Medication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin and Percocet) or dietary caffeine. About half of the people who stop taking these drugs improve, while the other half does not. A recent study by Dr. Andrew Hershey and his colleagues at the University of Cincinnati suggests that by doing genomic analysis of the blood we may be able to predict who is going to improve by withdrawing overused medication and who is not. This does not mean that the latter group is going to be left to suffer. However, this test could save a major effort that is involved in getting someone off medications. Instead these patients can be maintained on their medication while other preventive treatments are tried. These treatments can include biofeedback, magnesium infusions, Botox injections, prophylactic drugs, acupuncture, CoQ10, butterbur, and other treatments.
Read MoreSevere migraines are often accompanied by nausea and vomiting, making oral medications ineffective. Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently). Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex). Injections work fast, but are painful (even the needleless injection hurts) and expensive. Another way to get medicine into the body is rectally. Rectal suppositories are absorbed very quickly and more consistently than nasal sprays. Europeans are much more receptive to this route of administration than the Americans. A group of Italian researchers compared the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet. The suppository was slightly more effective than the tablet. Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order. With Imitrex going generic, the price should be more affordable.
There are two other products in development (not yet available), which will bypass oral route – a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex). The patch is somewhat large and may be awkward to use, while the inhaler is much more promising. Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex. According to the published data the efficacy of Levadex is very good with few side effects.
Read MoreMigraine sufferers are 2 – 3 times more likely to become depressed or anxious than those without migraines. The reverse is also true – depressed and anxious people are 2 -3 times more likely to develop migraines. According to a new study published in the journal Cephalalgia, being depressed or anxious does not prevent migraine drugs from working. The Greek researchers gave participants in the study sumatriptan (Imitrex), 50 mg for 3 attacks, and placebo, for another 3 attacks, without the doctors or the patients knowing what they were getting for any particular migraine attack. Presence of anxiety or depression did not have an impact on weather after taking sumatriptan the headache returned within 24 hours or not. Unfortunately, many physicians dismiss patients with migraine headaches as neurotics and hypochondriacs and the presence of anxiety or depression makes this bias even stronger. These doctors tend not to prescribe effective migraine drugs, which leads to unnecessary suffering. It is true that for some patients 1,000 mg of aspirin can be as effective as 50 or even 100 mg of sumatriptan with fewer side effects, but when aspirin is ineffective, sumatriptan or another drug in the triptan family should be used. One surprising detail of this study is that the researchers used 50 mg of sumatriptan, and not 100 mg, which should be the usual starting dose for most patients.
Read MoreOccipital nerve blocks can stop a migraine attack when other treatments fail. This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides. There are two branches of the nerve – greater and lesser occipital nerves and I usually inject both. The block can help even if the headache is not strictly localized to the back of the head. In some people headache returns after a few hours, once the effect of the local anesthetic wears off. However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient.
Read MoreReview of 16 published scientific articles on the efficacy of naproxen sodium as a treatment of acute migraine indicates that it is effective in the treatment of moderate to severe migraines. Naproxen sodium, 500 mg (2 tablets of Aleve) provided some relief after 2 hours to 45% of patients, complete pain relief to 17% and complete relief after 24 hours to 11%. Aspirin, 1,000 mg (2 extra-strength tablets) has been shown to do better, providing 52%, 27% and 24% of relief, respectively. Both naproxen sodium and aspirin relieve all of the migraine symptoms, including pain, nausea, sensitivity to light and noise.
Read MoreAnxiety and depression occur in migraine patients 2 to 3 times more often than in those without headaches. The opposite is also true, those with anxiety and depression are more likely to develop migraines. Certain antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), venlafaxine (Effexor), and duloxetine (Cymbalta) have been shown to help prevent headaches. However, when an antidepressant (or any other drug) is being tested for the prevention of headaches, patients with depression and anxiety are usually excluded. This is done to clearly establish if a drug works to prevent headaches directly, rather than indirectly through relieving anxiety and depression. There have been no studies of drugs to treat people who have both conditions. A report by Dr. Morris Meizels published in the current issue of Headache presents cases of three patients with severe migraines and anxiety who did not respond to the usual preventive medications. They did respond very well when he prescribed clonazepam (Klonopin), which is a tranquilizer in the family of benzodiazepines. Diazepam (Valium) and alprazolam (Xanax) are two other well-known members of that family, but they all have somewhat different clinical properties. Dr. Meizels stresses the fact that these drugs are potentially addictive and habituating and should be used in carefully selected patients and under close supervision.
Read MoreWe always try to use one preventive drug or Botox for the treatment of frequent or very severe migraine headaches. However, it is not unusual to go through several drugs and not find one which works well and does not cause side effects. Under those circumstances combining two drugs or Botox injections with a daily drug with is the next step. A study to be presented at the 62nd annual meeting of the American Academy of Neurology looked at 92 migraine patients who did not respond to a single drug. 86 of these patients found relief from a combination of either topiramate (Topamax) with verapamil (Calan, Verelan), or amitriptyline (Elavil) and a beta blocker (such as Inderal or propranolol, or atenolol). Combining two medications makes sense is they have different mechanism of action. For example topiramate is an epilepsy drug, while verapamil is a blood pressure medicine in the category of calcium channel blockers. Amitriptyline is an antidepressant with pain-relieving properties, while beta-blockers are blood pressure drugs. At times we combine two epilepsy drugs or two anti-depressants if they work in two distinct ways.
Read MoreVertigo is a common complaint of migraine patients. Ear-nose-throat specialists at the University of Pisa examined 22 patients with migraine headaches who complained of vertigo and 22 who did not, as well as 22 control subjects without migraines. They found that in both groups of patients with migraines a third had abnormal vestibular function on laboratory testing. In half of the patients in both groups the abnormality was in the inner ear (peripheral dysfunction) and in half in the brain (central dysfunction). This study confirms that both central and peripheral vertigo are common in migraine patients, whether they complain of vertigo or not. The most important question patients ask is what can we do about it. Fortunately, once migraines are brought under control, vertigo also subsides.
Read MoreMany migraine sufferers complain of dizziness, fatigue, exercise intolerance, blurred or tunnel vision, diminished concentration, tremulousness, nausea and recurrent syncope (fainting). These symptoms are often attributed to anxiety or panic attacks. A study to be presented later this month by Dr. Mark Stillman of Cleveland Clinic at the 62nd annual meeting of the American Academy of Neurology in Toronto reveals that the true cause of these symptoms in many migraine patients is POTS. Postural tachycardia syndrome, or POTS is a pronounced increase in heart rate (by at least 30 beats per minute) on standing up. Most of these patients do not suffer from a more familiar condition, orthostatic hypotension, which is a drop in blood pressure on sanding up. Treatment of POTS is difficult and usually involves increasing salt and water intake, aerobic exercise, and small doses of beta blockers (a type of blood pressure medicine also used for prevention of migraines).
Read MoreOccipital nerve stimulation has been under investigation for the treatment of difficult to treat migraine headaches for the past several years with promising results. A recent study at the Mayo Clinic in
It is very exciting to finally have two published studies (PREEMPT 1 and PREEMPT 2) which provide definitive proof that Botox is effective for chronic migraine headaches. More than 15 years ago a plastic surgeon in California, Bill Binder reported that many of his patients treated with Botox for wrinkles found relief from headaches. Everyone was very skeptical, but having many patients who failed every other treatment and having learned that Botox is very safe if used properly, I decided to try it. To my great surprise Botox worked exceptionally well. My most dramatic experience was in a 76-year-old woman who suffered from daily headaches for 60 years. She had failed a long list of medications, nerve blocks, acupuncture and other treatments. After the first Botox treatment, for the first time in 60 years she went for three months without a single headache. Her neurologist came to my office to learn the technique I developed and has been using Botox in his practice ever since. More than 200 doctors from around the world came to our Center to learn how to use Botox for headaches. They were all searching for new treatments for their desperate patients. At the same time most of the medical community had remained very skeptical and dismissive of this approach. They could not believe that Botox could help headaches and wanted to see double-blind, placebo-controlled trials before using it in their patients. Well, now they have it, but over the past 15 years many of their patients could have benefited from this safe and effective treatment. Yes, we do need proof that any new treatment works, but when this treatment is safe and there are no better alternative, it is appropriate to try it before definitive proof is available. We hope that these two studies will lead to the FDA approval of Botox for the treatment of chronic migraines before the end of 2010, which will make it easier for patients to obtain insurance reimbursement.
Read MoreA recent study by Dr. Bigal and his colleagues just published in Neurology compared more than 6,000 migraine sufferers with over 5,000 matched control subjects without migraines. They discovered that people with migraine with aura and to a lesser extent those with migraine without aura are significantly more likely to have strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol. This clearly does not mean that migraine causes all these diseases, but only that if you have one you are more likely to have the other. It is important to recognize this association in migraine sufferers in order to regularly screen them for these conditions. We know that controlling diabetes, high blood pressure, and high cholesterol can prevent strokes, heart attacks and poor circulation in extremities. We also recommend that women who have migraine with aura should not take estrogen-based oral contraceptives or hormone replacement therapy since estrogen in these women also increases the risk of strokes. All migraine suffererss (and everyone else) should not smoke and exercise regularly, which also reduces the risk of the conditions mentioned above.
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