Migraine and migraine medications do not appear to cause cognitive decline, according to a Dutch study just published in Headache. After 6 years of follow-up there was no difference between those who suffered from migraines and healthy controls. Taking migraine medications also did not have an effect on cognitive function. This is very reassuring, especially because a recent study in rats suggested brain damage from what the researchers felt was a process similar to migraine.
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One of the oldest preventive headache medications for migraines is propranolol (Inderal), which belongs to the family of blood pressure medications called beta-blockers. There are newer and better beta-blockers, such as nebivolol (Bystolic), which have fewer side effects than propranolol. We also use other types of blood pressure medications, such as calcium channel blockers (verapamil or Calan, and other) and ACE inhibitors (lisinopril, or Zestril/Prinivil is one example). The newest category of blood pressure medications is ACE receptor blockers (ARBs) which are at least as effective and have fewer side effects than ACE inhibitors. The best scientific evidence (from a single double-blind study) for the efficacy of ARBs in migraines is for candesartan (Atacand).
Read More74% of girls and 52% of boys have headaches at age 17, according to a Finnish study of 6,262 twins. At age 11, 60% of girls and 59% of boys had headaches at least once a month. The prevalence of weekly headaches increase d in girls from 16% to 25% between ages 11 and 14. Headaches in kids is a major problem, but unfortunately it does not receive proper attention. Sometimes parents do not believe that their child has a headache or if they do, they are reluctant to take the child to a doctor because they don’t want to resort to prescription medications. Fortunately, many non-drug approaches are very effective in kids. Regular sleep schedule (very hard to enforce in teenagers), regular meals, frequent aerobic exercise, biofeedback or meditation, and supplements can be very effective. Several studies have shown that kids with headaches are often deficient in magnesium, riboflavin (vitamin B2), and Co-enzyme Q10 (CoQ10). If a child still has headaches, a medications may also be appropriate.
Read MoreMigraines in blind people are made worse by light, according to Dr. Burstein and his associates at Harvard. Rami Burstein is one of the leading headache researchers who often asks questions no one else thought to ask. More importantly, he often finds the answers. When he mentioned to me that he wants to find out why bright light makes headaches worse (so called photophobia), I immediately thought of a blind patient I was treating. She was very interested in helping Rami discover the answer and helped him recruit many other blind migraine sufferers. After several years of work, his finding were published today in Nature Neuroscience. A recent discovery showed that in addition to rods and cones in the retina (cells that allow us to see), there are cells which react to light, but their input goes to non-visual parts of the brain. These cells regulate sleep-wake cycle and, according to Rami Burstein’s research, also magnify pain perception in headache patients.
Read MoreChildhood abuse or neglect was reported by 58% of 1,348 migraine sufferers according to a study published in the current issue of Headache. Emotional abuse and neglect was particularly common. Patients with other chronic pain conditions also have high incidence of emotional, sexual, and physical abuse. Migraine patients who suffered abuse are also more likely to have anxiety and depression. We do not know what physiological mechanisms that are triggered by abuse lead to chronic pain. This and similar studies suggest that greater attention should be directed at the psychological factors that contribute to migraine headaches. One possible negative outcome of this study is that some physicians, who may already consider migraine to be a purely psychological disorder, will be even more inclined to avoid treating migraine as a biological disease. In practice, it means that these doctors will be even more reluctant to prescribe appropriate acute migraine medications, such as triptans (Imitrex and other). Migraine is clearly a biological disorder with documented genetic predisposition and should be treated as such. At the same time, we know that psychological factors play a major contributing role and should be also addressed when treating headache and pain patients.
Read MoreA blinded study comparing Botox with Topamax for the prevention of migraine headaches was conducted by Drs. Jaffri and Mathew and published in the current issue of Headache. They enrolled 60 patients and divided them into two groups – one group received real Botox and placebo tablets, while the second group received saline water injections instead of Botox, but were given tablets of Topamax. At the end of 9 months and after 2 Botox treatments the efficacy of these two treatments was the same, but many more patients in the Topamax group developed side effects and dropped out of the study.
Read MoreNeedle-free injection of sumatriptan (Imitrex) was tested for its ease of use and for its bioequivalence in a study led by Dr. Jan Brandes. The new device that provides needle-free subcutaneous injections was easy to use and if injected into the thigh or abdomen (but not the upper arm) delivered the same amount of medicine as an injection with a needle. Unfortunately, needle-free does not mean pain-free, so the injection still hurts. This device, when it is approved by the FDA, may be useful for those patients who are afraid of needles. Many migraine sufferers still do not know that injections of sumatriptan can be easily self-administered using a pen-like device that does contain a needle. Many doctors do not offer this option because they do not think that patients will readily accept an injection or because they don’t realize how severe the migraines are. I see many migraine sufferers who gladly take an injection over the tablet. It is particularly effective for people who have severe nausea and vomiting with their migraine. The speed of relief is another reason to take an injection – some patients wake up with a migraine and have to go to work or take care of their children and cannot wait for 1-2 hours before the tablet provides relief. I have taken sumatriptan injection many times myself. Usually the tablet works for me, but if before going to bed I have a headache from the wine I had with dinner, I will often opt for a shot. The shot works within 10-15 minutes and allows me to fall asleep right after that, while a tablet may take an hour or longer.
Read MoreSome migraine patients are more disturbed and disabled by migraine aura symptoms than by the headache itself. Some people do not even have pain but only auras. In the majority the aura is visual and consists of squiggly lines, flashing lights, distorted vision, or partial loss of vision on one side of each eye. Less often people experience numbness of one side of the body, dizziness, or vertigo. These symptoms are sometimes more difficult to treat than the pain. Anecdotal reports suggest that a blood pressure drug belonging to the family of calcium channel blockers can help. Another medication that has been reported to be effective (also only in case series and not double-blind trials) is an epilepsy drug, lamotrigine (Lamictal). The effective dose of lamotrigine varies from 100 to 500 mg day, while verapamil is usually effective at 12-240 mg, although in some patients only much higher doses are effective.
Read MoreTwo 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.
Read MoreMigraine headaches are more frequent in people who suffer from allergic rhinitis and who have more than 10 positive skin allergy tests. This finding by Dr. Martin and his colleagues presented at the International Headache Congress last week is not surprising since many of my patients report that their migraines worsen during periods when their allergies flare up. It is also not surprising because almost any medical condition affecting the head, whether it is an ear infection, a dental problem, or conjunctivitis, can trigger a migraine attack.
Read MoreMigraine headaches are three times more common in patients with multiple sclerosis than in people of similar age and gender without MS. Ilya Kister and his colleagues at NYU who established this fact make a very important point – multiple sclerosis symptoms often overshadow the symptoms of migraine and this can result in migraine not being treated properly leading to additional avoidable disability.
Migrainous vertigo seems to respond to intravenous infusion of a high dose of corticosteroids, according to a report in the latest issue of Headache by a group of Indian doctors. Two of their patients had intermittent episodes of severe vertigo and two had chronic vertigo. All four respond to infusions of 1 gram of methylprednisolone. One require 3 infusions, one needed 2 and in another 2 vertigo stopped after a single infusion. We routinely use corticosteroids for severe migraine attacks when other medications fail. While occasional (once or twice a month) use of corticosteroids is relatively safe, frequent or daily intake of corticosteroids (besides methylprednisolone, these drugs include prednisone, prednisolone, and dexamethasone) can lead to dangerous side effects. It is possible that oral corticosteroids will produce a similar effect as an infusion and may be worth trying when nothing else helps relieve the vertigo.
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