In addition to the older but still relevant articles listed on the right, Dr. Mauskop’s blog contains up-to-date information on a variety of headache-related topics. It is regularly updated and contains more than 800 posts and more than 2,000 comments.

The New York Headache Center offers transcranial magnetic stimulation (TMS) for a variety of neurological problems. We use an advanced neuronavigation system (Soterix) for the precise targeting of brain regions that need to be treated. TMS is administered by state-of-the-art equipment made by MagVenture. When we use fMRI to individualize TMS targeting, we use Omniscient Technology software to analyze fMRI scans.

Neurologists frequently manage patients resistant to standard treatments. Some patients do not respond, cannot tolerate, or have contraindications to medications, Botox injections, supplements, and other therapies. 

One promising treatment is transcranial magnetic stimulation (TMS). TMS is a proven procedure for anxiety, depression, obsessive-compulsive disorder (OCD), smoking cessation, and acute and preventive treatment of migraines. TMS utilizes magnetic fields to stimulate underactive nerve cells in the brain or reduce the excitability of overactive cells. TMS can change the flow of information between different parts of the brain in various neurological conditions. Published reports show the potential benefit of TMS in migraine, fibromyalgia, neuropathic pain, cluster headaches, facial pain, trigeminal and other neuralgias, back pain, insomnia, memory disorders, tinnitus, post-concussion syndrome, post-traumatic stress disorder (PTSD), stroke rehabilitation, restless leg syndrome, and long COVID. However, the evidence for the efficacy of TMS for these neurological disorders is still limited.

The FDA approved single-pulse TMS for the acute and preventive treatment of migraines. The patient uses a portable device to self-administer four single pulses of TMS to the back of the head (occipital area) twice a day for prevention and as needed for acute treatment. Repetitive TMS (rTMS) has been studied for the prevention of migraines and other types of pain. It appears effective, but studies have been relatively small. The advantage of rTMS over single-pulse TMS is that patients receive a couple of thousands of pulses, and these are applied to different parts of the brain that are involved in pain messaging rather than only the occipital area. We stimulate over sites that have been reported to help with migraines and other neurological conditions. Our neuro-navigation system allows for a more precise localization of stimulation targets. We also started using functional MRI (fMRI) to detect abnormal connectivity in the brain. Targeting those areas may result in a better response to TMS. However, this technology is still in the research stage.

rTMS is safe and well-tolerated. During a TMS session, patients sit in a comfortable chair with earplugs. An electromagnetic coil is positioned near the scalp, delivering short magnetic pulses to specific brain regions involved in processing pain and other information. Patients feel and hear rapid tapping on their scalp that continues intermittently. Patients are awake and alert during the entire procedure. There are no limitations to activities before or after the treatment.

Treatment length varies from 20 to 45 minutes, depending on the stimulation pattern and number of sites stimulated. The frequency of treatments also varies – anywhere from daily for several weeks to once a week. After the initial period of more frequent sessions, some patients require weekly or monthly sessions to maintain the effect. It may take a few weeks to see noticeable effects. 

TMS is a good choice for people who have not responded to multiple standard therapies, people who do not want to take drugs, those who also suffer from depression and anxiety, and pregnant women. Neither the single pulse TMS device nor rTMS is covered by insurance plans.

Dr. Mauskop’s latest book, The End of Migraines: 150 Ways to Stop Your Pain. has been one of the best-selling books on migraine on Amazon since its publication in early 2021. The second edition was published in October 2022.

Other books by Dr. Mauskop

Download the full book here (.pdf)		Buy it at Amazon.com	Textbook for doctors Buy it at Oxford University Press

 

Review of The End of Migraines: 24 May 2021 in Headache: The Journal of Head and Face Pain.

Sooner or later someone in our field will do a “book” like this one. Whom is better than this author who has a unique approach to headache therapies and a very comprehensive and wide-ranging experience, over decades, of practicing neurology and treating numerous people with headache disorders? Although titled, “The End of Migraines: 150 Ways to Stop Your Pain!” the author quickly notes that there is no cure for migraine, but with the use of many things he describes as the ways to manage migraine, many people with migraine should be able to reduce the frequency and severity of their symptoms significantly. He also indicates early in the book that he has had migraine for decades and shares his experiences with what works and does not work for him.

This “book” appears to have largely been born out of his blog from the New York Headache Center. For years, he has regularly put up information, scientific and clinical, for his headache followers. He has created this “book,” actually an e-book, which takes relevant information from his experience and knowledge of migraine. There is no need for an index and chapter references. He uses hyperlinks, embedded in the e-book, to connect to material online, which he puts in context for the reader. This works very well as one hyperlink may go to an original paper or publication or a resource site.

He links to major medical journals including headache journals and his own publications, when helpful, as well as nonmedical literature and other sites. This format allows the e-book to be updated from time to time, which is easy to do with this approach.

The book has a very interesting introduction and deals with evidence-based medicine and its role in migraine therapy. When he begins the section on 150+ treatments, he starts with a very interesting comment. Many of the treatment ideas that I describe in this book are not just off-label (that is, not approved by the FDA) but may appear to be off-the-wall. It is refreshing to hear such intellectual honesty from a practicing neurologist.

There is a great section on supplements and finding someone to help with your migraine, such as coach, a partner, or a sympathetic friend. A diagnostic discussion follows and is most helpful, as proper diagnosis directs treatment, as are the detailed sections on triggers including environment, food, exercise, physical therapies, and sleep. Herbal therapies are covered as is neuromodulation and injections/blocks among others.

In the sections on drugs, he deals with acute therapies and the modern use of triptans and gepants, and a ditan. Preventive therapies start with monoclonal calcitonin gene-related peptide antibodies, tricyclic medications, and many other preventive therapies including beta blockers, anti-seizure drugs, nonsteroidal anti-inflammatory drugs, and botulinum injections. From acupuncture to Feldenkrais methods, he covers the contemporary plethora of migraine “treatments” as he sees it in practice.

He ranks all medications on a 1 to 10 scale regarding his own subjective opinions of the utility of each treatment. He indicates that no treatment gets 10 as a score and any receiving a score of 1 were not rated. He also lists his favorite migraine therapies separately. He includes a lot of data links here, from single case reports to full-scale randomized clinical trials, and detailed reviews. His clinical acumen shines through the volume and one gets the impression that this is a very personal view at times, not always backed by evidence, as there may not be any, but by experience, practice and pragmatism. He carefully notes the general things to be careful of in taking some treatments and warns if there are serious concerns. Nonetheless, he indicates clearly that the advice of a medical professional should be sought before trying the therapies mentioned.

Diagnosing secondary headache that can mimic migraine or vice versa is a useful section but does not go into depth about the disorders/diseases mentioned, as this is not the intention of the book. Special circumstances are given sections including menstrual migraine, pregnancy, resistant/refractory headache, aura and headache, and many others.

The author is a senior, highly experienced neurologist and has a high degree of interest in migraine and other headache disorders. He has a sense of curiosity about the brain and migraine and that comes through to the reader of this small volume. I count 23 endorsements, including the excellent foreward of the book from a wide range of well-known people, which includes two prior editors of this journal. He is well liked and highly respected by his colleagues.

In many ways, this book does what online databases on diseases cannot do most times. He tells the reader what he knows and how to use that knowledge. He directs the novice and experts to the right literature and takes the reader on a personal journey through the field of migraine treatments. He tells people, “…keep seeking relief, not to give up on or blame yourself for the pain you experience from migraine.”

There is a printed version of the book; however, the e-book is ideal for the intended purpose. I would recommend it the first instance. It is available via a commercial site and inexpensive.

I would recommend this book to anyone who has migraine or cares for people with migraine and wants a broad and sometimes detailed overview of the treatments. Available in the e-book format, it represents a lot of work for one person, but his passion, occasional humor, and historical perspectives are evident in this work. You don’t have to agree or accept everything the author says to enjoy and benefit from this “book,” and I know he would want people to be critical and skeptical where warranted. However, you will find more than you would usually need to know from this banquet of 150 ways to help your migraines! Enjoy, I did very much. Read it through once and save as reference.

Allan Purdy MD, FRCPC, FAHS

 

Dr. Uwe Reuter of Charité Universitätsmedizin Berlin, Germany has published a review of The End of Migraine in the August 2021 issue of the journal of the International Headache Society, Cephalalgia:

Alexander Mauskop´s personal view on migraine therapy is entertaining and relevant for patients, physicians and everybody who is interested in migraine. It is an easy to read e-book, which is full of practical advice to migraine patients. I also believe that even the experienced migraine doctor can learn something from the book. It covers every possible therapy from acute medication to preventive meditation, not in depth but rather in a way that stimulates the reader’s thinking. Some chapters contain bits and pieces of Alexander´s long experience as a clinician with reference to cases he has seen. Based on these stories I assume it is easy for patients to relate to Dr Mauskop. A lot of advice is evidence-based from migraine research, but some of the suggestions stem from personal practice. While I personally find the overview of so many topics interesting, I feel sorry for the patient who has not tried all possible remedies as described in the book. Friends, families and other well-wishers who have read the book may encourage the migraine patient to try out all open therapeutic options as the patient’s migraine has not completely resolved with current or past therapeutic approaches. On the other hand, patients may pick their treatment of choice out of an extensive therapeutic flower bucket. Of course, the book has also an interesting section on magnesium and its benefit in migraine. Needless to say, that Dr Mauskop has spearheaded the research on the use of magnesium in migraine (1). I am happy to encourage everybody who is interested in migraine to read this e-book.

Book Review: The Headache Alternative. Alexander Mauskop and Marietta Abrams Brill. New York: Dell Publishing, 1998. 400 pp. Price $13.95. Cephalalgia 1998;18:589. Oslo. ISSN 0333-1024

Whatever we as individual doctors may think of alternative medicine, there is no doubt that patients are looking to it: the authors cite a 1993 survey in the New England Journal of Medicine indicating that 34% of the U.S. population have sought alternative therapies. There is also no doubt that this book fills a gap in the market: it is relatively difficult to find books about alternative therapies written by authors with conventional medical qualifications.

Alexander Mauskop, Director of the New York Headache Center, and Marietta Abrams Brill, a freelance medical writer, have written principally for headache sufferers in North America. They answer questions like “is Rolfing covered by medical insurance?”, and include an excellent resource section in the back. of the book which lists American organizations for the various therapies. But they provide enough background information on both headache and alternative treatments to make their book interesting to readers from other countries, too. In covering most of the more common alternative therapies~like herbs, acupuncture, massage, Ayuverda and Eastern medicine, and qigong-they aim to inform rather than judge, cite research evidence where it exists, and point to potential dangers as well as benefits.

Each of the 10 chapters is introduced with a pithy quote: “Divine is the work to subdue pain” (Hippocrates) heads the first chapter. After general background on pain theories and headache diagnosis, common alternative approaches are covered in turn and there is, of course, oodles of advice on diet and nutrition. A helpful glossary guides readers through words that conventional doctors are familiar with, like Scotoma, and those with which we aren’t, like Qi, Vatta, and Pitta. To round off, a comprehensive resource section and selected bibliography give useful directions to readers wanting more information about specific therapies.

Like all good guides, this one follows a logical structure and so it is relatively simple to go quickly to the information you want to find. It is easy to read. All in all, it is a guide which headache sufferers looking for good information on alternative therapies can be thankful for.

BILL LAUGHEY