as well as lack of funding for research and lack of faculty trained in headache medicine.
Parents of children with migraines also sometimes minimize the seriousness of migraine as compared to epilepsy, however migraine is often more disabling than epilepsy, even if it is less dramatic in its manifestations. Migraine is highly treatable condition and children often do very well with biofeedback, magnesium, CoQ10 and other supplements and in case of very frequent attacks, Botox injections. If these, safer treatments fail, medications can be very effective. We use both abortive medications, such as sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert) and other triptan drugs, as well as prophylactic medications, such as beta blockers (blood pressure medications), some epilepsy drugs, and antidepressants (although some antidepressants can make seizures worse). If the pediatric neurologist is aware that the child also has migraine headaches she may decide to use an epilepsy drug that can help both conditions. Migraines improved in about 28% of children in this study when they were prescribed an epilepsy drug, but this number potentially might have been higher if doctors were aware of the migraine diagnosis. None of the children with weekly or more frequent migraines were prescribed a triptan drug.
Omega-3 fatty acids (most abundantly found in fish oil) may relieve migraine headaches but only one small study found this to be the case. However, there is mounting evidence for beneficial effects of omega-3 fatty acids for various conditions, such as strokes, heart disease, dementia, and other. A just published study in the journal BMC Cancer shows that omega-3 fatty acids prevent nerve damage caused by a chemotherapy drug used to treat breast cancer. Paclitaxel (Taxol) caused peripheral neuropathy in 60% of women who received placebo and in only 30% of those who were given omega-3 fatty acids (640 mg three times a day). Using this safe and natural supplement may allow many more women receive this life-saving chemotherapy without causing crippling side effects. Considering all of the positive studies of fish oil for a variety of neurological and other conditions and, considering its safety and low cost, it is reasonable to try this supplement for the prevention of migraine headaches despite the lack of definitive studies.
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