Headache coach, Jan Mundo will be conducting classes at the New York Headache Center. The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27. Jan’s course is “for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies.” For details and registration go to http://www.mundolifework.com.
Written by Dr. Mauskop | 16.08.2010 | No comments
Medication overuse (rebound) headache (MOH) has been the subject of many studies and reports. Another review of this subject appeared in the latest issue of journal Pain by Italian neurologists. This review addressed possible causes, predisposing factors, and possible treatments. The list of possible drugs which can lead to overuse headaches included in this article includes every possible headache medicine. However, the authors do not mention that for some drugs there is more scientific evidence than for other. For example, only caffeine and opioid (narcotic) analgesics have been proven to cause MOH, while drugs such as aspirin may actually prevent the development of MOH. There is only anecdotal (case reports) evidence for triptans (sumatriptan, or Imitrex, rizatriptan, or Maxalt, and other). The authors suggest that both environmental and genetic factors may contribute to patient’s vulnerability to substance overuse, dependence, and withdrawal in MOH. They also think that psychological comorbidities such as depression, anxiety and poor pain coping abilities may contribute to chronification of headaches.
The authors report on different detox strategies, including the need for hospital admission for patients taking large doses of narcotics or barbiturates (such as butalbital, found in Fioricet, Fiorinal, Esgic). However, almost all patients seen at the New York Headache Center are successfully withdrawn on an out-patient basis. Many patients fear worsening of pain from medication withdrawal, but several treatments can make the process less painful. Botox injections, intravenous infusions of magnesium, topiramate (Topamax), gabapentin (Neurontin) and a short course of steroids are some of the most commonly used strategies. Elimination of dietary caffeine, regular aerobic exercise, biofeedback, and acupuncture are also very useful adjunctive therapies.
Written by Dr. Mauskop | 11.08.2010 | No comments
Many migraine sufferers feel that food allergies cause their headaches. There is little dispute that certain foods can trigger migraines. Some of these foods include chocolate, wine, cheese, citrus fruit, onions, smoked, cured, and pickled foods. However, migraine that results from eating these foods is not due to an allergic reaction, but rather is due to a chemical reaction. An allergic reaction occurs when the body’s immune defense mechanisms try to isolate and attack an offending substance, called an allergen. It is possible to evaluate this immune response by measuring blood levels of immune globuline (IgG) which is specific to to a particular food or substance. Since there are so many different foods that we eat, literally hundreds of tests are required. Doing such extensive testing has been controversial, in part because of its high cost. This testing has been advocated for patients with irritable bowel syndrome. People who are found to have high levels of of IgG to certain foods can improve their condition by eliminating those foods. Another way to detect food allergies is by scratch test, where an extract of different foods is placed into skin scratches and then the skin reaction is measured.
A sophisticated study recently published in Cephalalgia by Dr. Ertas and his colleagues looked at food allergies in migraine patients. They tested IgG levels to 266 foods in the blood of 30 migraine sufferers. The number of foods these 30 patients were allergic to ranged from 13 to 35. After testing, for six weeks each patient ate a diet which included or excluded foods they were allergic to. After that, they had two weeks of unrestricted diet, followed by another 6 weeks of the opposite diet (if they first had a diet free of allergen, then they were switched to a diet with allergens, and vice versa). Neither the doctor, nor the patient knew what foods the patient was allergic to or which diet was given in each 6-week period. The results of the study showed that significantly fewer migraines occurred when the diet excluded foods patients were allergic to. This is the first rigorous study which suggests that food allergy testing may find a place in the management of patients with migraine headaches.
Written by Dr. Mauskop | 03.08.2010 | 4 comments
There are over 4 million chronic migraine sufferers in the US. Chronic migraine is defined as a headache with migrainous features, which occurs on more than 15 days each month. Many of these chronic migraine patients we see at the New York Headache Center have daily headaches. By the time they come to our Center, many have seen several doctors, including neurologists and found no relief from a variety of drugs. A new book just published by Oxford University Press may help doctors who care for headache patients to provide better care. The book is Refractory Migraine, Mechanisms and Management. Dr. Mauskop and Dr. Sun-Edelstein contributed a chapter to this book: Nonpharmacological Treatment for Refractory Migraine: Acupuncture, Vitamins and Minerals and Lifestyle Modifications. An important message contained in the chapter and the one we always stress to our patients is that the best way to approach a refractory headache is not by trying one drug after another, but by combining drugs with nonpharmacological treatments, such as biofeedback, magnesium, other supplements, Botox injections, acupuncture and other therapies.
Written by Dr. Mauskop | 18.07.2010 | 1 comment
Many, but not all epilepsy drugs are also effective in preventing migraine headaches. For example, divalproex sodium (Depakote), topiramate (Topamax), and to a lesser degree gabapentin (Neurontin), pregabalin (Lyrica), and levetiracetam (Keppra) relieve migraine headaches, while other epilepsy drugs, such as phenytoin (Dilantin) and carbamazepine (Tegretol) do not. A report by Drs. Krusz at the annual meeting of the American Headache Society held last month suggests that a new epilepsy drug, lacosamide (Vimpat) may also be effective for the treatment of headaches. Dr. Krusz treated 22 patients with chronic migraines (patients who had more than 15 headache days each month) with this medication and discovered that on average the monthly number of headaches dropped from 21 to 13. Side effects, such as drowsiness, nausea, and cognitive impairment lead 4 patients to stop the drug. Despite very impressive results it is premature to declare lacosamide an effective headache treatment because the study was very small and not placebo-controlled.
Written by Dr. Mauskop | 05.07.2010 | No comments
Aspirin and similar anti-inflammatory drugs have been proven to be effective for many migraine sufferers. In a recent report 1,000 mg of aspirin was found to be as effective as 100 mg of sumatriptan (Imitrex) with fewer side effects. Cambia is a new prescription drug, which was recently approved by the FDA specifically for the treatment of migraine headaches. The active ingredient in this drug is diclofenac, which is also sold under Voltaren and Cataflam names. But unlike other forms of diclofenac, Cambia is a powder which patients are supposed to dissolve in a glass of water and drink it. Drinking a solution rather than swallowing a pill speeds absorption of the drug, which can make a difference for those migraine sufferers who need to catch their attacks early, or drugs don’t help. The drug has a “black box” warning, which cautions about possible cardiovascular side effects, as well as gastro-intestinal side effects, including bleeding and ulcers. The cardiovascular side effects of diclofenac are similar to those of Vioxx which was taken off the market. Other NSAIDs also carry risk of cardiovascular (and GI) side effects, but their risk is lower. The only NSAID without cardiovascular risks is aspirin. In fact it is used to prevent strokes and heart attacks. Aspirin is also the only drug which prevents the development of rebound headaches - worsening of headaches from frequent intake of a headache medicines or caffeine.
Written by Dr. Mauskop | 30.06.2010 | 1 comment
Medication overuse headaches are usually treated by withdrawing the offending drug (usually Excedrin, Fioricet or narcotics, such as codeine, Vicodin and Percocet) or dietary caffeine. About half of the people who stop taking these drugs improve, while the other half does not. A recent study by Dr. Andrew Hershey and his colleagues at the University of Cincinnati suggests that by doing genomic analysis of the blood we may be able to predict who is going to improve by withdrawing overused medication and who is not. This does not mean that the latter group is going to be left to suffer. However, this test could save a major effort that is involved in getting someone off medications. Instead these patients can be maintained on their medication while other preventive treatments are tried. These treatments can include biofeedback, magnesium infusions, Botox injections, prophylactic drugs, acupuncture, CoQ10, butterbur, and other treatments.
Written by Dr. Mauskop | 16.06.2010 | No comments
Severe migraines are often accompanied by nausea and vomiting, making oral medications ineffective. Sumatriptan (Imitrex) and Zomig (zolmitriptan) are available in a nasal spray and Imitrex also as an injection (a needleless injection, Sumavel was launched recently). Nasal spray is not well absorbed and does not work well for many (in my experience, Zomig spray is somewhat better than Imitrex). Injections work fast, but are painful (even the needleless injection hurts) and expensive. Another way to get medicine into the body is rectally. Rectal suppositories are absorbed very quickly and more consistently than nasal sprays. Europeans are much more receptive to this route of administration than the Americans. A group of Italian researchers compared the effect of a suppository containing 25 mg of sumatriptan with a 50 mg tablet. The suppository was slightly more effective than the tablet. Imitrex suppositories are not available, but so called compounding pharmacies can prepare a suppository of any medication, if doctor writes an order. With Imitrex going generic, the price should be more affordable.
There are two other products in development (not yet available), which will bypass oral route - a sumatriptan skin patch and an inhaler of dihydroergotamine (Levadex). The patch is somewhat large and may be awkward to use, while the inhaler is much more promising. Inhaling a drug into the lungs provides very fast onset of action, faster than subcutaneous injection of Imitrex. According to the published data the efficacy of Levadex is very good with few side effects.
Written by Dr. Mauskop | 12.06.2010 | 2 comments
Migraine sufferers are 2 - 3 times more likely to become depressed or anxious than those without migraines. The reverse is also true - depressed and anxious people are 2 -3 times more likely to develop migraines. According to a new study published in the journal Cephalalgia, being depressed or anxious does not prevent migraine drugs from working. The Greek researchers gave participants in the study sumatriptan (Imitrex), 50 mg for 3 attacks, and placebo, for another 3 attacks, without the doctors or the patients knowing what they were getting for any particular migraine attack. Presence of anxiety or depression did not have an impact on weather after taking sumatriptan the headache returned within 24 hours or not. Unfortunately, many physicians dismiss patients with migraine headaches as neurotics and hypochondriacs and the presence of anxiety or depression makes this bias even stronger. These doctors tend not to prescribe effective migraine drugs, which leads to unnecessary suffering. It is true that for some patients 1,000 mg of aspirin can be as effective as 50 or even 100 mg of sumatriptan with fewer side effects, but when aspirin is ineffective, sumatriptan or another drug in the triptan family should be used. One surprising detail of this study is that the researchers used 50 mg of sumatriptan, and not 100 mg, which should be the usual starting dose for most patients.
Written by Dr. Mauskop | 02.06.2010 | No comments
Occipital nerve blocks can stop a migraine attack when other treatments fail. This is a relatively simple procedure (although not many physicians are trained in it), and it consists of an injection of lidocaine or a similar local anesthetic drug into an area at the back of the head on one or both sides. There are two branches of the nerve - greater and lesser occipital nerves and I usually inject both. The block can help even if the headache is not strictly localized to the back of the head. In some people headache returns after a few hours, once the effect of the local anesthetic wears off. However, a recent study presented at the American Academy of Neurology suggested that up to 60% of patients with an acute migraine may respond without return of the headache. Adding steroid medication to the local anesthetic does not seem to improve outcome. However, occipital nerve block with steroid medication (Depo-Medrol, Celestone, and other) is effective in aborting cluster headaches.
Obviously, occipital nerve block is not practical or necessary treatment for people who respond to oral or self-injected medications, but if these treatments fail such a block is an excellent option. However, even if other treatments fail, we usually start office treatment of severe migraines with intravenous magnesium, which is more effective than any other treatment in those 50% of patients who are magnesium deficient.
Written by Dr. Mauskop | 30.05.2010 | No comments
Next Page »
