Temporo-mandibular joint dysfunction (TMD) treated with a brief course of cognitive-behavioral therapy (CBT) in addition to standard care improves long-term outcomes, according to a new study published in journal Pain. A group of 101 patients who had pain in TMJ for at least 3 months were included in this study. Standard treatment included splinting, soft diet and an anti-inflammatory drug and was given to all patients. Fifty two patients also received six weekly sessions of cognitive-behavioral therapy. Both those who received standard therapy alone and those who also received CBT improved, however addition of CBT provided additional pain relief, particularly in those people who were open to it and prepared to use it.
Read MoreBotox was just approved by the FDA for the treatment of chronic migraine headaches. This is great news to the more than 3 million chronic headache sufferers in the US (people who have more than 15 days with headaches each month). In Dr. Mauskop’s opinion Botox is one of the most effective treatments for frequent and severe headaches and it is the first treatment approved FDA for chronic migraines. Dr. Mauskop was one of the first headache specialists to begin using this treatment more than 15 years ago. He has published several scientific articles and book chapters on the use of Botox for headaches. His most recent chapter on Botox for headaches was just published a month ago in the 97th volume of the Handbook of Neurology (Elsevier). Dr. Mauskop has trained over 200 doctors from all across the US, Canada and Europe who traveled to the New York Headache Center to learn this technique. Initial reports of the use of Botox for headaches were met with disbelief, while strong skepticism about the efficacy of this treatment persisted for many years. The main reason for this skepticism was the fact that migraine headaches are known to originate in the brain, while Botox affects only muscles and nerves on the outside of the skull. A large amount of research led to our current understanding of how Botox works: while the brain begins the headache process, it requires feedback from nerves and muscles on the surface of the head. By blocking activation of the nerves and muscles the feedback loop remains open and the headache does not occur. After the first few treatments some patients still develop a migraine aura or just a sensation that the headache is about to start, but it does not. After repeated treatments even the auras and this sensation stops occurring. Botox seems to be effective in 70% of patients, which is a rate significantly higher than with any preventive migraine medications, such as Topamax (topiramate), Depakote (divalproex sodium), Inderal (propranolol), or Neurontin (gabapentin). These drugs are effective in less than 50% of patients who try them. The other 50% do not respond or develop unacceptable side effects. Lack of serious side effects is another big advantage of Botox over medications. Botox can cause cosmetic side effects, such as a surprised look, droopy eyelids, or one eyebrow being higher than the other. These and other side effects become less common as the doctor who performs them becomes more experienced. Occasionally, patients develop a headache from being stuck with a needle. This is also uncommon because the needle is very thin and if done correctly, the procedure usually causes very little pain. The effect of Botox begins about 5-6 days after the injections, but the improvement continues to occur for 3 months, at which point the second treatment is given. Some patient require Botox injections at 2 month intervals. Published studies have shown that the second treatment is usually more effective than the first and the third one is better than the second. After several treatments some people improve completely (a small percentage of patients stop having all of their headaches after the first treatment). Dr. Mauskop’s experience suggests that children as young as 10 who suffer from daily headaches also respond well to Botox injections. The major drawback of Botox is its cost. However, several insurance companies have been paying for this treatment and with the FDA approval most of them will have to cover this treatment for patients with chronic (more than 15 days a month) headaches.
Read MoreA new treatment for motion sickness in patients with migraines was reported by a group of doctors from Pittsburgh. Giving migraine sufferers who are prone to motion sickness a migraine drug, rizatriptan (Maxalt) prevented motion sickness . There were 25 subjects in the study and 15 of them developed motion sickness after being rotated in the darkness. Of these 15 patients, 13 showed decreased motion sickness after being pretreated with rizatriptan. This was a small study and not all patients benefited, but this is an option that should be considered in patients who suffer from severe motion sickness. It is likely that the effect is not specific to rizatriptan, but that sumatriptan (Imitrex), eletriptan (Relpax) and other triptans are also effective. However, just like when treating migraine attacks, it is possible that some patients will respond better to one triptan and others to another.
Read MoreHeadache coach, Jan Mundo will be conducting classes at the New York Headache Center (this is a second announcement). The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27. Jan’s course is “for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies.” For details and registration go to http://www.mundolifework.com. Facebook page: http://www.facebook.com/pages/The-Headache-Coach/72585407316?v=app_2344061033#!/event.php?eid=102475893145453&index=1..
Read MoreAspirin is as effective as Imitrex (sumatriptan) in the treatment of migraine headaches with fewer side effects, according to an authoritative Cochrane review published earlier this year. The review examined 13 high-quality studies which involved 4,222 patients. Having such a large number of patients in well-conducted studies makes the data highly reliable. Some of the studies utilized 900 mg of aspirin and some 1,000 mg, some with and some without a nausea medicine, metoclopramide (Reglan). Aspirin was compared to both Imitrex, 50 or 100 mg and placebo. The authors concluded that “there are no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use are mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.
Vertigo and dizziness are common in migraine sufferers. It is much less common for vertigo to be the only symptom of migraines. This seems to be the case with vertigo that begin at menopause, according to a recent report presented at the last meeting of American Academy of Neurology. The report describes symptoms in 12 women, so its conclusions cannot be accepted as definitive. All of the women had history of menstrual migraines and all had a normal ear-nose-throat examination and a normal MRI scans. They all suffered from vertigo for at least a year. Treatment with standard migraine medications and hormonal therapy reduced attacks of vertigo by 50% and was more effective than non-hormonal treatment alone. It is not surprising that the hormonal therapy helped because some women with menstrual attacks also improve with hormonal therapy, such as continuous contraception. This report should raise awareness of the fact that menopausal women with vertigo may be suffering from migraines and may respond to hormonal and migraine therapies.
Read MoreHeadache coach, Jan Mundo will be conducting classes at the New York Headache Center. The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27. Jan’s course is “for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies.” For details and registration go to http://www.mundolifework.com.
Read MoreMedication overuse (rebound) headache (MOH) has been the subject of many studies and reports. Another review of this subject appeared in the latest issue of journal Pain by Italian neurologists. This review addressed possible causes, predisposing factors, and possible treatments. The list of possible drugs which can lead to overuse headaches included in this article includes every possible headache medicine. However, the authors do not mention that for some drugs there is more scientific evidence than for other. For example, only caffeine and opioid (narcotic) analgesics have been proven to cause MOH, while drugs such as aspirin may actually prevent the development of MOH. There is only anecdotal (case reports) evidence for triptans (sumatriptan, or Imitrex, rizatriptan, or Maxalt, and other). The authors suggest that both environmental and genetic factors may contribute to patient’s vulnerability to substance overuse, dependence, and withdrawal in MOH. They also think that psychological comorbidities such as depression, anxiety and poor pain coping abilities may contribute to chronification of headaches.
The authors report on different detox strategies, including the need for hospital admission for patients taking large doses of narcotics or barbiturates (such as butalbital, found in Fioricet, Fiorinal, Esgic). However, almost all patients seen at the New York Headache Center are successfully withdrawn on an out-patient basis. Many patients fear worsening of pain from medication withdrawal, but several treatments can make the process less painful. Botox injections, intravenous infusions of magnesium, topiramate (Topamax), gabapentin (Neurontin) and a short course of steroids are some of the most commonly used strategies. Elimination of dietary caffeine, regular aerobic exercise, biofeedback, and acupuncture are also very useful adjunctive therapies.
Many migraine sufferers feel that food allergies cause their headaches. There is little dispute that certain foods can trigger migraines. Some of these foods include chocolate, wine, cheese, citrus fruit, onions, smoked, cured, and pickled foods. However, migraine that results from eating these foods is not due to an allergic reaction, but rather is due to a chemical reaction. An allergic reaction occurs when the body’s immune defense mechanisms try to isolate and attack an offending substance, called an allergen. It is possible to evaluate this immune response by measuring blood levels of immune globuline (IgG) which is specific to to a particular food or substance. Since there are so many different foods that we eat, literally hundreds of tests are required. Doing such extensive testing has been controversial, in part because of its high cost. This testing has been advocated for patients with irritable bowel syndrome. People who are found to have high levels of of IgG to certain foods can improve their condition by eliminating those foods. Another way to detect food allergies is by scratch test, where an extract of different foods is placed into skin scratches and then the skin reaction is measured.
A sophisticated study recently published in Cephalalgia by Dr. Ertas and his colleagues looked at food allergies in migraine patients. They tested IgG levels to 266 foods in the blood of 30 migraine sufferers. The number of foods these 30 patients were allergic to ranged from 13 to 35. After testing, for six weeks each patient ate a diet which included or excluded foods they were allergic to. After that, they had two weeks of unrestricted diet, followed by another 6 weeks of the opposite diet (if they first had a diet free of allergen, then they were switched to a diet with allergens, and vice versa). Neither the doctor, nor the patient knew what foods the patient was allergic to or which diet was given in each 6-week period. The results of the study showed that significantly fewer migraines occurred when the diet excluded foods patients were allergic to. This is the first rigorous study which suggests that food allergy testing may find a place in the management of patients with migraine headaches.
Read MoreThere are over 4 million chronic migraine sufferers in the US. Chronic migraine is defined as a headache with migrainous features, which occurs on more than 15 days each month. Many of these chronic migraine patients we see at the New York Headache Center have daily headaches. By the time they come to our Center, many have seen several doctors, including neurologists and found no relief from a variety of drugs. A new book just published by Oxford University Press may help doctors who care for headache patients to provide better care. The book is Refractory Migraine, Mechanisms and Management. Dr. Mauskop and Dr. Sun-Edelstein contributed a chapter to this book: Nonpharmacological Treatment for Refractory Migraine: Acupuncture, Vitamins and Minerals and Lifestyle Modifications. An important message contained in the chapter and the one we always stress to our patients is that the best way to approach a refractory headache is not by trying one drug after another, but by combining drugs with nonpharmacological treatments, such as biofeedback, magnesium, other supplements, Botox injections, acupuncture and other therapies.
Read MoreMany, but not all epilepsy drugs are also effective in preventing migraine headaches. For example, divalproex sodium (Depakote), topiramate (Topamax), and to a lesser degree gabapentin (Neurontin), pregabalin (Lyrica), and levetiracetam (Keppra) relieve migraine headaches, while other epilepsy drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol) do not. A report by Drs. Krusz at the annual meeting of the American Headache Society held last month suggests that a new epilepsy drug, lacosamide (Vimpat) may also be effective for the treatment of headaches. Dr. Krusz treated 22 patients with chronic migraines (patients who had more than 15 headache days each month) with this medication and discovered that on average the monthly number of headaches dropped from 21 to 13. Side effects, such as drowsiness, nausea, and cognitive impairment lead 4 patients to stop the drug. Despite very impressive results it is premature to declare lacosamide an effective headache treatment because the study was very small and not placebo-controlled.
Read MoreAspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers. In a recent report 1,000 mg of aspirin was found to be as effective as 100 mg of sumatriptan (Imitrex) with fewer side effects. Cambia is a new prescription drug, which was recently approved by the FDA specifically for the treatment of migraine headaches. The active ingredient in this drug is diclofenac, which is also sold under Voltaren and Cataflam names. But unlike other forms of diclofenac, Cambia is a powder which patients are supposed to dissolve in a glass of water and drink it. Drinking a solution rather than swallowing a pill speeds absorption of the drug, which can make a difference for those migraine sufferers who need to catch their attacks early, or drugs don’t help. The drug has a “black box” warning, which cautions about possible cardiovascular side effects, as well as gastro-intestinal side effects, including bleeding and ulcers. The cardiovascular side effects of diclofenac are similar to those of Vioxx which was taken off the market. Other NSAIDs also carry risk of cardiovascular (and GI) side effects, but their risk is lower. The only NSAID without cardiovascular risks is aspirin. In fact it is used to prevent strokes and heart attacks. Aspirin is also the only drug which prevents the development of rebound headaches – worsening of headaches from frequent intake of a headache medicines or caffeine.
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