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.
Read MoreVertigo can induce a migraine attack in migraine sufferers, according to a study published in Neurology. In this study researchers induced vertigo in patients who had a history of migraines and in a control group. Almost half of those who had a history of migraines developed a migraine attack within 24 hours, compared with only 5% of those who were not known to have migraines. The study suggests that vertigo due to an inner ear problem can trigger a migraine attack. This finding will not come as a surprise to migraine sufferers who cannot ride a roller coaster or even go on bumpy a car ride without getting a migraine.
At times, migraine sufferers develop vertigo as part of their migraine attack and it can be difficult to tell if vertigo caused the migraine or was just one of the symptoms. A detailed description of more than one attack usually gives a clear answer.
Read MoreGood 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.
Read MoreIn 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.
Read MoreHigh homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid and vitamin B12 (cyanocobalamine). A study by Spanish doctors published in Headache found elevated homocysteine levels in patients who have migraines with aura. Patients who have migraine with aura are known to have increased risk of cardiovascular disease and it is possible that elevated homocysteine levels are at least in part responsible for this risk. I routinely check homocysteine, vitamin B12 and folic acid levels in all of my patients. One caveat is that vitamin B12 levels are not very reliable – you may have a normal level, but still be deficient. While laboratories consider a level of over 200 to be normal, clinical deficiency is often present at levels below 400. A single case report has been published of a severe deficiency with neurological symptoms and a vitamin B12 level of over 700. This patient lacked the ability to transport vitamin B12 from his blood into the cells. Injections of high doses of vitamin B12 corrected the problem. Oral magnesium supplementation is not as effective as injections because vitamin B12 is poorly absorbed in the stomach. Other ways to get vitamin B12 is by taking it sublingually (under your tongue) or by a nasal spray (it requires a prescription and is fairly expensive). Many of my patients a willing to self-inject vitamin B12, which they do anywhere fro once a week to once a month. Vegetarians are more likely to be deficient since meat (and liver) are the main sources of vitamin B12. Smokers are also at a high risk because cyanide in smoke binds to vitamin B12.
Read MoreMedications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain. An interesting study by Dr. Bigal and his colleagues, just published in Cephalalgia looked at this effect of drugs in 331 patients. They found that 16% of them gained weight (5% or more of their baseline weight) and 17% lost weight. The various treatments given to these patients were equally effective in both groups. However, not surprisingly, those who gained weight had elevation of their cholesterol, blood glucose, blood pressure and pulse. Patients who have migraine headaches with aura (about 15-20% of migraine sufferers) already have an increased risk of strokes, so adding additional risk factors for both strokes and heart attacks should be especially avoided in this group. The only preventive migraine drug which consistently lowers weight in many patients is topiramate (Topamax). This drug is now available in a generic form, making it much less expensive. While topiramate does lower weight and helps prevent migraine headaches only half of the patients stay on it. For the other half it causes unpleasant side effects (memory impairment and other) or it does not work.
Read MoreIn addition to an injection, tablet and a nasal spray, sumatriptan is being tested in two other formulations. No, it is not an inhaled form, which I just posted in my previous blog (dihydroergotamine inhaler), but through a skin patch and by a “lingual spray”, that is a spray into the mouth. The skin patch may work fast and will deliver medicine through the skin, bypassing the stomach, which would be very useful for people who get very nauseous and have difficulty swallowing medications. However, it is quite a large patch and will probably cost significantly more than a tablet, particularly in the generic form. The second new formulation, a spray into the mouth, appears to partially absorb in the mouth and partially in the stomach, making it also work faster, although so far it looks to be only as effective as a 50 mg tablet. The usual dose is 100 mg. Also, hopefully the company that is developing this product has been able to mask the taste of sumatriptan. Patients who have tried the nasal spray often complain of a very unpleasant taste, which can make nausea worse.
Read MoreTrials of an inhaled version of an old migraine drug show surprisingly good results. The drug is dihydroergotamine and in injectable from is considered to be one of the strongest migraine medications. It is often used intravenously to treat severe migraines that do not respond to other therapies and for medication overuse headaches. It can be also injected into the muscle, under the skin or sprayed into the nose. The main problem with this drug is that it often makes nausea worse or even causes severe nausea in patient who do not have it. What is surprising about the new product being developed by MAP Pharmaceuticals (to be called Levadex if and when FDA approves it) is not that is is very effective, but that it causes significantly less nausea than the same drug in an injectable form. Another advantage is that inhaling the medicine into the lungs results in a very quick delivery of the drug into the circulation – as quick as an injection but without a needle. A similar product, Ergotamine Medihaler was available until about 15 years ago, but was withdrawn because of manufacturing difficulties and limited demand. The demand for this new product will also be limited because it will be more expensive than a tablet of any migriane drug, it will be more bulky to carry around, and will be mostly utilized by patients who cannot take oral medications due to nausea or by those who need very quick onset of action to abort an attack.
Read MoreLower facial pain during a migraine attack occurs in 9% of migraine patients, according to a recent report published in Cephalalgia by German researchers. One of the 517 migraine patients they looked at had lower facial pain as the leading symptom of migraine. Some of my patients with lower facial pain wonder if they have a disorder of the temporo-mandibular joint (TMJ). Some of them do benefit from an oral appliance that reduces grinding and clenching, in most however, a successful treatment of their migraines with abortive or prophylactic medications will often relieve the jaw pain as well.
Read MoreImitrex and Topamax are two migraine medications that recently lost their patent protection and became available in a generic form, under the names of sumatriptan and topiramate. Many patients are concerned about the quality of generic products. A recent study published in Neurology looked at 948 patients with epilepsy who were treated with generic Topamax (it is approved for the treatment of both migraines and epilepsy). Compared to patients who used the branded Topamax, those on generic substitutions needed to have more of other medications, were admitted to the hospital more frequently and stayed in the hospital longer. The risk of head injury or fracture (presumably due to seizures) was almost three times higher after the switch to a generic drug.
Clearly, migraine patients do not run the same risk as epilepsy patients of having a seizure or being admitted to the hospital, however a small number of patients can have worsening of their migraines. The main reason is the legally permitted variation in the amount of medicine in each tablet. Taking a higher dose of the generic drug can help.
The same applies to Imitrex – a small number of patients will find that the generic sumatriptan is slightly less effective. The only, albeit significant, advantage of the generic drugs is cost savings. At this point we have only one generic substitution for Imitrex and the price difference is only 20%, but in a few months more generics will appear and the price should drop significantly, which is a very welcome development for patients with frequent migraines.
Read MoreOccipital 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.
Read MoreHeadache 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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