Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This recall affects only two lots of 100 mg tablets. This recall does not affect topiramate, generic copies of this brand. Since the generic form is much cheaper, most patients have switched to it from branded Topamax. This adds another problem to this beleaguered drug. It was recently reclassified by the FDA from pregnancy category C to category D, which means that it is much more dangerous for the fetus than originally thought. Topiramate is also associated with a high incidence of kidney stones (20%) and can cause other serious problems. This is why we always emphasize non-drug approaches (exercise, acupuncture, biofeedback magnesium, Botox, etc), which can be more effective and are much safer than drugs.
Read MoreMigraine headaches are very common in chronic fatigue syndrome (CFS) sufferers, according to a new study just published by researchers from Georgetown University. Migraine headaches were present in 84% of patients with CFS (60% had migraine without aura and 24% had migraine with aura) and tension-type headaches were present in 81% of CFS sufferers. Only 4% of CFS patients had no headaches at all. This compares to 12% of the general population, or 18% of women (two thirds of CFS patients were women) who suffer from migraines. Fibromyalgia (diffuse muscle pains in four quadrants of the body) was much more common in CFS patients with migraines (about 50%) compared to healthy controls. The authors speculate that the same brain disturbances which cause migraine headaches may be also responsible for the fatigue in patients with CFS and that successful treatment of migraines may improve symptoms of CFS. It is well known that migraine sufferers have increased excitability of their brains, even between attacks, compared to healthy individuals. This may be why migraine sufferers are more likely to have other pain syndromes, such as fibromyalgia, back pain, irritable bowel syndrome, TMJ syndrome, and other. More importantly, several treatments have been shown to be effective (to various degrees) for all of these conditions. These include biofeedback and cognitive-behavioral therapy, tricyclic antidepressants, acupuncture, and aerobic exercise.
Read MoreTemporo-mandibular joint disorders (TMD) have long been known to be associated with headaches. A very interesting study conducted in Brazil and published in the Clinical Journal of Pain examined this association in 300 patients with TMD. The researchers carefully evaluated the type of TMD and its severity as well as the type of headache that might have been also present. Compared to those without TMD, patients with myofascial type of TMD were more likely to have chronic daily headaches, migraines and tension-type headaches. The more severe was TMD pain, the more likely it was that these headache conditions were present. An important question which is not answered by this study is, what comes first – TMD or headaches? It is likely that having one condition can cause and make the other worse, forming a vicious cycle. I see patients who can clearly identify that they first developed pain in the jaw and then headaches came along, but treating only their TMD does not seem to help. There are many more patients who present with headaches as the main complaint but who also have TMD. The treatment should always be directed at both conditions and many treatments we use have been shown to be effective for people with only TMD or only headaches. These treatments include regular aerobic exercise, biofeedback, acupuncture, Botox injections, massage, and medications. The list of medications include NSAIDs, such as aspirin (or Migralex), Advil, and Aleve, antidepressants, such as Elavil, Pamelor, and Cymbalta, epilepsy drugs, such as Neurontin and muscle relaxants, such as Zanaflex.
Read MoreTopiramate (Topamax) increases the risk of birth defects, such as cleft lip and palate, warned the Food and Drug Administration (FDA). Topiramate is an epilepsy drug which is also approved for the preventive treatment of migraine headaches. It is a very popular drug, in part because it can cause weight loss in some patients. In clinical trials only half of migraine patients who started taking this drug remained on it for more than a few months because it was ineffective for some and caused intolerable side effects in others. One of the main side effects which makes people stop taking this drug is difficulty speaking and thinking. Topiramate is also known to cause kidney stones and the initial data suggested that less than 1% of patients taking it developed kidney stones. However, a recent report suggested that up to 20% of people taking topiramate for a period of two years will develop kidney stones. Half of the patients who developed kidney stones were not aware of it. Kidneys stones not only can be very painful, but in severe cases can impair kidney function.
These two newly discovered dangers are additional reasons to avoid taking topiramate and if possible, to avoid taking any medications. While we do prescribe many medications, including topiramate, we always begin with life style modification (diet, sleep, exercise), biofeedback or meditation, magnesium, CoQ10, and other supplements, acupuncture, and Botox injections.
Migraine prevention is most effective when a preventive medication and behavioral management are combined together. A study by Dr. Holroyd and his colleagues published in the British Medical Journal showed that a beta blocker alone and behavioral management alone did not help patients with migraine headaches. However, combining these two resulted in a significant improvement. This was a very rigorous trial involving 232 patients who were divided into 4 groups: behavioral management alone (with a placebo pill), beta blocker alone, both interventions, and no intervention group (they did receive placebo pills). Patients and doctors did not know which patient received a beta blocker or placebo. Every patients was seen every month for four months and had 3 telephone calls in these four months. During each visit the behavioral management group received one hour of training. All patients were given optimal acute therapy with a triptan and if needed, ibuprofen and a nausea medication.
All patients were evaluated 10 and 16 months later and the combined group was improved compared to the other 3 groups both in the number of attacks, number of migraine days, and in the quality of life.
This confirms the validity of our usual practice of combining several approaches at once rather than trying one at a time. The list of our typical recommendations includes combination of several of these options: avoidance of caffeine, aerobic exercise, behavioral management, magnesium and other supplements, Botox injections, non-prescription medications, such as ibuprofen, naproxen, and Migralex, as well as triptans and prophylactic medications, such as beta blockers, epilepsy drugs, and antidepressants.
Body–Mind, Self-Care Program:
Everything you do – eat, drink, sleep, move, sit, stand, think, feel, interact – adds up to how you feel and function. In a body-mind program, as with one for diet or exercise, by changing your daily practices, you will get a different result.
Headache Coach Jan Mundo will guide you to wellness and help you overcome your pain. Lessons, accompanied by handouts, individualized coaching, and assessments, include: tracking your triggers, headache-healthy diet, stress relief, and harnessing the power of your body and mind for healing.
The New York Headache Center, located at 30 East 76th Street, New York, NY generously offered its space for this program to be held weekly from March 8 until April 12, 2011, at 6 – 8:15 pm.
For more information see Jan Mundo’s site
Taking two different triptans (drugs such as Imitrex, or sumatriptan, Maxalt, or rizatriptan and other) within 24 hours of each other is contraindicated according to the FDA. However, there is no scientific reason for such prohibition. You are allowed to take a second dose of the same triptan 2 hours after the first dose, so it makes no sense why you could not take a different one. Most of the triptans (five out of seven) get washed out from the body within 2 – 3 hours, so even if there was an interaction between different triptans (and there is absolutely no evidence for that) it would be safe to give a different one 3 hours later. A report in the latest issue of the journal Headache by Dr. Rothrock studied 200 patients who “mixed triptans”, that is took a shot of sumatriptan and two hours before or after a tablet of either rizatriptan (Maxalt, zolmitriptan (Zomig), almotriptan (Axert), or eletriptan (Relpax). He found that not only there were no problems, patients were highly satisfied with this approach. I also hear from my patients that sometimes they know that one tablet of a triptan will not be enough for their severe attack and they will take two at once. Many doctors strongly advise their patients against it, but there is no evidence of any great danger from a higher dose. These dosages were arrived at by looking for an optimal dose which provides good relief and few side effects and for most people the standard dose will suffice. But some people need higher amounts. In case of eletriptan (Relpax), 20 mg and 40 mg are available in the US, but in some European countries it is available in 80 mg. It is clear that some patients benefit from a higher than recommended dose without an increase in side effects.
Read MoreBotox is now approved for chronic migraine headaches. However, it may help you feel happier not only because your headaches improved. Several studies suggest that the inability to frown caused by Botox makes people happier too. Psychologists at the University of Cardiff in Wales showed that healthy people (not headache sufferers) who had cosmetic Botox injections were happier and less anxious than those who hadn’t. Another study published in the Journal of Pain showed that people who grimaced during a painful procedure felt more pain than people who did not. In an experiment by German researchers, healthy people were asked to make an angry face while their brains were being scanned by a functional MRI. Those who received Botox injections had much less activation in areas of the brain that process emotions than those who had no injections. My patients who receive Botox for headaches also report that because they cannot make an angry face they feel less angry. We need a large study of the effect of Botox injections on the mood, so that if this finding is confirmed, Botox can be recommend for the treatment of mood disorders.
Read MoreMelatonin does not seem to be effective for the prevention of migraine headaches, according to a study published in Neurology. The researchers from Norway gave 2 mg of extended release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo and neither the doctors nor the patients knew whether the first treatment was with melatonin or placebo (so called double-blind crossover trial). Migraine frequency did improve from an average of 4.2 a month to 2.8, but the same results were observed while on melatonin as on placebo. This study confirms a well established observation that taking a placebo helps, or perhaps that what helps is just keeping track of your headaches and seeing a medical provider on a regular basis.
One argument against the validity of the study is that the dose of melatonin might have been too low because one small trial of 10 mg of melatonin in cluster headache sufferers did show benefit. Another possibility is that the dose was too high. There is a study that suggests that taking 0.3 mg (or 300 mcg) helps insomnia, while 3 mg does not. Anecdotally, I find that for me and many of my patients 0.3 mg works better for insomnia and jet lag than 3 mg.
Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by relaxing tight muscles around the scalp. However, several recent studies determined that besides relaxing muscles, Botox also stops the release of several neurotransmitters from the nerve endings. These neurotransmitters are released by messages sent from the brain centers that trigger a migraine attack. In turn the released neurotransmitters send pain messages back to the brain completing a vicious self-sustaining cycle. A meticulous study just published in the journal Pain by Danish researcher confirmed that injections of Botox stop the release of neurotransmitters and reduce sensitivity of rat’s chewing muscles. Not knowing the exact way how Botox works makes many doctors skeptical about its efficacy. However, we have no idea how preventive medications, such as beta blockers, antidepressants and epilepsy drugs prevent headaches either. These drugs, like Botox, were also discovered to help headaches by accident. This does not and should not stop us from using them. Botox is more effective and safer than medications taken by mouth and is an excellent option for over 3 million Americans who suffer from chronic migraines.
Read MoreIntranasal sumatriptan powder seems to be a new and very promising way to deliver a migraine drug. Sumatriptan (Imitrex) nasal spray has been available for many years, however it is not very effective or at least is not consistently effective. The liquid tends to leak out of the nose, get swallowed, or just not get absorbed. Nasal spray of Zomig (zolmitriptan) appears to be more effective, perhaps because of the smaller volume of the liquid and a finer spray particles. The new product, OptiNose nasal powder seems to be even more effective. It is a sophisticated device which does not allow for the powder to enter the lungs and deposits the medicine only in the nasal cavity. In a study of 117 patients, 57% were pain-free and 80% had pain relief 2 hours after receiving 20 mg of sumatriptan powder, which was very significantly better than with placebo. The nasal powder seems to be three times more effective than the nasal spray and almost as effective as an injection. We hope that the FDA will approve this product in the near future.
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