Slow breathing can reduce pain, according to a recently published study in The Journal of Pain. Researchers at the University of Tulsa led by Satin Martin evaluated the effect on pain of slow breathing, normal and fast breathing in 30 healthy volunteers. Pain was induced by an electric shock to the leg. Slow breathing (50% of normal rate) significantly reduced pain perception when compared to normal or fast (at 125% of normal rate) breathing. Slow breathing has been long utilized for the reduction of pain and is usually included in biofeedback, meditation, and other relaxation methods. This study provides solid scientific support for this simple and ancient technique, which should be utilized more widely in the management of pain, including migraine and other headaches.
Read MoreExtraordinary benefits of meditation are described in the current issue of Neurology Now – The American Academy of Neurology’s Magazine for Patients & Caregivers”. Dr. Mauskop is extensively quoted in this article.
Read MoreMany patients ask about the best type of magnesium supplement to take for the prevention of migraines and other symptoms. Research studies have compared magnesium oxide with chelated magnesium and a slow release form of magnesium chloride and showed that all three types are absorbed equally well. I usually recommend starting with 400 mg of magnesium oxide but chelated magnesium is also very inexpensive and either one can be effective. However, if one type of magnesium causes upset stomach or diarrhea, another one should be tried. Chelated magnesium is a form of magnesium which is attached to an amino acid and depending on the amino acid it is called magnesium aspartate, glycinate, gluconate, orotate, malate, and other. Besides chelated and magnesium oxide, magnesium citrate or carbonate can be tried. When these magnesium salts are not tolerated or not absorbed, slow release forms should be considered, although they are much more expensive. There are two slow release forms, Mag Tab SR (containing magnesium lactate) and Slow Mag (magnesium chloride with calcium). Each tablet of these two products contains only a small amount of magnesium and the daily dose is at least 4 tables. Presence of calcium in Slow Mag may impair absorption of magnesium, making Mag Tab SR the preferred product. People who need to take calcium as well as magnesium should be taking these two separately because calcium interferes with the absorption of magnesium. The reason calcium and magnesium are often combined in one pill (Cal-Mag, Slow Mag, and other) is that magnesium helps improve the absorption of calcium, so it would not be too much to take Cal-Mag with one meal and magnesium alone with another. Patients with serious kidney problems should not be taking magnesium or any other supplements without consulting their nephrologist and having regular blood tests.
Read MoreBoswellia extract may relieve migraine, cluster and indomethacin-responsive headaches. Boswellia serrata (Indian frankincense) has been long reported to relieve migraines, although I could not find any scientific articles. A study recently published in journal Cephalalgia by Christian Lampl and his colleagues describes four patients with chronic cluster headaches whose headaches improved after taking Boswellia extract. The dose of Boswellia was 350 to 700 mg three times a day. All four patients failed at least three standard preventive medications for cluster headaches, such as verapamil (Calan), topiramate (Topamax), and lithium. It is very surprising that an herbal remedy helps what many consider to be the most painful type of headaches.
Dr. Eric Eross reported that Boswellia extract was also reported to help another very severe headache type – indomethacin responsive headache syndrome. Of the 27 patients with this type of headaches who were given Boswellia, 21 responded. The starting dose was 250 mg three times a day and then the dose was increased as needed, although it is not clear what the highest dose was. Indomethacin is a very strong non-steroidal anti-inflammatory medication, but it also tends to have strong gastro-intestinal side effects.
Finding a safe natural alternative is a very important discovery. Unlike butterbur, Boswellia has no toxic ingredients and is safe to consume in any form. The mechanism of action of Boswellia is not entirely clear, but it seems to have anti-inflammatory properties similar to aspirin. Obviously, it does more than that since aspirin is usually ineffective for cluster or indomethacin-responsive headaches.
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We no longer recommend butterbur to our patients. We participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in the leading neurological journal – Neurology and the American Academy of Neurology recently endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex and other brands), where it had to pass strict safety studies. However, Germany is no longer allowing butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur made in Germany and in the US is still sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany. This is why we no longer recommend butterbur for our patients.
Read MoreRestless leg syndrome (RLS) is more common in women who also suffer from migraines, according to a new study published in the journal Cephalalgia. Women with migraines are 20% more likely to also have RLS. This study involved 31,370 US health professionals making its findings highly reliable. In my previous post 5 years ago I mentioned that RLS, by disrupting normal sleep, may increase the frequency and severity of migraines, but at that time we did not know that these two conditions are connected. Possible causes of this association include the fact that disturbance of metabolism of iron and dopamine in the brain is thought to play a role in both conditions. People who have symptoms of RLS should be tested for iron and vitamin B12 deficiency which can cause similar symptoms. A sleep study is sometimes necessary to confirm the diagnosis of RLS. This study involves sleeping in a sleep lab with wires attached to the scalp, monitors measuring breathing and video camera recording movements of legs and body. Most major hospitals have a sleep lab and it is usually covered by insurance.
Fortunately, we have many effective drugs to treat RLS – Requip (ropinirole), Mirapex (pramipexole), Horizant (gabapentin), Neupro patch (rotigotine), as well as opioid drugs, such as Vicodin (hydrocodone), Percocet (oxycodone), and other. Horizant is a long-acting form of gabapentin, which is available in a short-acting form as a generic, much cheaper form. The advantage of gabapentin (also known as Neurontin and Gralise) is that it has also been shown to prevent chronic migraine, so this one drug can potentially treat RLS and migraine.
Until now, migraine headaches have not been associated with erectile dysfunction (ED). A study by Taiwanese doctors published in journal Cephalalgia makes a strong case that such a connection exists. The researchers analyzed electronic records of one million patients randomly selected out of almost 24 million who are covered by the Taiwan National Health Insurance. They eliminated from this analysis patients with mental illness and they also controlled for hypertension, diabetes, obesity and other condition known to cause ED. Men who suffer from migraines were 1.6 times more likely to have ED. Surprisingly, younger men with migraines, aged 30 to 39 had the highest risk of having erectile dysfunction – they were twice more likely to have ED than men of that age without migraines. The causes for this association are not clear. We do know that patients with chronic pain are more likely to have sexual dysfunction. We also know that migraine patients have impaired regulation of their brain blood vessels, so it is possible that penile blood vessels are also affected. Men are less likely to see doctors for all medical conditions compared to women and this includes migraines – I see about ten times as many women as men, while we know that women outnumber men only by 3 to 1 ratio. This may apply even more to such an embarrassing condition as sexual dysfunction, making these young men suffer unnecessarily from both migraines and ED. Encourage men with migraines to see a doctor, while in the office they may also get help for their sexual dysfunction, if they have it.
Read MoreBurning mouth syndrome (BMS) affects over a million Americans. It has no known cause or otherwise it would not be called a syndrome. For example, burning pain in the mouth due to chemotherapy damage to the mouth lining is called oral mucositis. This condition is not related to migraines, but just like with migraines, three times as many women suffer from BMS than men. Some people with BMS have a sensation of having sand in their mouth and itching, in addition to the burning pain. The pain can be very intense and can persist for many months. A recent study by Italian researchers published in the journal Headache examined 53 patients with with BMS and compared them to 51 healthy volunteers. They discovered that patients with BMS were much more likely to have anxiety and depression than the healthy controls. This is not surprising since patients with chronic headaches or pain of any kind are also more likely to be anxious and depressed. This does not mean that the pain is a manifestation of depression, as suggested by the authors.
A more interesting study of BMS in the same issue of Headache was published by Brazilian doctors. They treated 26 patients with mechanical stimulation of their mouth in order to increase the flow of saliva. This was achieved by having patients chew on a rubbery stick for ten minutes three times a day for 90 days. This resulted in a significant reduction of pain, even though the amount of saliva produced did not increase. In addition to improvement in pain, they also had fewer burning sites in the mouth and their taste improved as well.
Another approached that has been used to increase the flow of saliva reported in the medical literature is to stimulate salivary gland with a transcutaneous electrical nerve stimulation (TENS). The TENS electrodes are applied to the skin over the parotid salivary glands. There has been no reports of using TENS for the treatment of BMS, but considering that it is a safe and inexpensive treatment, it may be worth a try.
Many migraine sufferers complain of headaches on weekends, vacations, or after a period of stress. Researchers at the Montefiore Medical Center in the Bronx confirmed this observation by observing 17 migraine patients. The patients completed over 2,000 twice daily diary entries about their headaches and the amount of stress they had. The doctors found that patients had 20% higher chance of developing a migraine 12 to 24 hours after their mood changed from “sad” or “nervous” to “happy” or “relaxed”. There are several possible explanations for this phenomenon. One, is that some people have a certain amount of control over their headaches and do not allow themselves to have a headache when they know that they have to perform important functions, but as soon as this demand ends, they pay for the stress by getting a headache. Another possibility is that sleeping longer on weekends, vacations, or after the stress is over, triggers a migraine. Migraine sufferers can be very sensitive to changes in their sleep schedule with both too much and not enough sleep being a trigger. Weekend headaches can be also triggered by caffeine withdrawal – drinking your first cup of coffee at 10 instead of 8 in the morning.
Read MoreBehavioral therapies, such as biofeedback, progressive relaxation, cognitive therapy, and other alternative therapies are routinely recommended only by a quarter of headache specialists, according to research presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles by Robert Nichols of St. Louis. This despite the fact that these therapies are considered proven (so called, Grade A evidence) to relieve migraine and other headaches. Physicians are more likely to prescribe medications, even if they are less proven to work and carry a risk of serious side effects, which are absent with behavioral therapies. Cost of biofeedback and cognitive therapy can be one of the obstacle for some patients, but many techniques such as relaxation training or meditation are inexpensive and are easily learned without the help of a mental health professional. Other studies have shown that combining a behavioral technique with a preventive migraine medication results in better outcomes than with either therapy alone. So, if you take a medication it does not mean that you could not find additional relief from behavioral approaches, as well as aerobic exercise, magnesium, and other alternative therapies.
Read MoreMany patients visiting the New York Headache Center with persistent post-traumatic headaches report having had a relatively mild head injury. The perception by neurologists has always been that milder injuries without loss of consciousness are more likely to cause headaches that severe ones. A research study just presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles confirms this old observation. Dr. Sylvia Lucas and her colleagues at the University of Washington in Seattle evaluated 220 patients with a mild traumatic brain injury (TBI) and a group of 378 individuals with moderate or severe brain injury. Both groups were evaluated within a week of the head injury and then again, by phone, 3, 6 and 12 months later. Both groups had similar demographics (age, sex, etc) and similar causes of injury (motor vehicle accidents was the most common cause). In the mild TBI group headaches were present in 63% after 3 months, 69% after 6, and 58% after 12 months. In the moderate and severe TBI group these numbers were 37%, 33%, and 34%. In both groups about 17% also had headaches prior to the injury. As far as the kind of headaches these individuals experienced, migraine was the most common type in both groups. It remains unclear why a milder injury should cause so many more headaches than a severe one. Treatment of post-traumatic headaches includes the usual approaches to the treatment of migraines – aerobic exercise, biofeedback and relaxation training, magnesium, butterbur, CoQ10, and other supplements, abortive medications, such as Migralex and triptans, prevention with Botox and other medications.
Read MoreSinus inflammation can seriously worsen migraine attacks according to a recent presentation by Dr. V. Martin and his colleagues made at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles. Migraines are often mistaken for sinus headaches because pain of migraine is often felt in the area of sinuses and many migraine attacks are accompanied by a clear nasal discharge. These patients will naturally first see an ENT specialist and often undergo treatment with antibiotics and even surgery before the diagnosis of migraine is considered. However, sinus inflammation, both allergic and non-allergic in nature, can coexist and worsen migraines and increase disability caused by migraine according to these new findings. Many neurologists will often dismiss the diagnosis of sinus headaches and proceed with treating only migraine symptoms. On the other hand, many patients and ENT doctors will focus solely on treating sinus disease and ignore the possibility of migraines. As a neurologist, I also tend to be biased in the direction of migraine headaches, however, but now will try to always consider the possible contribution of sinus disease as an aggravating factor. This study may explain why some of my patients with definite migraines will often report at least some improvement from sinus or allergy medications.
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