Narcotics are not only ineffective for the treatment of headaches, but they can also make headaches worse and transform an episodic migraine into chronic. A study mentioned in a previous post showed that more than half of migraine sufferers who went to an ER were given a narcotic.

A new study recently published in the journal of the International Headache Society, Cephalalgia showed that if patients presenting with a headache to an ER are treated with an injection of opiates (narcotics) they will stay in the hospital longer than if no narcotics are given. This treatment also leads to an increased risk of return visits to the emergency department within seven days.

The study was conducted by two neurologists, Dr. McCarthy at Puget Sound VA Healthcare System in Seattle and Dr. Cowan at Stanford University in California. They examined charts of 574 people and discovered that 23% received a narcotic when they were seen at an emergency department. Only 53% were given an injection of a drug recommended by a published consensus of headache experts. These include sumatriptan (Imitrex, the only injectable triptan), prochlorperazine (Compazine), metoclopramide (Reglan), chlorpromazine (Thorazine), ketorolac (Toradol), aspirin, acetaminophen, and dihydroergotamine. The remaining 24% were given an injection of another non-narcotic drug.

Patients who were given opiates were 4 times more likely to have a long stay, compared with patients given first-line recommended medications. 69 participants had at least one readmission for headache, of whom 20 returned to the emergency department within seven days. Interestingly, patients who had a CAT or an MRI scan of the brain had a significantly higher rate of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended drugs.

Dr. McCarthy was quoted saying that “Opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications”. He added that regardless of whether the acute headache was diagnosed as a migraine or a tension-type headache, it is likely to respond to most non-narcotic injectable treatments.

An editorial accompanying this article concluded that “The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department”.

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The existence of gluten sensitivity has been long denied by the mainstream medical establishment. A study described in a previous post over two years ago documented higher incidence of migraine headaches in people with gluten sensitivity than in those with celiac disease (56% vs 30%). Celiac disease, which is a severe autoimmune disease caused by wheat allergy, affects about 3 million Americans, but the estimates of gluten sensitivity run as high as 18 million. Billions of dollars of gluten-free products are sold in the US and they can be found in almost every grocery store.

A recent study by the National Institutes of Health led by Dr. Sabatino examined 59 patients who did not have celiac disease, but believed gluten-containing food was causing them intestinal and other symptoms. Every day for one week these people were randomly given capsules containing 5 grams of gluten or a placebo of rice starch. After only one week, those who were taking the gluten pills reported a significant difference in symptoms compared to those who took non-gluten placebo pills. In addition to intestinal pains, they felt abdominal bloating, a foggy mind, depression, and canker sores. Clearly, they didn’t know if they were taking the gluten pill or the placebo, but their symptoms were very revealing and proved the existence of gluten sensitivity.

The bottom line is, if you have stomach pains, bloating, foggy mind, depression, headaches, malaise, and other symptoms, it may be worth going on a gluten-free diet for a couple of weeks to see if your symptoms improve. Unfortunately, we do not have any tests to document this condition, so this is the only way to find out if you have gluten sensitivity.

We do have tests for celiac disease – this condition can be detected by a blood test and an intestinal biopsy done through an endoscopy. However, despite the availability of these tests, even this severe form of gluten sensitivity is diagnosed in only one out of six Americans who suffer from it. And the number of cases of celiac, just like with non-celiac gluten sensitivity, are going up. The incidence of celiac is now five times higher than 50 years ago.

Stomach pains and bloating are the most common symptoms of celiac, but a recent review in JAMA Pediatrics, lists other symptoms, including persistent or intermittent constipation, vomiting, poor appetite, weight loss or growth delay in children, fatigue, anemia, dental problems, canker sores, arthritis and joint pains, bone loss and fractures, short stature, delayed puberty, unexplained infertility and miscarriage, recurring headaches, loss of feeling in hands and feet, poor coordination and unsteadiness, epileptic seizures, depression, hallucinations, anxiety and panic attacks. Many of these symptoms are the result of poor absorption of vitamins and minerals, including magnesium, vitamin D, vitamin B12, and other because of the damaged intestinal lining.

Those with celiac disease are more sensitive to even minute amounts of gluten than people with non-celiac gluten sensitivity.

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Doctors in St. Louis, MO examined how well headaches are treated in children. There has been little research about how well doctors in the US care for children and teens with migraine and if the treatment is consistent with evidence-based guidelines. They also assessed how often opioids (narcotics) are prescribed for children with migraines. The study used Electronic Health Record data to look at how almost 40,000 children and teens with migraine who presented to primary care providers, specialty care, or Emergency Room or Urgent Care (ER/UC) across four states in metropolitan and non-metropolitan areas were treated from 2009-2014.

The results showed that among children and teens presenting for care for migraine or likely migraine, nearly half (46%) were not prescribed or recommended any medication. Only one in six (16%) were prescribed or recommended an evidence-based medication. Among those who received medication, nearly one in six (16%) were prescribed an opiod (narcotic), and these numbers are even higher among teens 15-17.

The findings also revealed that the odds of getting an evidence-based medication were significantly higher if migraine was diagnosed, and the odds of getting any medication (evidence-based or not) were higher in non-metropolitan areas. Children and teens treated in a specialty care setting or the ER/UC were twice as likely to be prescribed an opioid than if treated in primary care.

The authors concluded that “Too many children who present for migraine or likely migraine are not getting any medication for their pain. Too few are receiving care consistent with evidence-based guidelines. And far too many are being prescribed an opiod. Five out of six children and teens are receiving suboptimal migraine care. A significant need exists to increase doctor awareness of the benefits of optimal migraine care and the potential dangers of prescribing opioids for children and teens with migraine.”

Guidelines issued by many medical organizations call for the use of ibuprofen as the first line treatment, however most children with severe migraines need to take a triptan. Triptans include sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), and four other similar drugs. Rizatriptan has been shown to be effective in children as young as 6, while other triptans have been approved for children older than 12. It is very likely that, just like in adults, some children respond better to one triptan and several triptans may need to be tried to find the best one. Just because the FDA approved one triptan for children above the age of 6 and another above the age of 12, it does not mean that there is a significant difference among the seven available triptans. These are safe drugs that have been in use for over 20 years and several of them are available in Europe without a prescription.

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Several million Americans suffer from chronic migraines, headaches that occur on at least half of the days and often daily.

A new study suggests one of the way to prevent this disabling disease. In the American Migraine Prevalence and Prevention Study, people with episodic migraines (those occurring on less than half of the day each month) completed the Migraine Treatment Optimization Questionnaire and provided outcome data in 2006 and in 2007. They were asked four questions about the efficacy of their acute migraine therapies and the responses were divided into: very poor, poor, moderate, and maximum treatment efficacy.

Among 5,681 study participants with episodic migraine in 2006, 3.1% progressed to chronic migraine in 2007. Only 1.9% of the group with maximum treatment efficacy developed chronic migraine. Rates of new-onset chronic migraine increased in the moderate treatment efficacy (2.7%), poor treatment efficacy (4.4%), and very poor treatment efficacy (6.8%) groups. The very poor treatment efficacy group had a more than 2-fold increased risk of new-onset chronic migraine compared to the maximum treatment efficacy group.

The authors concluded that inadequate acute treatment efficacy was associated with an increased risk of new-onset chronic migraine over the course of 1 year. They speculated that improving acute treatment outcomes might prevent chronic migraine. However, they also said that reverse causality cannot be excluded, meaning that it is possible that those who would go on to develop chronic migraine had poor response to acute treatment because their headaches were worse and that they would develop chronic migraine regardless of how well their acute treatment worked. However, it makes a lot of sense to assume that effective treatment of individual attacks may prevent headaches from becoming chronic, especially because we know that each migraine attack leaves the brain more excitable for weeks and this makes the next attack more likely.

Effective treatment of acute attacks usually involves the use of triptans, (drugs like sumatriptan, or Imitrex, eletriptan, or Relpax, rizatriptan or Maxalt, and other), although NSAIDs, such as aspirin, iboprofen and other can also help, both alone or in a combination with a triptan. Medications that should not be used are drugs such as Fioricet or Fiorinal (butalbital, caffeine, and acetaminophen / aspirin), codeine, Percocet (oxycodone / acetaminophen), Vicodin (hydrocodone / acetaminophen). These drugs are not only ineffective, but can make it more likely that episodic migraines will turn into chronic. This also applies to other caffeine-containing drugs (Excedrin and other) and even dietary caffeine.

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The new dietary guidelines issued by a government advisory committee have many positive changes from the old guidelines. These include a focus on food rather than nutrients. For example, there is no proposed limit on the intake of cholesterol and eating eggs is encouraged. There is an emphasis on eating less meat and more fruits and vegetables and on limiting sugar intake. All these recommendations apply to headache sufferers as well.

However, the guidelines are advising people to increase their consumption of coffee. They suggest that 3 to 5 cups a day can be part of a healthy diet because there is evidence that coffee may reduce risk of type 2 diabetes and heart disease (and possibly Parkinson’s disease). This is because coffee contains flavonoid compounds that have health benefits. However, coffee and caffeine in general are proven to cause worsening of headaches. As little as 2-3 cups a day can worsen headaches by causing caffeine withdrawal. Flavonoids are present in many fruits and vegetables, so it is not necessary to drink coffee to benefit from these compounds. If you are prone to having headaches it is better to limit your caffeine intake to one cup of coffee a day.

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The Journal of Nutrition just published a study that suggests life-extending benefits of taking vitamin and mineral supplements. Multivitamin with minerals products are the most commonly used supplements in the United States, followed by multivitamin products without minerals. While prior studies did not show an effect of such supplements in preventing deaths from cardiovascular disease, however, no previous trial looked for potential benefits just in women.

This new study examined the effect of a multivitamin with or without minerals on 8678 men and women. An adjustment was made for many potential confounders, that is factors that could have influenced the results, including age, race, education, weight (body mass index), alcohol, aspirin use, serum lipids (cholesterol, etc), blood pressure, and blood glucose.

The researchers observed no significant association between mortality due to cardiovascular disease in users of supplements compared with nonusers. However, when users were classified by the reported length of time products were used, a significant association was found with the use of multivitamins with minerals if they were taken for more than three years, compared with nonusers. This finding applied only to women and only to multivitamin products that also included minerals.

Magnesium is one of the minerals which is always included in combination vitamin products. Many studies have shown a beneficial effect of magnesium on cardiovascular and other causes of death in both women and men. And, of course, taking magnesium prevents migraine headaches since magnesium deficiency is found in up to 50% of migraine sufferers.

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Eating more salt leads to more headaches, according to a study published in BMJ Open last December. In a multicentre feeding study with three 30-day periods, 390 participants were randomised to the DASH (a healthy diet that was expected to lower blood pressure) or control (regular, not very healthy) diet. On their assigned diet (DASH and regular), participants ate food with high sodium during one period, intermediate sodium during another period and low sodium during another period, in random order. The occurrence and severity of headache were recorded at the end of each feeding period. The researchers did not attempt to determine which type of headaches people were suffering from, but it is safe to assume that the majority suffered from tension-type and migraine headaches. The average age was 48 and 57% were women.

The occurrence of headaches was similar in DASH versus control, at high, intermediate and low sodium levels. By contrast, there was a lower risk of headache on the low, compared with high sodium level, both on the control and DASH diets. Obviously, there are many reasons to eat a healthy diet, but prevention of headaches is not one of them.

Interestingly, there was no correlation between elevated blood pressure and headaches.

The authors concluded that reduced sodium intake was associated with a significantly lower risk of headache, while dietary patterns had no effect on the risk of headaches in adults. This study showed that reducing dietary sodium intake offers a new approach to preventing headaches.

P.S. DASH stands for Dietary Approaches to Stop Hypertension, diet rich in fruits, vegetables and low-fat dairy products with reduced saturated and total fat.

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Epilepsy drugs Depakote and Topamax are two of only four drugs approved by the FDA for the prevention of episodic migraines (the other two are blood pressure medications in the beta blocker family, propranolol and timolol, while Botox is the only drug approved for the preventive treatment of chronic migraines). However, these two drugs are contraindicated in pregnancy. Considering that the majority of migraine sufferers are young women, this is a topic that needs to be revisited regularly, especially when additional data appears.

A new study just published in the journal Neurology followed children in the British National Health Service whose mothers suffered from epilepsy and who were taking Depakote (valproate) or Tegretol (Carbamazepine) or Lamictal (lamotrigine). Only Depakote caused a significant drop in IQ in children whose mother was taking more than 800 mg of Depakote a day. Children whose mother took less than 800 mg (the usual dose for migraines is 500 mg, but sometimes 1,000 mg is needed) did not have a lower IQ, but had impaired verbal abilities and a 6-fold increase in needing educational intervention.

Unfortunately, Tegretol and Lamictal are not effective for the prevention of migraine headaches, while Topamax which is effective, can cause birth defects. Neurontin (gabapentin) is a relatively benign medication, which is safe in pregnancy and it is somewhat effective in the prevention of migraines, including chronic migraines.

Ideally, all drugs should be avoided in pregnancy. We usually advise non-drug approaches, including regular sleep, healthy diet, exercise, biofeedback or meditation, and magnesium supplementation. If this is insufficient, we usually recommend Botox if migraines remain frequent (they often improve in pregnancy). Botox is not approved for use in pregnant women, but considering that it acts locally on nerve endings with very little of it getting into the blood stream, it is most likely safer than any drug that is ingested.

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I recommend several supplements to my headache patients. However, the supplement industry is not regulated by the FDA and a few days ago another scandal has erupted. The attorney general of New York ordered Walgreens, WalMart, Target and GNC to stop selling their store brand herbal supplements. His investigation revealed that most of the supplements contained no active ingredients. In case of WalMart, only 4% of their herbal products contained an active ingredient. The tests involved Gingko biloba, St. John’s Wort, Ginseng, Garlic, Echinacea, Saw Palmetto, and Valerian root.

Of the herbal supplements for headaches, I recommend Boswellia and Feverfew made by a high quality manufacturer, Nature’s Way. I do not recommend butterbur, even though I participated in a large study that showed its efficacy in preventing migraine headaches. Butterbur contains several toxic chemicals, which can cause liver damage and other serious problems. Petadolex brand of butterbur claims to be free of these toxic ingredients, but the product is not allowed to be sold in Germany where it is manufactured. Here is my previous post on Petadolex.

Non-herbal supplements such as CoQ10 could also present a problem. For years, I have been recommending WalMart’s brand because it was much less expensive than any other brand and because I assumed that such a large company will have strict quality controls. Now I am thinking that it is possible that the price is so low because there is not much CoQ10 in it. CoQ10 by Nature’s Way costs more than twice as much as WalMart’s ($75 vs $30 for a month supply of 300 mg a day), but it may be worth it.

My most recommended supplement for migraines is magnesium and it is much less likely to present a problem because it is very inexpensive. Most of the cost is in manufacturing, bottling, shipping, etc. and not in the active ingredient.

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An email I just received, which is attached at the end of this post, prompted me to write again about magnesium. In my opinion, every migraine sufferer should try taking magnesium. It’s been 20 years since we published our first study of magnesium, in which we showed that during an attack, half of migraine sufferers have a magnesium deficiency. In that study, patients who were deficient had a dramatic relief of their acute migraine with an intravenous infusion of magnesium. Subsequent studies by other researchers have shown that oral magnesium supplementation can also help. The results of those studies were not as dramatic because many people do not absorb magnesium taken by mouth and in one large study the type of magnesium that was used caused diarrhea in almost half of the patients. The magnesium salts that are better absorbed include magnesium glycinate, gluconate, aspartate (these are so called chelated forms), but some people do well with magnesium oxide, citrate, or chloride. The recommended daily dose of magnesium for a healthy adult is 400 mg a day, but some people need a higher dose. However, higher doses can cause diarrhea, while in others, even a high dose does not get absorbed. In these cases, monthly intravenous injections can be very effective. To establish who is deficient, a special blood test can help. The regular blood test is called serum magnesium level, but it is highly unreliable. A better test is RBC magnesium, but even with this test, if the value is normal, but is at the bottom of normal range, a deficiency is likely to be present. In many people there is no need for a test because they have multiple symptoms of magnesium deficiency. These symptoms include coldness of extremities, leg or foot cramps, PMS in women, “brain fog”, difficulty breathing, insomnia, and palpitations.

Here is the email I just received:

Dr. Mauskop,

I am a 76 year old male; serious headaches began at 8 years of age.
Full migraines started at 18 years of age, with aura, intense pain on one side, violent vomiting.
Sought treatment at UCLA, Thomas Jefferson University, London, Singapore. Had brain scans, biofeedback, full allergy testing, beta blockers. Started on Imigran/Imitrex in 1993 in Singapore, worked well, but did not stop pain completely. Still took a day to recover.
Nothing stopped the 2 to 4 episodes per week.
Two months ago, I read about magnesium deficiency. (Not recommended by any doctor before.)
Took 600 mg capsule per day for three days. No migraine.
Had a bit of diarrhea – checked on internet, saw it was the dose of magnesium.
Dropped intake to 340 mg per day.
Miracle: No migraine in two months.
Thank you for your research and service.
I had an annual physical in December, and mentioned to my doctor – an internist – what I had recently read about magnesium. He had not heard about it; checked on the internet while I was there; and said “interesting”. So, the word is certainly not out.

BH

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