Headache NewsBlog

Post-COVID headaches

By: Dr. Mauskop

19-08-2022

Brain disorders, Chronic migraine, Headaches

Headache is a common symptom of any infectious illness, including COVID. A group of Spanish researchers analyzed six published studies of headaches in adult Spanish COVID patients.

According to their review, headache is an early symptom of COVID. It typically lasts two weeks. Patients in these studies were followed for up to a year. One out of five patients had developed a headache that persisted for at least a year. Women and older patients were more likely to be affected. This persistent headache most often resembled chronic migraine. The pain was throbbing with associated sensitivity to light and noise, and worsening with physical activity. The authors did not observe a difference between patients with and without prior history of headache. Patients with more intense headaches were more likely to develop a chronic headaches.

The published studies reviewed by the authors did not address the treatment of headaches. Considering that the persistent headaches resembled migraines, we tend to treat them as we do chronic migraines. This means the use of antidepressants, epilepsy drugs, blood pressure medications, Botox, triptans, and CGRP drugs (both oral and injectable). It is likely that with early and aggressive treatment, many patients would not have headaches persist for such a long time. Doctors in Europe are less likely to prescribe medications and use Botox in headache patients than we are in the US.

COVID vaccination also carries a risk of developing persistent headaches. As mentioned in a previous post, people who received Pfizer or Oxford-AstraZeneca vaccine were twice as likely to develop a headache as those who received the placebo. The headache in these patients also tended to resemble migraine.

If the effect of Botox does not last 3 months, taking a zinc supplement might help.

By: Dr. Mauskop

08-08-2022

Alternative Therapies, Botox, Headaches, Migraine

Dr. Brian Loftus, a Texas neurologist, alerted me to the possibility that the shortening of the effect of Botox can be reversed by taking a zinc supplement. Dr. Loftus shared an unpublished report by Houston physicians who showed that zinc supplementation can extend the effect of Botox.

There is a good theoretical reason to suggest that for Botox to work, you need to have sufficient amounts of zinc. You can read about this connection in a review article by one of the leading movement disorders specialist, Dr. Mark Hallet. He concludes that “Toxins are zinc dependent proteases, and supplemental zinc may produce a greater effect.”

It is very likely that taking zinc will benefit mostly people who are deficient. I just saw a patient in whom Botox provides relief for only 2 months and whose blood test showed a low zinc level. I suggested that he takes 50 mg of zinc every day.

Zinc is necessary for the activity of over 100 different enzymes that are involved in vital chemical processes of the body. Zinc is involved in the immune system, growth of cells, building proteins, and many other functions.

We might consider adding zinc to the usual battery of tests done on the first visit to our clinic. These include RBC magnesium, vitamins B12 and D, and routine blood tests.

Migraine patients stick with Botox longer than with injections of CGRP mAbs

By: Dr. Mauskop

30-07-2022

Botox, Headache medications, injections, Migraine

Patients with chronic migraine who were started on Botox were significantly more likely to continue to be treated with Botox after one year than patients who were started on a CGRP monoclonal antibody (mAb). mAbs are given monthly by injection. This category includes erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality).

The results of this large retrospective study that included 1,974 patients were presented at the last meeting of the American Headache Society held in June of this year. The lead authors were Dr. Todd Schwedt of the Mayo Clinic and Dr. Andrew Blumenfeld.

The study was sponsored by the manufacturer of Botox which makes it inherently biased. However, the difference between the two groups was striking. Of patients who were started on Botox, 66% continued the treatment at the end of the year. Less than a third of patients who were started on a mAb were still getting it at the end of the year.

The researchers looked at differences in outcomes in patients enrolled before and during COVID. The results were similar before and during the pandemic. This is surprising because, during the pandemic, many patients were reluctant to come to the office for Botox injections. Many preferred to self-inject mAbs at home. Despite this obstacle, Botox patients were twice as likely to continue treatment at the end of the year.

Besides efficacy, the major reason I recommend Botox ahead of mAbs and other drugs is its proven long-term safety. Botox was first approved by the FDA in 1989. Botox is my preferred treatment for chronic migraines even in pregnant women.

Both mAbs and Botox are fairly expensive. The same group of researchers presented a second study that evaluated all-cause and migraine-related costs in these two groups of patients. They found no difference in total healthcare costs and migraine-related costs, including emergency department expenses.

Rimegepant for trigeminal neuralgia: a case report

By: Dr. Mauskop

18-07-2022

Brain disorders, New treatments, Pain, Trigeminal and other neuralgias

A case report presented at the annual meeting of the American Headache Society described a patient with trigeminal neuralgia (TN) whose pain responded well to rimegepant (Nurtec). Rimegepant is a drug approved for the acute and preventive treatment of migraines. This patient did not obtain relief from surgery and several medications. He was taking 300 mg of oxcarbazepine, buprenorphine (narcotic) patch, and up to 120 mg of oxycodone with partial relief. Within 12 hours of starting rimegepant he was pain-free. In the six months of taking rimegepant he experienced very infrequent and mild pain.

There have been several reports indicating that injections of CGRP monoclonal antibodies such as erenumab can relieve the pain of TN. So it is not surprising that an oral CGRP drug helped this patient.

I’ve treated several TN patients with CGRP antibodies. One such patient has been receiving injections of galacanezumab for over 3 years. He requires injections of 240 mg every 3 weeks and also has to take daily medications. This combination has allowed him to be fully functional and to keep his job. I may now try him on an oral CGRP drug.

In addition to rimegepant, there are two other oral CGRP drugs – ubrogepant (Ubrelvy) and atogepant (Qulipta). They are very similar but many patients have a clear preference for one over the others. It may be worth trying them all if the first drug is not fully effective. A major obstacle to using these medications “off label” for TN is their high cost.

Magnesium and migraines – an interview with Dr. Amelia Scott Barrett

By: Dr. Mauskop

11-07-2022

Alternative Therapies, Chronic migraine, Migraine, Science of Migraine

Last week I spoke to Dr. Amelia Scott Barrett, a neurologist and headache specialist based in Denver. She shares my interest in combining medications with various non-drug therapies. In our first conversation, we discussed the role of magnesium in treating migraines.

The 6th Annual International Headache Symposium in Israel

By: Dr. Mauskop

06-07-2022

Alternative Therapies, Chronic migraine, Headaches, Migraine, Science of Migraine

The 6th Annual International Headache Symposium in Israel will be held at Daniel Hotel, Herzliya (8 miles from Tel Aviv), on October 27, 2022. THe symposium is organized by the President of the Israeli Headache Association, Dr. Oved Daniel and by Dr. Arieh Kuritzky.

I am honored to have been invited to speak alongside the President of the International Headache Society Dr. Messoud Ashina, Dr. Rami Burstein of the Harvard Medical School, and other leading headache experts. The topic of my presentation will be “What to do when nothing works”. Other topics to be discussed include, Molecular signaling pathway in migraine: update, (Messoud Ashina), Connecting the line between dizziness, occipital headache, muscle tenderness and the cerebellum (Sait Ashina), Open-label studies: do they have any value? (Cristina Tassorelli), and others.

You can see the full program and registration information on this website.

Intravenous magnesium prevents migraines in children

By: Dr. Mauskop

27-06-2022

Alternative Therapies, Headaches in children, Migraine

Regular intravenous infusions of magnesium prevented migraines in five children, according to a report presented at the annual meeting of the American Headache Society by A.J. Freed and S. Sahai-Srivastava. The children were between the ages of 11 and 16. Four of them had the diagnosis of chronic migraines and one, episodic. Two of them continued to have daily headaches but they were mild with the infusions. The other three also had a significant drop in the number of headache days.

Over the past 30 years, we’ve given monthly infusions to thousands of patients, including children as young as 6. Genetic factors play a role in some patients with magnesium deficiency. We’ve had three generations of a family coming for monthly infusions. Besides genetics, other reasons for magnesium deficiency include stress, alcohol, gastrointestinal disorders, poor diet, and others.

About half of migraine sufferers are deficient. They are likely to respond to oral magnesium supplementation. Many, however, do not absorb magnesium taken by mouth. If we know that a patient is deficient because they have other symptoms of magnesium deficiency (cold extremities, muscle cramping, PMS, palpitations, brain fog, and others) or because their blood level (RBC magnesium) is low or is at the bottom of the normal range, we give magnesium intravenously.

If you cannot find a doctor who gives infusions of magnesium, you may want to search for an infusion center or an urgent care facility that would do it. In many large cities, magnesium and vitamin infusions are done at some spas. There are also companies that offer home visits by a nurse.

Acute migraine therapy in pregnancy – triptan is the safest choice.

By: Dr. Mauskop

20-06-2022

Chronic migraine, Headache medications, Migraine, Migraine in pregnancy

Two out of three women stop having migraines during pregnancy, especially in the second and third trimester. The difficult question is how to treat migraines in the first trimester and in women whose migraines do not improve or get worse in pregnancy.

Acetaminophen (Tylenol, paracetamol) is considered safe in pregnancy and that is what many women take for migraines and other pains. Unfortunately, acetaminophen is usually ineffective for severe migraines. It is also not as safe as many physicians and the general public thinks. Several studies indicate that acetaminophen increases the risk of attention-deficit hyperactivity disorder (ADHD) and with heavy use, possibly even autism spectrum disorder.

Some obstetricians strongly advise against taking any migraine medications. However, the stress of an acute migraine attack with severe pain, vomiting, and dehydration is likely to have a deleterious effect on the fetus. A Danish study of 22,841 pregnancies among women with migraine showed that untreated migraine leads to an increased risk of low birth weight, preterm birth, and cesarean delivery.

A report just published in the journal of the American Medical Association (JAMA) examined “Association of Maternal Use of Triptans During Pregnancy With Risk of Attention-Deficit/Hyperactivity Disorder in Offspring”.

The study used the data from the Norwegian Mother, Father and Child Cohort Study, linked to the Medical Birth Registry of Norway, the Norwegian Patient Registry, and the Norwegian Prescription Database using the mother’s personal identification number. The conclusion of this large and rigorous study was: “This cohort study found no association between prenatal triptan exposure and ADHD diagnosis or ADHD symptoms at 5 years of age. This study adds to the growing literature on the safety of triptan use during pregnancy and expands it to an important neurobehavioral outcome.”

Triptans have been available without a prescription in all European countries for over a decade. In the US, triptans are available only by prescription. This is one of the reasons for the perception of acetaminophen as being more benign than sumatriptan and other triptans. The opposite is likely to be true. If you are a pregnant woman suffering from severe migraines, ask your doctor for a prescription for sumatriptan.

Cove presents its data on the efficacy of telemedicine in treating migraines

By: Dr. Mauskop

11-06-2022

Alternative Therapies, Chronic migraine, Headaches, Migraine

With tens of millions of Americans suffering from migraines, access to care is a major problem. Cove, a telemedicine startup, offers a practical and affordable solution. They deliver evidence-based therapies to patients in need. To prove that their approach works, Cove collects and analyzes vast amounts of data. The study I just presented at the annual scientific meeting of the American Headache Society shows that with Cove underserved minorities obtain excellent outcomes that are equal to those of whites.
Disclosure: I am a paid consultant to Cove.

Triptans are safe even in those with cardiovascular conditions – a new report

By: Dr. Mauskop

10-06-2022

Chronic migraine, Headache medications, Migraine

A paper presented at the annual meeting of the American Headache Society that is taking place this weekend examined the risk of major adverse cardiovascular events (MACE) in patients with preexisting cardiovascular (CV) conditions. The researchers compared the risk of triptans with that of opioid/barbiturate drugs (drugs like codeine, Vicodin, Percocet, Fioricet) and non-steroidal anti-inflammatory drugs (NSAIDs).

They used Mass General Brigham Research Patient Data Registry database to identify 12,121 prescriptions. Of these, 33% were for triptans, 50% for opioid/barbiturate drugs, and 17% for NSAIDs.

MACE occurred in 1% of those taking triptans, 4.5% taking opioid/barbiturate drugs, and 3.8% taking NSAIDs.

This goes against the established dogma of avoiding triptans in patients with CV problems. Instead, doctors are advised to offer opioid/barbiturate drugs or NSAIDs. Unfortunately, according to the FDA-approved package insert, triptans are contraindicated in patients with CV, cerebrovascular, and peripheral vascular problems. This contraindication came about from purely theoretical reasoning rather than real-life experience. Triptans do in fact have mild vasoconstriction properties and it is possible that someone with severe occlusion of coronary or other blood vessels can have dangerous constriction of a blood vessel. There have been also reports of healthy people developing cardiovascular complications, but those are very rare.

This new data indicates that triptans are safer than the alternatives most doctors prescribe. The two alternatives described in the report also carry significant risks of addiction, stomach ulcers, and bleeding. It is very likely, however, that doctors will continue to avoid prescribing triptans in this population because of legal concerns and ingrained habits.

We do have two new classes of drugs to treat an acute migraine attack that are proven to be safe in patients with CV conditions. These are gepants – rimegepant (Nurtec) and ubrogepant (Ubrelvy) as well as ditans – lasmiditan (Reyvow). These drugs are very expensive and insurers always require that patients first try other drugs.

Another study confirms vascular safety of triptans

By: Dr. Mauskop

04-06-2022

Chronic migraine, Headache medications

Sumatriptan (Imitrex) and other triptans have been available without a prescription in all European countries for over a decade. A new study by Austrian researchers published in the current issue of Headache confirms the outstanding safety of these drugs.

The study looked at 13,833 people over 50 years of age who were prescribed a triptan in 2011, the year before triptans became available over-the-counter. The comparison group included 41,400 triptan non-users. Of the 13,833, 19% were older than 65. The researchers established that 16% “overused” triptans, defined as getting more than 30 doses in a 90-day period, although the concept of “overuse” clearly lacks a scientific basis.

They discovered that those who were taking triptans did not spend more time in a hospital. They also did not have a higher frequency of heart attacks, hypertension, irregular heartbeats (arrhythmias), strokes, circulation problems in their extremities, or other vascular problems. This was true even for those who “overused” triptans.

These findings are consistent with the “Consensus Statement: Cardiovascular Safety Profile of Triptans in the Acute Treatment of Migraine” by the Triptan Cardiovascular Safety Expert Panel published in 2004. It states “The incidence of serious cardiovascular events with triptans in clinical trials and clinical practice appears to be extremely low “.

Unfortunately, in the US triptans are available only by prescription. About 15 years ago, the FDA blocked an application by the American Home Products (a company that Pfizer later acquired) to launch over-the-counter sumatriptan. This greatly restricts access to a highly effective and safe migraine drug. Many physicians remain under the impression that triptans cause heart attacks, strokes, and other dangerous side effects. My patients often tell me that this is what their previous doctor warned them about.

It is clear that triptans are safer than Excedrin, aspirin, ibuprofen, or naproxen. Several dozen of my patients have been taking triptans daily for years. They do not have medication overuse headaches, do not suffer any long-term side effects, and do enjoy disability-free life.

Primary stabbing headache

By: Dr. Mauskop

22-05-2022

Brain disorders, Headaches

Primary stabbing headache is a rare disorder. Because it is rare, it is often misdiagnosed and not treated properly. This post was prompted by a patient with this condition I saw last week. She went undiagnosed for 45 years.

This 57-year-old woman has been having intermittent headaches since age 12. Her headaches would occur in bouts lasting anywhere from a few days to a couple of weeks. She’s had periods of up to a year without any headaches. Her latest period of daily headaches has been the longest – it has lasted almost 4 weeks and was still ongoing. Her headaches were left-sided and localized to the temple. The pain was very severe in intensity (9 on a 1 to 10 scale), sharp and stabbing in character. The pain lasted only a second but occurred 1-2 times an hour. She was having difficulty working as her work involved being in a videoconference all day long. She had no associated tearing, nasal congestion, nausea, or sensitivity to light or noise. She was taking 400 to 800 mg of ibuprofen with modest relief. During one of her previous bouts, she had tried gabapentin, 100 mg three times a day, which helped initially, but then became ineffective and she stopped it.

As is the case with all rare conditions, controlled treatment trials are very difficult to do. Anecdotally though, indomethacin, a strong anti-inflammatory drug, seems to be very effective. Gabapentin, which the patient tried in a small dose, has been also reported to help. I prescribed indomethacin as her first treatment.

If headaches persist or if indomethacin causes stomach upset or other side effects, I will start her on gabapentin, 300 mg three times a day. There are two other rare indomethacin-sensitive headache types – hemicrania continua and chronic paroxysmal hemicrania. A few reports suggested that an herbal supplement, Boswellia can be effective for patients who cannot tolerate indomethacin. After that, another reasonable option would be to try Botox injections. Botox has been reported to help hemicrania continua, chronic paroxysmal hemicrania, cluster, and other types of headaches. Because the area where she experiences pain is small and circumscribed, she will need a very small amount of Botox, making it relatively inexpensive.