Headache NewsBlog

Botox for trigeminal neuralgia due to multiple sclerosis

By: Dr. Mauskop

07-01-2023

Botox, Brain disorders, Pain, Trigeminal and other neuralgias

Botox has been shown to relieve the pain of trigeminal neuralgia (TN). TN is an excruciatingly painful and debilitating condition. The most common cause of TN is compression of the trigeminal nerve by a blood vessel. This tends to occur in older people in whom blood vessels may harden with age. The definitive treatment of TN is surgical decompression of the trigeminal nerve. This is done by opening the skull and placing a Teflon patch between the nerve and the blood vessel. Several medications and invasive procedures directed at the peripheral nerve have been also proven effective. They are usually tried before surgery because of the risk of complications from surgery.

Besides the elderly, younger people with multiple sclerosis (MS) are also predisposed to developing TN. The mechanism is somewhat different. There is less or no compression of the nerve but rather there is damage to myelin, a sheath that covers the nerve inside the brainstem. Myelin prevents cross-talk between nerve fibers, which is the cause of the pain.

According to a report by Turkish neurologists that was recently published in Headache, Botox can relieve the pain of TN in MS patients as well. They compared the response to Botox in 22 patients with primary TN and 31 with MS-related TN. Ten patients of 22 in the first group and 16 out of 31 in the second group improved with Botox. Patients who had interventional treatments in the past did not respond as well. Those who had mild continuous pain between bouts of severe pain were more likely to respond to Botox.

Botox is not the first-line treatment for TN. Medications such as carbamazepine and oxcarbazepine are. However, Botox is a very safe treatment and should be tried before considering surgery and other invasive procedures.

Go ahead, have a drink. Science proves that it won’t give you a migraine.

By: Dr. Mauskop

18-12-2022

Alternative Therapies, Migraine, Science of Migraine

Holidays are again upon us. There are many reasons why people experience more migraines this time of year. Family drama, all the delicious unhealthy food, and alcohol. A report just published in the journal Headache brings some good news. Scientists proved that alcohol does not trigger migraines.

The researchers evaluated the digital diaries of 493 migraine sufferers who reported drinking alcohol. They used sophisticated statistical analysis including standard deviations, Bayesian statistics, Markov Chain Monte Carlo simulations, and the like, to show that there was no correlation between drinking alcohol and developing a migraine the next day.

If you still insist that alcohol gives you migraines, to paraphrase Groucho Marx, who are you going to believe, the scientists or your own lying eyes?

Another amusing paper comparing red wine with vodka as a trigger of migraines was published years ago by British researchers in The Lancet

Migraine patients who believed that red wine but not vodka triggered their attacks were challenged either with red wine or vodka. It was a blinded study – patients were not told what they were drinking. Vodka was diluted to equivalent alcohol content, and both were “consumed cold out of dark bottles to disguise colour and flavour”. And indeed, only wine triggered a migraine attack. A group of French doctors responded to this study in a letter to the editor. They stated that the only thing this study proved was that the Brits can’t tell wine from vodka.

Strength training vs aerobic exercise for migraine

By: Dr. Mauskop

05-12-2022

Alternative Therapies, Brain disorders, Headaches, Migraine

Multiple posts on this blog have described clinical trials that prove the benefit of exercise for the prevention of migraine headaches.

In a recent paper published in The Journal of Headache and Pain Stanford researchers compared the efficacy of aerobic and strength training exercises. They conducted a meta-analysis of 21 clinical trials that involved a total of 1,195 migraine patients.

Simplifying the statistics, compared to no exercise, strength training was 3.55 times more effective, high-intensity aerobic exercise was 3.13 times more effective, and moderate-intensity aerobic exercise was 2.18 times more effective.

For general health and for the prevention of migraines, 2-3 weekly sessions of strength training and 2-3 sessions of aerobic exercise would be an ideal regimen. As I mentioned in a recent post, an additional benefit of exercise is a larger brain volume. The only other intervention that has been shown to expand the brain and prevent its shrinkage with age is meditation.

Exercise and meditation are the first two recommendations on my list of top 10 treatments described in my latest book, The End of Migraines: 150 Ways to Stop Your Pain.

Cognitive impairment due to migraine

By: Dr. Mauskop

25-11-2022

Brain disorders, Chronic migraine, Headaches, Migraine

According to a new report by Spanish researchers published in The Journal of Headaches and Pain, effective preventive treatment of migraines can improve cognitive impairment in patients with frequent attacks.

Patients with migraines often complain that their memory is not as good as it used to be, that they have difficulty concentrating, or can’t think clearly.

There are many possible causes of such symptoms. Stress is probably the most common reason people have trouble with memory and concentration. There is just too much on their mind. Certain drugs, most notably topiramate (Topamax), can cause pronounced cognitive impairment. Nutritional deficiencies, particularly of vitamin B12 and other B vitamins, magnesium and vitamin D can cause brain fog and other cognitive problems. Alzheimer’s disease, which is what people fear most, thankfully is rare at the age when most people suffer from migraines.

I also see patients who do not have any of the above reasons. There are several possible explanations for why migraines alone can cause cognitive problems. We know that if a patient has only a few attacks a month, the brain remains hyperexcitable even between attacks. Some patients have a prodrome – one or two days of brain dysfunction prior to an attack. Others have post-drome – a feeling of exhaustion as if being hungover for a day or two after the attack. There is also a likely contributing effect of anticipatory anxiety – living in fear of the next attack.

Christina Gonzalez-Mingot and her colleagues in Lleida, Spain, compared 50 control subjects and 46 patients with chronic migraine. These patients were evaluated using a battery of tests prior to the use of preventive treatment based on botulinum toxin (Botox) or oral drugs and after 3 months of this treatment.

Compared with controls, patients with chronic migraine had lower scores on three standard tests of cognitive performance and had lower quality of life. Three months after the use of preventive treatment, improvement was observed in all but one cognitive parameters and in the quality of life.

Thiamine (vitamin B1) may be more effective for migraines than riboflavin (vitamin B2)

By: Dr. Mauskop

20-11-2022

Alternative Therapies, Headache medications, Migraine, Science of Migraine

Riboflavin (vitamin B2) has been a popular supplement for the prevention of migraine headaches. The evidence for its efficacy is limited. Only one small double-blind, placebo-controlled trial showed that a very high dose of riboflavin (400 mg daily) is better than a placebo. The study included only 55 patients, which makes the results not very reliable. Besides, the difference between the riboflavin and the placebo groups appeared only in the third month. There was no difference during the first two months. This study was published over 20 years ago and my clinical impression over this long period of time has been fairly negative.

A study just published in the journal Headache examined dietary intake of riboflavin and thiamine (vitamin B1) and correlated it with the occurrence of migraines or severe headaches. The researchers used the data from 13,439 adult participants in the National Health and Nutrition Examination Survey conducted between 1999 and 2004 in the United States. They found that people with a high intake of thiamine were significantly less likely to suffer from severe headaches or migraines. This was more pronounced in women. They found no such association for riboflavin.

Supplements with the most evidence in treating migraines are magnesium and CoQ10. I recommend riboflavin, folate (vitamin B9) and vitamin B12, to patients with an elevated homocysteine level. Excessive amounts of this amino acid are damaging to blood vessels and may be responsible for the increased risk of strokes in patients who have migraine with aura. It is worth checking homocysteine levels in all patients who have migraine auras, even if the auras occur infrequently.

“B complex” is a popular combination of various B vitamins. This latest paper is making me consider adding B complex rather than individual B vitamins to magnesium and CoQ10 in all of my migraine patients.

Microdosing for chronic pain

By: Dr. Mauskop

14-11-2022

Alternative Therapies, Chronic migraine, Headache medications, Headaches, Migraine, Pain, Pain Research

Psychedelics are being actively studied for depression and post-traumatic stress disorder (PTSD). These trials usually involve hallucinogenic doses. Microdosing psychedelic substances such as psilocybin, lysergic acid diethylamide (LSD), and methylenedioxymethamphetamine (MDMA) has become a popular treatment for depression. Microdosing means that the amount of a psychedelic is too low to cause hallucinations or other overt sensory experiences.

There is an accumulation of evidence that psychedelics can provide pain relief. A case series just published in the journal Pain describes three patients with chronic pain who obtained significant relief from microdosing psilocybin-containing mushrooms.

The first patient was a 37-year-old man with severe pain due to traumatic quadriplegia. He had almost complete relief of pain and was able to stop taking tramadol, an opioid analgesic, diazepam (Valium), and marijuana. The relief was ongoing for six months when he was last seen by the doctors.

The second patient was a 69-year-old woman with complex regional pain syndrome (also known as reflex sympathetic dystrophy) secondary to left leg trauma. She had tried nerve blocks, other invasive procedures, stem cell injections, acupuncture, opioid analgesics, and many other medications, all with no relief. At the time of the published report, microdosing was providing continued significant relief for over a year.

The third patient was a 40-year-old woman with pain in her leg due to degenerative disk disease in her spine. Her pain did not improve with epidural injections, back surgery, muscle relaxants, opioid drugs, and physical therapy. Psychedelic mushrooms had a profound effect on her pain.

Psychedelic mushrooms have been reported by many patients to be effective in the treatment of cluster headaches (see ClusterBusters.org). A small double-blind study by Yale researchers showed a beneficial effect of synthetic psilocybin in treating migraine headaches.

It remains to be proven that sub-hallucinogenic doses of psychedelic drugs provide relief of painful conditions. If proven effective, however, such drugs will offer a much safer option than any opioid and NSAID analgesics, epilepsy drugs, antidepressants, or any other prescription drug. They are very safe even at hallucinogenic doses.

I am often asked about the practical side of using psychedelic mushrooms – where to buy them, how much to take, and for how long. Since the state of NY, unlike some other states, has not legalized or decriminalized the use of psychedelic mushrooms, I cannot answer these questions. Even if it was legal for me to do, I would not have reliable answers until clinical trials give us good data.

Acupuncture relieves chronic tension-type headaches

By: Dr. Mauskop

07-11-2022

Alternative Therapies, Headaches

A recent study by Chinese researchers showed that acupuncture is an effective treatment for tension-type headaches. The results were published in a leading neurology journal, Neurology. Being published in such a journal suggests that the study was scientifically rigorous and the results are likely to be reliable.

The study included 218 patients with half receiving true acupuncture and the other half, sham acupuncture. In the first group, after inserting each needle, the acupuncturist induced a specific deqi sensation. Patients describe it as a sensation of fullness, aching, or tingling. You can experience this sensation without needles – try squeezing hard the thick muscle between your thumb and the index finger. Needling or pressing on this acupuncture spot can provide relief of a headache and facial pain. The second, control group, had needles inserted without any further manipulation.

The main outcome measure in this trial was the number of patients who achieved at least a 50% reduction in the number of monthly headache days. In the true acupuncture group, 68% achieved this result compared to 48% in the control group. The difference was statistically highly significant.

These results are not surprising. Hundreds of clinical trials (admittedly, of varying quality) have shown that acupuncture can relieve migraine headaches and other painful conditions.

I am a licensed acupuncturist but use this treatment very infrequently. It is time-consuming (it should be done at least once a week) and expensive, especially if done by an MD (it is not covered by most insurance plans). For patients who are interested in trying it, I recommend finding a conveniently located non-physician acupuncturist whose fees are usually more affordable.

The 6th Annual International Headache Symposium in Israel

By: Dr. Mauskop

29-10-2022

Alternative Therapies, Botox, Chronic migraine, Headache medications, Migraine, New treatments, Science of Migraine

It was an honor to speak in Israel at the 6th Annual International Headache Symposium along with past presidents of the International Headache Society, Drs. Messoud Ashina and Alan Rapaport, the current IHS president, Cristina Tassorelli, the president-elect, Dr. Rami Burstein, and other leading headache experts. The symposium was organized by the President of the Israeli Headache Association, Dr. Oved Daniel, and by Dr. Arieh Kuritzky.

The 2nd edition of The End of Migraines, 150 Ways to Stop Your Pain was just published

By: Dr. Mauskop

15-10-2022

Uncategorized

The second updated and expanded edition of The End of Migraines, 150 Ways to Stop Your Pain is now available on Amazon.com. The book is available as an ebook, paperback and hardcover. I would recommend getting the Kindle or ebook version as it has over 100 hyperlinks to original articles and other resources.

Thank you to all of my colleagues who gave a rousing endorsement for the first edition. This a self-published book without the marketing force of a major publisher. If you read it, please post a review on Amazon and spread the word about it.

How to treat nummular headache

By: Dr. Mauskop

05-10-2022

Alternative Therapies, Botox, Headaches

Nummular (coin-shaped) headache is an uncommon condition. It is defined as intermittent or continuous pain in a small circumscribed area of the scalp with the following four characteristics: sharply-contoured, fixed in size and shape, round or elliptical and 1-6 cm in diameter. The pain is usually mild or moderate in intensity, but some patients have severe pain. These headaches often occur in patients who also have migraines.

Nummular headaches often respond to ibuprofen, naproxen, and other NSAIDs. Botox injections are also very effective. They provide relief for 3 months, obviating the need for daily medications which are more likely to cause side effects. A very small amount of Botox is needed to treat nummular headaches, so the cost is much lower than when treating migraine headaches.

A case report just published in the journal Headache describes a patient who suffered from migraines and nummular headaches. His nummular headaches did not respond to medications and Botox injections but he had complete elimination of his nummular headaches along with improvement of his migraines after he received an injection of galcanezumab (Emgality).

Galcanezumab and other CGRP monoclonal antibodies have been also reported to help trigeminal neuralgia as has rimegepant (Nurtec ODT), an oral CGRP receptor blocker. It is possible that nummular headache is the result of damage or irritation of a small terminal branch of a nerve. This is suggested by the fact that the pain is invariably superficial. And we know that CGRP is involved in pain messaging along the nerves. So it is not surprising that anti-CGRP drugs can help relieve nummular headaches.

Exercise prevents not only migraines but also shrinkage of the brain

By: Dr. Mauskop

26-09-2022

Alternative Therapies, Brain disorders, Headaches, Migraine, Science of Migraine

Regular exercise has been proven to prevent migraine headaches in many studies. A Swedish study of 91 patients established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate, however, caused significant side effects. Another study by the same group of researchers of 46,648 people found a strong inverse correlation between physical activity and the frequency of headaches.

A report by German researchers in the September 13 issue of the journal Neurology provides strong evidence that physical activity leads to larger brain volumes. This was a rigorous study that included 2,550 participants. The physical activity was measured using an accelerometer, a device similar to a fitness tracker.

The authors discovered that “Physical activity dose and intensity were independently associated with larger brain volumes, gray matter density, and cortical thickness of several brain regions.” The most notable change occurred in people who went from a sedentary lifestyle to a modest amount of low-intensity exercise when compared with those who already engaged in at least moderate amounts of physical activity. And this trend continued – very high frequency and intensity of training did not offer any additional benefits.

Two other reports of various benefits of exercise were published this month.

One was a study published in JAMA Neurology. This study also used accelerometers to count the steps made by 78,430 people. The researchers found that a higher number of steps prevented the development of dementia. The optimal dose was just under 10,000 steps and a higher speed had an additional benefit.

The second report in JAMA Internal Medicine analyzed the same group of 78,430 people and discovered that accumulating more steps per day (up to 10,000) may be associated with a lower risk of all-cause, cancer, and cerebrovascular disease mortality and incidence of cancer and cerebrovascular disease. Here they also found that a higher step intensity may provide additional benefits.

Daxxify, a new Botox competitor

By: Dr. Mauskop

08-09-2022

Alternative Therapies, Botox, Chronic migraine, Headache medications, Headaches, Migraine, New treatments, Pain

No, Daxxify is not really a competitor in the treatment of chronic migraines or any other medical condition. Daxxify, a new botulinum toxin, was just approved by the FDA only for cosmetic use. Daxxify does stand out from five other botulinum toxin brands in that its effect lasts longer. The other toxins are Xeomin, Dysport, Jeuveau, and Myobloc. Myobloc is approved only for medical conditions, Jeuveau only for cosmetics, and Xeomin and Dysport are approved for both cosmetics and a few medical conditions.

Initially, Botox was approved by the FDA in 1989 to treat eye problems. Since then, it has been approved for many medical and cosmetic indications, including chronic migraine. None of the other toxins are approved for such a wide range of indications. It remains by far the most widely used type of botulinum toxin with tens of millions of people treated for medical and cosmetic reasons.

Yes, having a longer-acting botulinum toxin is an advantage. You will need to have less frequent treatments. However, if you have any side effects, they will also take longer to go away. We are talking mostly about cosmetic side effects, such as droopy eyelids. When treating headaches, with proper technique, side effects are uncommon. These may include weakness of the neck muscles or, if treating TMJ syndrome, difficulty chewing.

Since Botox is approved by the FDA for chronic migraines, Botox is the drug insurance companies cover. Allergan (a division of Abbvie), the manufacturer of Botox, has many more years left on their patent to treat chronic migraines. Botulinum toxin is a biological product (made by bacteria rather than synthesized from chemicals) and every version of it is slightly different. This is why when Allergan’s patent to treat migraines expires, the competitors will have to conduct large trials to prove that their product is also effective for migraines.