Steroid medications can be very effective for migraine headaches that fail to respond to other medications. Steroids, such as prednisone, dexamethasone, methylprednisolone have many potential serious side effects if taken for a long time. We know about these long-term side effects from patients with asthma, arthritis, lupus and other conditions who have take steroids daily for months and even years. However, these medications are relatively safe if taken for only a few days. If a severe headache does not respond to Migralex, sumatriptan, (Imitrex), or other medications, I prescribe a two-day course of dexamethasone. The usual dose is 8 mg daily for two days. Other doctors prescribe a six-day course of methylprednisolone (Medrol Dosepak). However, if a headache completely resolves after two days, it seems unnecessary to continue this medication for the full six days. In the office, we also give intravenous dexamethasone which provides faster relief than tablets. Another indication for steroids is for cluster headaches. A ten-day course of prednisone (starting with 100 mg and reducing by 10 mg every day) can sometimes stop the entire cluster period. Unfortunately, for some cluster headache sufferers headaches return as soon as the dose of prednisone is lowered. If no other preventive medication, such as verapamil, lithium, topiramate (Topamax) or divalproex (Depakote) work, some patients with severe attacks are willing to accept the risk of long-term side effects of steroids. Some of these side effects are weight gain, diabetes, stomach ulcers, glaucoma, high blood pressure, and osteoporosis.
Read MoreInjections of sumatriptan (Imitrex) are very underutilized. Many doctors fail to offer this option to their migraine and cluster headache sufferers because they are not aware of this option or more often because they are not aware how debilitating migraines can be or because they consider it to be dangerous. Patients who wake up with a severe headache (migraines commonly occur in the morning) and have to go to work or take care of their children often become disabled for the day because oral medications are not effective. Another group of patients who benefit from injections are those with nausea and vomiting. But you do not have to have a severe attack or have vomiting to take an injection. I have occasional migraines, usually triggered by wine or lack of sleep and if I take an oral medication it will usually help, but it may take an hour or even two before it works. So, if I have a headache late in the evening, I take an injection which stops my migraine within 10 minutes and I can fall asleep right away instead of waiting for an hour before the tablet takes effect. Sumatriptan injection is the only drug approved for the treatment of cluster headaches and it is a true life saver for cluster sufferers.
It is very easy to give yourself an injection of sumatriptan. There are three different devices on the market. The oldest one is a little more cumbersome to use, which can be a factor when you are in the midst of a severe attack, but it costs the least and is more likely to be covered by the insurance. Another injector, Sumavel does not have a needle – the device shoots the medicine into the skin through a tiny hole. This device is easier to use but some people complain that it is more painful despite it being needleless. The third device, Alsuma is identical to the one used in the Epi-Pen and it is also very easy to use. Sumatriptan is also available in vials. Some people prefer to use vials for several reasons. First, they are cheaper, second, they may be less painful to inject since you can use a syringe with a smaller needle than the ones in autoinjectors and third, some people get excellent results and fewer side effects with a smaller dose and the vial allows them to use 2 or 3 mg. Being able to use 2 or 3 mg at a time is particularly useful for cluster headache patients who have one or two headaches a day for extended periods of time and don’t get enough injections from their insurer.
If you suffer from severe migraine or cluster headaches ask your doctor about injections of sumatriptan. The main contraindication is heart disease or multiple risk factors for heart disease, but otherwise it is a very safe medicine. In Europe tablets of sumatriptan are sold without doctor’s prescription.
Migraine patients can sometimes benefit from an Alzheimer’s drug, Namenda (memantine). All drugs for the preventive treatment of migraines, including Botox, had been first approved for a completely different indication. Beta blockers and other high blood pressure drugs, epilepsy drugs, and antidepressants are the most commonly used medications for migraine. It is surprising that such a wide variety of medications with very different mechanisms of action would all provide relief for migraines. We have only a basic understanding of how these drugs might work because they were discovered to help migraines by accident. Namenda is a very old medicine that has been available in Europe for over 30 years. It was used for a variety of neurological conditions, but in the US it was introduced and approved only for Alzheimer’s disease in 2003. It works by blocking an NMDA receptor, which is found in brain cells and which is responsible for letting calcium into the cells. Excessive inflow of calcium leads to many negative effects, including propagation of pain messages along the nervous system. Magnesium is a natural NMDA receptor blocker and we often add Namenda to magnesium for stronger effect. Namenda is not a very strong medication, meaning that it probably works for less than half of the patients, but it also causes fewer side effects than many other drugs. It is well tolerated even by the elderly Alzheimer patients, although like any other drug it can cause side effects, including nausea, drowsiness, and dizziness. Another problem with the drug is that some insurance companies do not pay for it because it is not approved for the prevention of migraines.
Read MoreChronic and episodic paroxysmal hemicrania and hemicrania continua are rare types of headaches that have one common feature – they respond very well to indomethacin (Indocin). The diagnosis is actually based not only on clinical features but also on the response to indomethacin. Indomethacin belongs to the category of NSAIDs (non-steroidal anti-inflammatory drugs) such as aspirin, ibuprofen, naproxen, and other. Indomethacin is somewhat unique in the way it works and it is often stronger, however it also causes more gastrointestinal side effects than other NSAIDs. Symptoms of paroxysmal hemicrania are similar to those of cluster headaches: the pain is very severe, very brief (lasting a few minutes) and occurs anywhere from a few times to a few hundred times a day. The pain is always one-sided, localized to the eye and it is often accompanied by tearing, nasal congestion, and redness of the eye. Hemicrania continua is very different in that it is present constantly and it is not very severe, but it also involves only one side of the head. Hemicrania continua is often mistaken for chronic migraine or chronic tension-type headache, which leads to ineffective treatments. The dose of indomethacin varies from 25 to 75 mg, taken three times a day. Some patients with these headache types do not tolerate indomethacin, which can cause heartburn, stomach ulcers, bleeding ulcers and other side effects. In those patients we try epilepsy drugs, other NSAIDs (which may or may not be better tolerated), as well as Botox injections and sometimes these treatment do help, if not as well as indomethacin, at least enough to improve patients’ quality of life.
Read MoreBiofeedback is an excellent preventive headache treatment with its efficacy proven in many rigorous studies. What prompted me to write this blog post is seeing yet another child (I see kids with headaches aged 10 and older) who had seen his pediatrician and a pediatric neurologist and neither physician mentioned biofeedback. Instead, they just prescribed drugs. Biofeedback is very effective for adults as well, but seeing a 10-year-old child with headaches who is prescribed medications as the only option was somehow more upsetting than when I see and adult under the same circumstances. Children tend to learn biofeedback with greater ease than adults – sometimes they need only 4 – 5 sessions instead of the usual 10 or more. Biofeedback is a way to learn to relax and stay relaxed under pressure, at least relaxed as far as your body goes, if not the mind. The person learning biofeedback is usually connected to a computer by a probe which measures body’s temperature or muscle tension (or brain wave activity in case of neurofeedback). The computer displays this information on the screen, which helps you learn how to relax your body. Biofeedback is taught by a psychologist, a nurse or another trained professional. Some insurers will cover this treatment, but many do not. Fortunately, studies show that self-taught relaxation training can be as effective as biofeedback. There are many free sources and some that you can buy. Many people are skeptical about biofeedback, but there is a simple explanation why it works. You are supposed to stop for a minute or even less to take an inventory of neck, facial, and other muscles, to make sure you are not tensing them up, then take a few deep breath. This will bring your tension down just a little, but if you repeat this one minute exercise every hour, at the end of the day you will avoid having knots in your shoulders and your neck and may avoid a headache. Eventually, this exercise becomes subconscious as you automatically monitor your body and whenever you feel that you are frowning, holding shoulders up, or holding your breath, you stop doing that without having to pause.
In addition to biofeedback and obvious sleep, exercise, and food recommendations, I suggest that all children take a magnesium and CoQ10 supplements. Both have been shown to help children with migraines.
Botox injections relieve pain of trigeminal neuralgia, according to a new study just published in Cephalalgia, a leading headache journal. Trigeminal neuralgia is an extremely painful condition which manifests itself by intense electric shock-like pain on one side of the face. The pain is triggered by speaking, chewing and often without any provocation. Persistent pain can lead to malnutrition from the inability to chew and to severe depression and despondency. Epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and other types of drugs often relieve the pain, but not always and at times the drugs can cause intolerable side effects.
Research on the mechanism of action of Botox has shown that it may be blocking sensory nerves and this led me to try Botox for a few of my patients with conditions other than chronic migraines and other headaches. Several patients with post-herpetic neuralgia (shingles) and a few with trigeminal neuralgia responded very well.
This rigorous double-blind, placebo-controlled study in Cephalalgia by Chinese researchers involved 42 patents with trigeminal neuralgia, of whom 40 completed the study. Among the patients who received Botox injections, 68% had significant improvement compared to only 15% of responders in the group tht received placebo. This study strongly suggests that Botox is an effective treatment for some patients with trigeminal neuralgia. The advantage of Botox is that it has significantly fewer side effects than oral drugs.
Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been established. A recent study showed that even low levels of particulate matter can increase the risk of a stroke. Doctors looked at 1,705 patients who were admitted to the hospital with an acute stroke and checked pollution records on the days these strokes occurred. They found that strokes were more common within 12 hours of the rise in the level of pollution. The correlation was linear – the higher the pollution, the higher the risk of stroke. The risk of stroke was elevated even at pollution levels considered “satisfactory”.
Read MoreMal de debarquement syndrome (MdDS) or disembarkment syndrome is a rare condition which often, but not always, occurs after getting off a ship. Many people have “sea legs” after getting off a boat, but in most this sensation of still being on a rocking boat quickly subsides. Very few unfortunate people continue to have this sensation for months and even years. Last week I happened to see two patients with this condition. It was not entirely a coincidence since both read online report by a patient whom I helped. One woman I saw today said that she feels that her life was taken away from her. Despite her symptoms, she was able to hold a full-time job and care for her 3 children. However, the second patient with the worst case of MdDS I’ve seen, demonstrated how debilitating this seemingly minor disorder can be. She had to quit her job, became very anxious and depressed, which never happened to her before this illness. She also reported feeling very tired, could not think clearly, complained of difficulty breathing, diarrhea, constipation, and had many other debilitating symptoms. When I examined her, she was unable to stand with her feet together and eyes closed and could not walk a straight line, heel-to-toe. Almost all patients I’ve seen with MdDS had extensive testing, which was normal. Vestibular rehabilitation seems to help a few, as does acupuncture, or medications such as Klonopin or clonazepam (which seems to be the most commonly prescribed drug). Most of the patients with MdDS also suffer from headaches, often migraines. Even if they don’t have headaches, they are referred to me because the ENT or the primary care doctor thinks that this condition may be related to migraines. It is true that migraine sufferers are more likely to have disorders of the inner ear and difficulties with balance and coordination.
Our research has shown that up to 50% of migraine sufferers are deficient in magnesium and this deficiency is not detectable by routine magnesium test. Other symptoms suggestive of magnesium deficiency include coldness of extremities, or just being cold most of the time, leg or foot muscle cramps (often occurring at night), brain fog or spaciness, difficulty breathing, and other symptoms. Most of the patients with MdDS I’ve seen had many of these symptoms and what made a dramatic difference for more than half was an infusion of magnesium, often combined with a vitamin B12 injection (another common deficiency). Some patients were already taking oral magnesium supplement, but it did not make a difference. This is not unusual because some people have either a genetic inability to absorb oral magnesium or have gastro-intestinal disorders (irritable bowel syndrome, diarrhea, etc) which impair magnesium absorption. Some people need to have repeated monthly infusions of magnesium.
Another common contributing factor to this syndrome is neck muscle spasm, which alone can be responsible for a sense of dizziness, but more often just makes MdDS worse. Treatment of neck muscle spasm can produce significant improvement.
So, what happened to my two patients from last week? The first one felt only a little better right after the infusion and I asked her to call me back in a week or two, while the second one had a dramatic improvement: she could stand still without swaying with her eyes closed and walked a straight line without difficulty. We’ll see if this improvement will last. I suspect that it will. I also encouraged her to slowly get off clonazepam and an antidepressant she was taking, but to continue seeing a social worker for psychotherapy. I recommended to both patients several supplements, including CoQ10, 300 mg daily and 6 grams of omega-3 fatty acids.
If magnesium is ineffective, medications, such as gabapentin (Neurontin), memantine (Namenda), and tizanidine (Zanaflex) can help without causing habituation seen with clonazepam. For neck muscle spasm, isometric neck exercises that strengthen neck muscle can help. I also treated one patient who improved when I combined magnesium infusions with weekly acupuncture sessions. Acupuncture tends to be more effective with more frequent sessions, 2-3 times a week, which is impractical for many because of the time and cost involved.
Risks involved in using Chinese herbs are highlighted in the just released AFP report, which you can read on Yahoo News. Here is an edited quote from this story: The samples analyzed for this study included herbal teas, capsules, powders and flakes were tested by scientists at Australia’s Murdoch University. 68 different plant families that were detected in the 15 samples can be toxic if taken in the wrong doses, but the packaging did not list the concentrations of the elements inside.
I am a big proponent of alternative and complementary medicine, recommend herbs, and am a certified acupuncturist. I think acupuncture and many herbal products have a place in the modern medicine because they’ve been shown to be effective. However, many people who go to acupuncturists are often given Chinese herbs along with acupuncture. Unfortunately, there is very little or no quality control in the production of the Chinese herbs. The most dramatic example of this problem was described in the New England Journal of Medicine in 2000 – an herb people were taking for weight loss was contaminated by a toxic plant which caused kidney failure and urinary cancer in 18 of 105 patients. China (just like India, Russia, etc) still has extreme levels of corruption, which means that we cannot rely on their herbal products unless they are first tested in an American laboratory for purity. For now, stick with herbal products made in the US or Western Europe. Feverfew, boswellia, ginger, valerian root, and other are available from major manufacturers, such as Solgar, GNC, Nature Made, and other.
We should not complain about our health care system. People in such advanced European countries as Netherlands have it much worse. I just saw a 27-year-old Dutch woman with chronic migraines who has been coming to see me for Botox injections every three months for the past 3 years. Three years ago she was told by her neurologist to quit law school because even if she was able to graduate, her migraines will prevent her from being able to hold a job. She is graduating from law school this June. Her doctors also told her not to take sumatriptan (called Imigran in Europe and Imitrex in the US) more than once or twice a week and take only aspirin on other days. This approach made her unable to function on the five days when she did not take sumatriptan, but even with sumatriptan her headaches were still disabling. Botox injections produced a significant improvement in the severity of her attacks, although not in the frequency. However, now sumatriptan provides complete relief and she can function normally. She tried to find a way to get Botox injections in Holland and offered to pay the doctor. He was not able to do it because medicine is socialized in Holland and he could not accept payment for procedures not covered by the health service. She turned to the government and offered to reimburse the health service for Botox, but they also refused. She is fortunate in that she is able to afford to come to New York every three months and buy as much sumatriptan as she needs to function normally.
Things are not much better in the UK and other European countries. The UK approved the use of Botox for chronic migraine before it was approved in the US. However, their national health service also refuses to pay for it. My Italian colleagues have told me that as a society they’ve decided that Botox was too expensive to be used for the treatment of migraines, despite the evidence that it works. I should note that just like many other drugs, Botox is significantly cheaper in Europe than in the US.
Muscle relaxants can be surprisingly effective for the prophylactic treatment of migraine headaches. It is surprising because migraine is a brain disorder and not a disorder of muscles. However, studies have shown that during a migraine attack muscles are in fact very contracted and that is probably why people find some relief by rubbing their temples and the back of the head. We also thought that Botox works by relaxing these tight muscles, but it turned out that it also works on nerve endings. Muscle relaxants also do more than just relax muscles – they actually work on brain mechanisms of migraines. Not all muscle relaxants help migraines and the most evidence exists for tizanindine (Zanaflex). A double-blind study was done by Dr. Alvin Lake and his colleagues and it showed very good efficacy and few side effects. The target dose was 8 mg three times a day, but the average dose was 18 mg a day. The main side effect of this drug is sedation, but otherwise it is fairly benign. Baclofen (Lioresal) is another muscle relaxant that has been subjected to a double-blind study and was found to be effective for the prevention of migraine headaches. The drug was also given three times a day with a total dose ranging from 15 to 40 mg a day. The main side effect of baclofen is also sedation. Other muscle relaxants, such as metaxalone (Skelaxin), cyclobenzaprine (Flexeril), clonazepam (Klonopin), and other have helped some patients, but there are no scientific studies to prove their efficacy in migraine.
Read MoreA throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a year seemed to indicate a typical chronic migraine headache in a man I saw last week. His headache did not respond to pain medications, short courses of steroids and sinus surgery. The MRI scan of the brain and neurological examination was normal. The only unusual part was that this was a 66-year-old man who never had any headaches before and who had no family history of headaches. Migraines can begin as early as infancy and as late as 50’s, but it is extremely unusual to start having migraines for the first time in the 60s. Headaches that occur in later years are more likely to be due to conditions such as brain tumors (primary – glioma or meningioma, or secondary due to metastases from breast, lung and other tumors), subdural hematoma, or inflammation of blood vessels, which was the case in this 66-year-old man. He suffered from temporal arteritis, also called giant cell arteritis. The diagnosis is confirmed by blood tests (elevated ESR and CRP) and biopsy of the artery. Treatment is usually very effective and typically consists of a steroid medication such as prednisone. Unfortunately, many patients with temporal arteritis need to stay on at least a small amount of this medicine for many years if not the rest of their lives and this drug has many potential serious side effects. However, if left untreated temporal arteritis can cause strokes and blindness, so it is very important to diagnose and treat it as soon as possible.
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