migraine | Headache NewsBlog

Neck weakness and tension-type headaches

By: Dr. Mauskop

13-05-2015

Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

Narcotics (opioids) are still overused in ERs for migraines

By: Dr. Mauskop

11-05-2014

Headaches, New treatments

Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers.

In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn’t changed.

Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx.

In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients.

Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not cause addiction and rebound (medication overuse) headaches, which narcotics do.

Dr. Friedman and his colleagues looked at the national data for 2010 and found that there were 1.2 million visits to the emergency departments for the treatment of migraine. Migraine was the 5th most common reason people come to the emergency room.

They also discovered that people who were given a triptan in the emergency department had an average length of stay in the ER of 90 minutes, while those given Dilaudid (hydromorphone) – the most popular narcotic, stayed in the ER for an average of 178 minutes.

Opioids should be used only occasionally – when triptans, ketorolac, and metoclopramide are ineffective or are contraindicated. This should be the case in maybe 5% of these patients, according to Dr. Friedman

One possible reason why ER doctors do not follow recommended treatments and use narcotics instead, is that they do not recognize a severe headache as migraine and misdiagnose it as sinus, tension-type or just as a “severe headache”. Many doctors still believe that migraine has to be a one-sided headache, or a visual aura must precede a migraine, or that the pain has to be throbbing. It is well established that none of these features are required for the diagnosis of migraine.

Another possible reason for the widespread use of opioid drugs in the ER is that doctors are very accustomed to using them, while triptans may be unfamiliar and require thinking about potential contraindications, what dose to give, what side effects to expect, etc.

In summary, if you or someone you know has to go to an ER with a severe migraine, ask for injectable sumatriptan (which you should have at home to avoid such visits to the ER) or ketorolac.

Magnesium improves response to Tylenol and Advil in kids with migraines.

By: Dr. Mauskop

10-02-2014

Headaches in children

Children with migraine headaches are usually given acetaminophen (Tylenol) or ibuprofen (Advil). A group of Italian doctors compared responses to these two drugs in kids with migraines who took a daily magnesium supplement to those who did not. Results of their study were published in the latest issue of the journal Headache. One hundred sixty children (80 boys and 80 girls) aged 5-16 years were enrolled and assigned to four groups to receive a treatment with acetaminophen or ibuprofen without or with magnesium. The dose of each drug was adjusted according to the child’s weight. Those children who were in the magnesium arm were given 400 mg of magnesium (the article does not mention which salt of magnesium was given – oxide, glycinate, citrate, or another). Migraine pain severity and monthly frequency were similar in the four groups before the start of the study. Both acetaminophen and ibuprofen produced a significant decrease in pain intensity, but not surprisingly, did not change the frequency of attacks. Magnesium intake induced a significant decrease in pain intensity in both acetaminophen- and ibuprofen-treated children and also significantly reduced the time to pain relief with acetaminophen but not ibuprofen. In both acetaminophen and ibuprofen groups, magnesium supplementation significantly reduced the attack frequency after 3 and 18 months of supplementation.

This study was not the most rigorous because it did not include a placebo group as the authors felt that placing children on a placebo would be unethical. However, it was rigorous in other respects and still provides useful information. The first conclusion is that taking magnesium reduces the frequency of migraines in children. The second is that taking magnesium significantly improves the efficacy of acetaminophen and ibuprofen.

The bottom line is that every child (and adult for that matter) should be taking a magnesium supplement. I have written extensively on the importance of magnesium because our research and that of others, including the above study, has consistently shown the benefits of magnesium. Unfortunately, after dozens of publications, hundreds of lectures, and recommendations from medical societies, many doctors still do not recommend magnesium to their migraine patients. Some are not familiar with the research, others dismiss any supplements out of hand, and yet others do not believe the studies because they think that magnesium is too simple and too cheap to be effective. Most doctors are trained to prescribe drugs and they feel that patients expect prescription drugs, so giving them a supplement will disappoint the patient and will reduce doctor’s standing in patients’ eyes. This is clearly not the case since many people prefer more natural approaches and because recommending a supplement does not mean that a prescription drug cannot be also given. In fact, magnesium improves not only the efficacy of acetaminophen and ibuprofen, but also prescription drugs such as sumatriptan (Imitrex).

White matter lesions on MRIs of children with migraine.

By: Dr. Mauskop

05-02-2014

Headaches in children

White matter lesions that often seen on MRI scans of adult migraine sufferers were also found in children. A study by Washington University researchers inn St. Louis examined MRI scans of 926 children 2 to 17 years of age (mean age was 12.4 and 60% were girls) who were diagnosed with migraine headaches. They found white matter lesions (WMLs) in about 4% or 39 of these children, which is not much higher than in kids without migraines. Just like in the adults, these WMLs were slightly more common in kids with migraine with aura. None of these lesions were big enough to be called a mini-stroke or an infarct. There was no correlation between the number of lesions and the frequency or the duration of migraines. In conclusion, WMLs in children with migraines do not appear to be caused by migraines and are most likely benign in origin. The origin, however remains unknown, which often causes anxiety in parents of these children.

Unlike in children, adults with migraines and especially those with migraines with aura, are much more likely to have WMLs than adults without migraines. But even in adults, these appear to be benign as I mentioned in my previous post.

Magnetic brain stimulation may relieve migraines with aura

By: Dr. Mauskop

05-01-2013

New treatments

Transcranial magnetic stimulation (TMS) seems to be effective for the treatment of migraines with aura. “Spring TMS” device which delivers a jolt of such stimulation has been on the market in Europe since 2011. The American company that manufactures this device, eNeura Therapeutics hopes to obtain approval to sell it in the US in the near future. The approval of this device in Europe was based on a multi-center study results of which were published in Lancet Neurology. Unfortunately, the device is fairly bulky and needs to be carried around constantly because it seems to work only if used during the aura phase of the migraine. Auras usually begin unpredictably and last 20-60 minutes. Migraine with aura affects only 15-20% of all migraine sufferers, further limiting the potential market for this device.

Aspirin is best to prevent migraine with aura

By: Dr. Mauskop

25-12-2012

New treatments, Science of Migraine

Aspirin is by far the most effective drug for the prevention of migraine with aura, according to Italian researchers from Turin. They reported on 194 consecutive patients who had migraine with aura and who were placed on a prophylactic medication. Ninety of these patients were on 300 mg of aspirin daily and the rest were given propranolol (Inderal), topiramate (Topamax), and other daily medications. At the end of 32 weeks of observation 86% of those on aspirin had at least a 50% reduction in the frequency of attacks of migraine with aura compared with their baseline frequency, while 41% had even better results – at least a 75% reduction. In contrast, only 46% of patients on other drugs had a 50% improvement in frequency. The probability of success with aspirin was six times greater than with any other prophylactic medication, according to the lead author, Dr. Lidia Savi.
Aspirin is not only effective for the prevention of migraines with aura but also for acute therapy of migraine attacks. In previous posts I mentioned that a rigorous analysis of large numbers of patients showed that 1,000 mg of aspirin is better than 500 mg of naproxen (2 tablets of Aleve) and that 1,000 mg of aspirin was as good as 100 mg of sumatriptan (Imitrex) with fewer side effects.
Many health benefits of aspirin, which was originally derived from the willow bark, are becoming widely known. In addition to helping prevent heart attacks and strokes, aspirin has cancer-fighting properties. You may want to read a very interesting article about aspirin, The 2,000-Year-Old Wonder Drug, just published in the New York Times.
Willow
Aspirin formula

Exercise-related headaches among cyclists

By: Dr. Mauskop

11-12-2012

Science of Migraine

Exercise-induced headaches are thought to occur more often in people who do not exercise regularly and my usual recommendation is to exercise regularly, starting with low intensity and short duration exercise sessions. If headache occurs with minimal exertion, I suggest taking Advil (ibuprofen), Aleve (naproxen), Migralex (aspirin/magnesium) an hour before exercise for several weeks. However, it appears that even experienced athletes suffer from what is officially known as a primary exertional headache. Dutch researchers are reporting on the incidence of exercise-related headaches among cyclists in the latest issue of journal Headache. They performed an online survey of 4,000 participants of a very challenging cycling race. Thirty seven percent of them suffered from such headaches at least once a month and 10% had them at least once a week. Women were more likely to have these headaches – 54% vs 44% in men. Older cyclists were significantly less likely to have these headaches. Tension-type and migraine headaches were most common. Headache medications were used by 37% of participants. Extreme exertion was the most commonly reported contributing factor (50%), while some reported that low fluid intake (39%) and warm weather (39%) contributed to their headaches; 26% could not identify their trigger. Another possible trigger not reported in the article is neck strain. Riding sports bikes with low handlebars makes riders strain their neck and trigger a cervicogenic headache.
The authors concluded that these headaches are widely underestimated and may cause many people quit their sports. They also called for research into causes and treatment of exercise-related headaches. cycling

Erythromelalgia and migraine

By: Dr. Mauskop

07-12-2012

Science of Migraine, Uncategorized

Erythromelalgia is a rare, often inherited pain syndrome which causes pain and redness of hands and feet. I just saw another woman who had both erythromelalgia and migraines. My observation of several patients who had both diseases does not mean that these conditions are connected since migraines are very common in the general population. However, magnesium is known to help both conditions, so it is possible that there are common underlying causes. In fact, a sodium channel mutation which is responsible for erythromelalgia was also found in a family with familial hemiplegic migraine. Magnesium is involved in the regulation of sodium channels (as well as calcium and potassium channels) in all cells of the body. Most people who are deficient in magnesium and suffer from erythromelalgia and/or migraines respond well to oral magnesium supplementation, but a small percentage requires monthly intravenous infusions. We give intravenous infusions to those patients who do not tolerate oral magnesium (get diarrhea or stomach pains), those who do not absorb it (as evidenced by persistently low RBC magnesium levels) and those who prefer a monthly infusion to taking a daily supplement. Erythromelalgia

Topamax recall

By: Dr. Mauskop

14-04-2011

Headache medications

Migraine and epilepsy drug Topamax is being recalled by its manufacturer, Ortho-McNeil Neurologics, a division of Johnson and Johnson. This recall affects only two lots of 100 mg tablets. This recall does not affect topiramate, generic copies of this brand. Since the generic form is much cheaper, most patients have switched to it from branded Topamax. This adds another problem to this beleaguered drug. It was recently reclassified by the FDA from pregnancy category C to category D, which means that it is much more dangerous for the fetus than originally thought. Topiramate is also associated with a high incidence of kidney stones (20%) and can cause other serious problems. This is why we always emphasize non-drug approaches (exercise, acupuncture, biofeedback magnesium, Botox, etc), which can be more effective and are much safer than drugs.

Bariatric surgery relieves migraine headaches

By: Dr. Mauskop

28-03-2011

New treatments

Obese people are more likely to suffer from more frequent and severe migraine headaches. The question that remained unanswered was whether losing weight helps relieve headaches. A new study just published in the leading neurology journal, Neurology suggests that this may be the case. Researchers from Brown University in Providence, RI examined 24 severely obese patients before and after bariatric (weight reduction) surgery. Their mean body mass index (BMI) was 46 and their mean age was 39. A direct correlation between the amount of weight loss and the reduction in the number of headache days was observed. Weight loss was also associate with reduced disability. This study gives scientific support to the idea that weight loss may improve migraine headaches.

Melatonin does not help prevent migraines

By: Dr. Mauskop

28-12-2010

New treatments

Melatonin does not seem to be effective for the prevention of migraine headaches, according to a study published in Neurology. The researchers from Norway gave 2 mg of extended release melatonin every night for 8 weeks to 46 migraine sufferers. All 46 received also received 8 weeks of placebo and neither the doctors nor the patients knew whether the first treatment was with melatonin or placebo (so called double-blind crossover trial). Migraine frequency did improve from an average of 4.2 a month to 2.8, but the same results were observed while on melatonin as on placebo. This study confirms a well established observation that taking a placebo helps, or perhaps that what helps is just keeping track of your headaches and seeing a medical provider on a regular basis.
One argument against the validity of the study is that the dose of melatonin might have been too low because one small trial of 10 mg of melatonin in cluster headache sufferers did show benefit. Another possibility is that the dose was too high. There is a study that suggests that taking 0.3 mg (or 300 mcg) helps insomnia, while 3 mg does not. Anecdotally, I find that for me and many of my patients 0.3 mg works better for insomnia and jet lag than 3 mg.

How does Botox help headaches?

By: Dr. Mauskop

07-12-2010

New treatments

Botox, which was recently approved for the treatment of chronic migraine headaches, was originally thought to relieve migraine headaches by relaxing tight muscles around the scalp. However, several recent studies determined that besides relaxing muscles, Botox also stops the release of several neurotransmitters from the nerve endings. These neurotransmitters are released by messages sent from the brain centers that trigger a migraine attack. In turn the released neurotransmitters send pain messages back to the brain completing a vicious self-sustaining cycle. A meticulous study just published in the journal Pain by Danish researcher confirmed that injections of Botox stop the release of neurotransmitters and reduce sensitivity of rat’s chewing muscles. Not knowing the exact way how Botox works makes many doctors skeptical about its efficacy. However, we have no idea how preventive medications, such as beta blockers, antidepressants and epilepsy drugs prevent headaches either. These drugs, like Botox, were also discovered to help headaches by accident. This does not and should not stop us from using them. Botox is more effective and safer than medications taken by mouth and is an excellent option for over 3 million Americans who suffer from chronic migraines.