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Tag "headache"

Headache Relief is a new iPhone app which I developed to help patients better manage their headaches.  The main feature of the app is a headache diary.  A summary of all your diary entries can be emailed to yourself or your doctor in an Excel spreadsheet form.  I find that patients who keep a diary benefit from it in many ways.  The diary makes it easier to figure out what may be causing your headaches, how well the treatment works, and allows you to better control your headaches.  The potential triggers that are recorded in the diary include stress, menstrual cycle, food, sleep, and other.  Weather can be a major contributor and the three most common weather-related triggers are temperature, humidity and barometric pressure.  A unique (and very neat) feature of this app is that if you to enter your zip code these three weather parameters will be downloaded into your diary.  The app also contains an e-book with a wealth of information on headaches, natural and pharmacological therapies.  And the price is right – it’s free.  Please let me know what you think or better still, post your evaluations on the iTunes store.

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Botox appears to be effective for peripheral nerve pain according to a study by French researchers.  This finding is consistent with my observation that injecting Botox into the skin of the top of the head in patients with headaches relieves pain in that area.  When I started injecting botulinum toxin (Botox) for headaches about 15 years ago the assumption was that Botox works by relieving spasm of muscles in the forehead, temples, back of the head, and neck.  However, some patients would come back and report that their headache was gone in the injected areas, but not on the top of the head.  When gave additional injections the top of the head pain also stopped.  I also see patients who get Botox injections for their headaches from dermatologists or plastic surgeons and do not obtain adequate relief.  This is usually because only the front of the head is injected, rather then all areas of pain.   There have been other reports of Botox relieving pain of diabetic as well as trigeminal neuralgia, however the French group conducted a very rigorous double-blind study which provides scientific proof of pain-relieving properties of Botox.

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Dr. Oz : “Like Alexander Mauskop, I believe that magnesium can help—it relaxes arteries and muscles in the body, both of which can help with headaches”.   This statement in the latest issue of O, The Oprah Magazine is not very surprising coming from a cardiac surgeon – magnesium is routinely used after open heart surgery.  Unfortunately, many neurologist and other physicians treating headaches still do not recommend magnesium for their headache patients.  And this is despite all the scientific evidence and despite the recommendation of the American Academy of Neurology.  I think this is in part due to their training that emphasizes the use of drugs rather than natural approaches.  This bias is reinforced by the strong influence of the pharmaceutical industry.

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Two large trials of Botox provide unequivocal proof of its efficacy in the treatment of chronic migraine headaches.  The results of these two double-blind, placebo-controlled studies (I participated in one of the two trials) of onabotulinumtoxinA (Botox) in chronic migraines were presented at the International Headache Congress in Philadelphia last week.  Botox was proven to reduce the number of days with headaches, improve multiple headache symptoms, and improve the quality of life.  The treatment was extremely well tolerated with very few side effects overall and no serious side effects.   Having used Botox for the treatment of various headache types for over 15 years in several thousand patients it is very gratifying to finally have well-designed trials which confirm my and my colleagues’ experience.   The manufacturer is submitting the results of these trials to the FDA and we expect to have approval of Botox for the treatment of chronic migraines by the end of 2010.  FDA approval will force insurance companies to pay for this highly effective treatment and will make it affordable for people who desperately need it.

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A blood pressure medication telmisartan (Micardis) was shown to be effective in the prevention of migraine headaches by a group of German researchers led by H-C Diener.  Several blood pressure medications have been proven to prevent migraine headaches.  The oldest category of blood pressure drugs, beta-blockers have the most evidence to support their use and two of them (propranolol and timolol) are approved by the FDA for the preventive treatment of migraines.  However, beta-blockers are not high on my list because they tend to cause more side effects than other blood pressure medications.  The most common side effects are due to excessive lowering of blood pressure – lightheadedness, fatigue, and fainting.  They also slow down the heart rate, which can make it difficult to exercise, while regular aerobic exercise is the first treatment I recommend to my headache patients.  Calcium channel blockers, such as verapamil, are not as effective for migraine prevention as they are for the prevention of cluster headaches and can cause constipation, swelling and irregular heart beats.  Another blood pressure medication, lisinopril which belong to the family of ACE inhibitors has also been shown to prevent migraine headaches.  The most common limiting side effect of ACE inhibitors is coughing.  A newer group of medications, which are similar in action to ACE inhibitors is ACE receptor blockers, or ARBs.  ARBs do not cause coughing and telmisartan which is one of the ARBs caused as few side effects as the placebo.

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Good news for adolescents with chronic daily headaches (CDH) was reported by Taiwanese researchers followed 122 kids, aged 12 to 14 who were diagnosed with this condition.  A year later 40% still had CDH, and after 2 years, 25% had symptoms of CDH.  They followed 103 of the original 122 for 8 years and found that only 12% still had daily headaches with 10 out of 12 diagnosed as having chronic migraines.  This is what we see in practice, but now we have good evidence and can be more certain when we tell our adolescent patients and their parents that they will “grow out” of their headaches.  Another piece of good news was that most kids were not actively treated and headaches improved on their own.  However, it may take months or years for headaches to improve and we should not just sit and wait while the child suffers.  Active treatment includes sleep hygiene, regular exercise, avoiding dietary triggers, biofeedback or relaxation training, magnesium, CoQ10 and other supplements, possibly acupuncture, Botox injections and medications.

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In my post 2 years ago I wrote about surgery for migraines and the many reasons why Botox injections is a better option than surgery to permanently cut nerves and muscles.  I also wrote that there were no controlled studies to show that surgery actually works.  Now we do have one study.  The study was blinded, which means that some patients had nerves and muscles cut, while others had only a skin incision.  The results were much better in patients who had real surgery.  The plastic surgeons who performed the study tried their best to produce a blinded study, but they admit that blinding is far from perfect since patients who had real surgery can see their muscles shrink or not move.  But even if we accept that blinding was achieved and surgery indeed provides relief of headaches, all of my other arguments stand.  These include surgical risks (bleeding, infection, scarring, and persistent nerve pain) and high cost.  Yes, Botox is expensive too, but migraine usually is not a life-long illness and migraine attacks often stop for long periods of time or permanently with or even without treatment.  I have seen many patients whom I treated with Botox every 3 months and whose headaches stop after a year or two.  Two years of Botox treatments is significantly cheaper than surgery and it does not carry all of the surgical risks.

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Occipital nerve stimulation appears to be a promising new treatment for migraine and cluster headaches.  Phase II trials performed by Medtronics, the manufacturer of one type of  stimulator, have been positive.  This stimulator requires implantation of a stimulator wire next to the occipital nerves and a separate incision to implant a stimulator device with a battery in the upper chest.  A recent report suggests that the same effect can be achieved by implanting a small self-contained device without the need for wires, large battery, or a separate incision.  This “Bion Microstimulator” has not been subjected to any extensive studies similar to ones  performed by Medtronics, but the preliminary data looks promising.

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Headache diary plays an important role in the management of headache patients.  Drs. McKenzie and Cutrer from the Mayo Clinic compare patient recall of migraine headache frequency and severity over 4 weeks prior to a return visit as reported in a questionnaire vs a daily diary.   Here are some of their findings “Many therapeutic decisions in the management of migraine patients are based on patient recall of response to treatment.  As consistent completion of a daily headache diary is problematic, we have assessed the reliability of patient recall in a 1-time questionnaire.  209 patients completed a questionnaire and also maintained a daily diary over the 4-week period. RESULTS: Headache frequency over the previous 4 weeks as reported in interval questionnaires (14.7) was not different from that documented in diaries (15.1), P = .056. However, reported average headache severity on a 0 to 3 scale as reported in the questionnaire (1.84) was worse than that documented in the diaries (1.63), P < .001. CONCLUSIONS: In the management of individual patients, the daily diary is still preferable when available. Aggregate assessment of headache frequency in groups of patients based on recall of the prior 4 weeks is equally as reliable as a diary. Headache severity reported in questionnaires tends to be greater than that documented in daily diaries and may be less reliable. “

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Physical inactivity was strongly associated with headache disorders, according to a large study by Swedish researchers published in Headache.  They looked at 43,770 people with recurrent headaches and migraines and found that economic hardship and psychosocial factors (poor social support and experience of being belittled) seem to play a role in headache disorders.   Of lifestyle factors, physical inactivity was strongly associated with headache disorders, while smoking to a lesser extent.  Skipping breakfast, being overweight and underweight seemed to be connected to headaches.

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Magnesium is effective in preventing migraine headaches according to a new study published in the last issue of journal Magnesium Research.  The researchers found that patients treated with magnesium, compared to those treated with placebo, had fewer migraine attacks and the attacks were milder.  In addition, magnesium treated patients had improved blood flow in their brains, while those on placebo did not.  This is just another confirmation of previous findings of the efficacy of magnesium in the treatment of migraine headaches.  Since magnesium is very inexpensive and extremely safe, every patient with migraine headache should be given a trial of magnesium supplementation.

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15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by the German government.  Results published in the latest issue of journal Cephalalgia by S. Jena and colleagues indicate that “acupuncture plus routine care in patients with headache was associated with marked clinical improvements compared with routine care alone”.  This study should dispel any remaining doubt about the efficacy of acupuncture in the treatment of headaches.

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