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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Vitamin D deficiency has become a very popular topic in lay and professional literature, and deservedly so. Vitamin D is important not only for bone health, but for normal functioning of many organs. Its deficiency appears to be much more common than it was previously suspected. Dr. Steve Wheeler has found vitamin D deficiency in 42% of 55 patients with chronic migraine headaches. He presented these findings at the recent meeting of the American Headache Society. We do not have evidence that taking vitamin D will help relieve headaches, however if a deficiency is present correcting it can certainly improve overall health of the patient. One possible cause of what appears to be increasing incidence of vitamin D deficiency is widespread use of prescription and over-the-counter antacids. Reducing stomach acidity helps relieve heartburn and other symptoms of reflux, but it may also interfere with absorption of vitamins and minerals.
Read MoreA study conducted by one of the leading headache researchers, Dr. Richard Lipton looked at possible factors that worsen migraine headaches. The study looked at people with frequent migraines (15 or more days with headache a month) and found that these patients were more likely to be female, overweight, depressed, have a lower education level and overused medications. The overused medications included narcotics, barbiturates (Fioricet, Fiorinal and Esgic) but also over-the-c0unter drugs such as Excedrin. The only exception was aspirin – it appeared to be protective, that is people taking aspirin were less likely to develop chronic headaches. Dietary caffeine and stresful life events were also more common prior to development of chronic migraines.
Read MoreTreating migraines in adolescents presents some unique challenges. Besides difficulties, such as getting them to bed before midnight and getting them to improve their diets, we face the problem of not having any FDA-approved drugs to treat migraine attacks. And it is not for lack of trying on the part of makers of triptans, which are drugs that work miracles for many adult headache sufferers. The problem has been proving to the FDA that these drugs work in kids. Because children tend to have shorter attacks, by the time we try to assess the efficacy of a particular drug two and four hours after the pill is taken, the headache is gone even if the pill was a placebo. Many studies have shown that the triptans are safe and effective (as was observed in kids who have longer duration of attacks). Many, but far from all headache specialists use triptans, such as Imitrex and Maxalt in adolescents. A study just published in Headache proved that Axert, another drug in the triptan family and that was tested in 866 children, is effective in children 15 to 17 years of age. The bottom line is that triptans can be safely used in kids who suffer from severe migraine headaches. I am often asked by other physicians, what is the youngest age I would prescribe a triptan? Because of a shortage of pediatric neurologists I feel compelled to see children as young as 10 and this is the youngest age at which I will prescribe triptans.
Read MoreFor many years headaches were thought to be triggered by elevated blood pressure. Evidence had suggested that only very sudden increase in blood pressure triggered a headache in some patients, but the myth of high blood pressure headaches has persisted. Norwegian researchers published a very surprising finding in the April issue of journal Neurology. They looked at the data on 120,000 people and found that increasing systolic blood pressure was associated with a decrease in migraine and non-migraine headaches. Even more striking was the inverse correlation with the pulse pressure (difference between systolic and diastolic pressure, for example blood pressure of 110/80 means that the pulse pressure is 30). Patients with higher pulse pressure had fewer migraine and other headaches. It can be speculated that hardening of arteries that occurs with elevated blood pressure makes them less likely to constrict and dilate, which is part of a migraine process.
Read MoreMenstrual migraines are at times very difficult to treat. Triptans, such as Maxalt, Imitrex and other are usually very effective, but in some patients do not provide sufficient relief. Corticosteroid drugs, such as prednisone and dexamethasone can help some patients. Marcelo Bigal and his colleagues compared treatment of menstrual migraines with Maxalt alone, dexamethasone alone, and combination of the two. Maxalt was much better than dexamethasone, providing sustained 24-hour relief in 63% of patients vs 33%, but the combination was better than Maxalt alone, giving relief to 82% of women. We would always try Maxalt or a similar drug alone, but if one drug is insufficient a combination with dexamethasone should be tried. Corticosteroids should not be used for more than a few days a month because frequent and prolonged use can lead to serious side effects.
Read MoreScientists in Trieste, Italy suggested a new approach to the treatment of migraine headaches. They hypothesized that combining two different approaches would yield better outcomes than either one alone. A neurotransmitter CGRP antagonists appear to be effective in the treatment of an acute migraine. Merck has a product in late stages of development that works through this mechanism and hopefully will be the first of a new class of migraine drugs. Based on laboratory research the Italian group suggests that combining a CGRP antagonist with a blocker of nerve growth factor may result in a more effective treatment. This fits with a new trend in treatment of many conditions – combining drugs that work in different ways, rather than trying to always use a single medication.
Read MoreTreatment of migraines leaves a lot to be desired and in part not because we do not have effective treatment, but because of a communication barrier. Doctors appear not to want to hear what migraine patients have to say about their headaches, according to a remarkable study by a top headache researcher Richard Lipton and his colleagues. Patients and doctors agreed to be videotaped during a visit and 60 such interactions were analyzed. The analysis showed that doctors did not ask about the disability of headaches and tended to ask closed-end short questions. Very often the information they did obtain was incorrect. 55% of doctor-patient pairs were misaligned regarding frequency of attacks; 51% on the degree of impairment. Of the 20 (33%) patients who were preventive medication candidates, 80% did not receive it and 50% of their visits lacked discussion of prevention. The authors recommended that doctors assess impairment using open-ended questions in combination with what is called the ask-tell-ask technique.
Read MoreTreximet, a new migraine treatment was approved today by the FDA. Treximet is a combination of two old drugs – sumatriptan (Imitrex), 85 mg and naproxen (Aleve), 500 mg. The combination is more effective than Imitrex alone because naproxen provides additional relief through its anti-inflammatory and pain relieving effects. Imitrex is losing its patent protection and is going to be available as a generic drug in 2009. The maker of Treximet, GlaxoSmithKline is hoping to switch most of the patients currently taking Imitrex to Treximet before patent expiration, in order to reduce its losses to generic competition. However, it is likely that insurance companies will force physicians to prescribe generic Imitrex and generic naproxen rather than pay for Treximet. GSK argues that the combination drug, just like Imitrex are fast-dissolving and therefore faster acting drugs than the generic naproxen is and the generic Imitrex is going to be.
Read MoreFor many years migraines have been thought to occur more often in left-handed people, but a new study from Germany disputes this theory. A recent study published in journal Cephalalgia looked at 100 people with migraines and 100 controls and also reviewed five similar studies and found no difference in the incidence of migraines in left-handed and right-handed people. This has been the observation at our headache clinic as well.
Read MoreMigraine and cluster headaches that do not respond to the usual treatments, may improve with injections of histamine. Dr. Seymour Diamond of the Diamond Headache Clinic in Chicago has pioneered the use of histamine in cluster headaches. We have found that in cluster headache patients for whom nothing else works histamine often provides excellent relief. A recent study published in the journal European Neurology suggests that histamine injections may also help migraine patients.
Read MoreA new drug may be better for the prevention of migraines than the old ones in the same category. A study just published in Headache suggests that nebivolol, a beta-blocker just approved in the US for the treatment of high blood pressure may be as effective as old beta-blockers, but with significantly fewer side effects. Beta-blockers, such as propranolol (Inderal), timolol (Blocadren) metoprolol (Toprol), atenolol (Tenormin) and nadolol (Corgard) have been used for the prevention of migraines for many years. However, many patients could not tolerate them because of side effects, mostly fatigue, slow heart beat and low blood pressure. Nebivolol appears to cause these side effects 50% less often, while preventing migraine attacks with equal efficacy.
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