Magnesium infusion given before or during surgery reduces the amount of opioid analgesics (narcotics) needed in the 24 hours following surgery. Doctors at the Saint Barnabas Medical Center in Livingston, NJ reviewed 14 of the most rigorous clinical trials which involved 910 patients. Half of those patients were given intravenous magnesium and the other half, placebo. During the first day after surgery there was a significant reduction in the need for morphine by those receiving magnesium compared with placebo.

Another study published in 2013 reviewed 20 clinical trials of magnesium for post-operative pain. These trials included 1,257 patients. This review also concluded that magnesium improved pain and reduced the need for narcotic pain killers.

Prescription narcotics are frequently in the news because of the epidemic of prescription drug abuse. However, the advantages of not using as much of these drugs after surgery are far greater than just a reduction of the risk of addiction. These drugs cause constipation, which is a problem after surgery even without opioid drugs, and it makes recovery more difficult. They can also cause confusion, difficulty breathing, and other side effects.

There are many possible explanations for the pain-relieving effects of magnesium. We know that it regulates the function of several receptors involved in pain, including serotonin and NMDA. It also relaxes muscles, opens constricted blood vessels, and reduces excitability of the brain and the entire nervous system. Both mental and physical stress depletes magnesium and they are very much present with surgery.

Magnesium is a natural pain blocker, which is effective for many patients with migraine and cluster headaches, as well as those with fibromyalgia, back pain, neuropathy, and other types of pain. Here is a recent blog post on magnesium and migraines.

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Sphenopalatine ganglion (SPG) block has been used for the treatment of headaches and other pain conditions for over 100 years. The original method involved placing a long Q-tip-like cotton swab dipped in cocaine through the nose and against the SPG.

SPG is the largest collection of nerve cells outside the brain and it sits in a bony cavity behind the nasal passages. These nerve cells are closely associated with the trigeminal nerve and include sensory nerves, which supply feeling to parts of the head and autonomic nerves, which regulate the function of internal organs, blood vessels, as well as tearing and nasal congestion. Considering that these nerve cells produce such a wide range of effects, it is logical to expect that blocking these nerves might help headaches.

For obvious reasons we no longer apply cocaine, but instead use numbing medicines, such as lidocaine or bupivacaine. A small study suggested that just putting lidocaine drops into the nose can relieve an acute migraine. I’ve prescribed lidocaine drops to some patients with cluster headaches and a small number reported relief. The problem with nasal drops is that we are not sure if lidocaine actually reaches all the way back to numb the SPG even if they are lying down with the head hanging back over the edge of the bed. Using long Q-tips is uncomfortable and in many patients the Q-tip may also not reach the SPG.

To solve the problem, two doctors developed thin intranasal catheters that appear to consistently reach the area of SPG. Dr. Tian Xia’s Tx360 device seems to be more comfortable for patients because his is a thinner and a more flexible catheter. The recommended local anesthetic is bupivacaine (Marcaine), which lasts longer than lidocaine. A small double-blind study of SPG block using Tx360 in chronic migraine patients showed it to be effective. The active group had a reduction of the Headache Impact Test (HIT-6) score, while the placebo group did not. In this study patients were given the SPG block twice a week for 6 weeks. We need larger and longer-term studies in chronic migraine patients before advising such frequent regimen, not in the least because of cost.

SPG block seems to be more appropriate (and this is what we use it for at the NYHC) for patients with an acute migraine that does not respond to oral or injected medications and for those with cluster headaches. Since cluster headaches usually last for a few weeks to a couple of months (unless it is a patient with chronic cluster headaches), it is practical to try SPG blocks on a weekly basis. Theoretically, because there is so much autonomic nervous system involvement in cluster headaches (tearing, nasal congestion, and other), SPG should be particularly effective for cluster headaches.

Another way to affect the SPG is by stimulating it with electrical current, which seems to be effective for chronic cluster headache patients, according to a small study. This method requires surgical implantation of a device into the area of the SPG. See my previous post on this.

Below is an illustration of the SPG and the Tx360 device.

Sphenopalatine ganglion block with  Tx360 device

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Since my early 20s I’ve been getting visual auras without a headache several times a year. I still get them in my late 50’s and they still occur without a headache. In my 40s I started to have migraine headaches without an aura. My migraines are always left-sided and if I don’t treat them, I will develop sensitivity to light and nausea. Luckily, my migraines are not at all disabling because they remain mild for hours, so I have plenty of time to take 100 mg of sumatriptan, which works very well. The tablet works within one to two hours. When I want to have faster relief, I take a 6 mg sumatriptan injection. This usually happens at night when I want to go to sleep and I don’t want to wait for the pill to start working. I can’t fall asleep with a migraine, while for some, sleeps actually relieves the attack.

I am not happy about having migraines, but they do not interfere with my life and give me a better understanding of what my patients are going through. Also, I try to subject myself to treatments I offer my patients. I do not need to take a daily preventive medicine, such as topiramate or propranolol or Botox injections. However, since Botox is very safe, I did inject myself with Botox once to see what it feels like. It was not very painful, but obviously everyone has a different pain threshold (here are video 1 and video 2 of me injecting patients with Botox). I also gave myself an intravenous infusion of magnesium, which did make me feel warm, but had no beneficial effects since I am not one of the 50% of migraine sufferers who are deficient in magnesium.

The next thing I decided to try is a nerve block. Nerve blocks are injections of a local anesthetic, such as lidocaine or bupivicaine to numb the nerves around the scalp (here is a previous blog on nerve blocks). It is somewhat surprising that numbing a superficial nerve under the skin stops a migraine, which we know to originate in the brain. For the same reason a lot of scepticism greeted me at medical meetings over 20 years ago when I gave lectures on Botox for migraines. Now we know that although the migraine process begins in the brain, peripheral nerves send messages back to the brain closing a vicious cycle of brain activating the nerves and nerves feeding back pain messages into the brain. Disrupting this circuit with a peripheral nerve block for short-term relief and with Botox for long-term prevention seems to be very effective. Nerve blocks can be effective when drugs are not or when drugs are contraindicated because of an illness or pregnancy.

Sometimes, blocking the occipital nerve at the back of the head works well, but other patients need nerves blocked in their temples or forehead. Since my migraines are always localized to the left temple, I decided to give myself a block of the temporal branch of the left trigeminal nerve. The nerve block helped one of two times I tried it. Obviously, I do not recommend DIY nerve blocks or teach patients how to do it, but I did encounter one patient who learned how to give himself an occipital nerve block before coming to see me. There might be some exceptions, such as for people living in remote areas and who do not respond to any other treatments, or in not such distant future, for those traveling to Mars.

The next treatment I will try is a sphenopalatine ganglion block. I will describe this treatment in my next post.

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Acupuncture and Alexander technique appear to be equally effective and significantly more effective for the treatment of chronic neck pain than routine care, according to a study by British researchers published in the latest issue of the Annals of Internal Medicine.

The doctors divided 517 patients who suffered from neck pain for at least 6 years into three groups. The first group received an average of 10 50-minute acupuncture treatments, the second had an average of 14 30-minute Alexander technique lessons, and the third group received the usual care. The authors found that acupuncture and Alexander technique both led to a significant reduction in neck pain and associated disability compared with usual care at 12 months.

One possible explanation of such good efficacy beyond the direct effect of the treatments was that patients in the active treatment groups had improved self-efficacy. Self-efficacy is the belief that one’s actions are responsible for successful outcomes and it was measured by a standardized questionnaire.

It is possible that other forms of therapy that enhance self-efficacy, such as tai chi, meditation, and other can also improve long-standing neck pain, as well as headaches. There are many acupuncture studies that show a significant benefit for migraine headaches (here is one described in a previous post), however unlike this neck pain study most of them did not follow patients for such a long period of time. Alexander technique has been also helpful for some of my patients, but again, good studies are lacking.

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Richard Wenzel PharmD of the Diamond Headache Clinic in the latest issue of the leading medical journal, Headache writes about the shocking fact that this country’s pharmaceutical industry cannot reliably supply medications for patients. He also talks about a connected, also undeniable development: “generic drugs currently push the boundaries of affordability”.

Drug shortages involve easily replaceable drugs, but also many life-saving cancer medications. Headache sufferers have not been spared, especially those with severe illness requiring injectable products; droperidol has been unavailable since 2013, various haloperidol and magnesium products are currently on backorder, and the availability of ketorolac, diphenhydramine, and valproic acid has recently been sporadic.

Dr. Wenzel writes that as of July, 2015, the American Society of Health Systems Pharmacists (ASHP) cited 265 active drug shortages. There’s also a “drugs no longer available” list of 57 medications unlikely to ever be commercially manufactured again, including ergotamine.

In the past two years, injections of dihydroergotamine, an irreplaceable migraine drug developed in 1940s, had been unavailable for two periods of lasting several months. The cost of this generic drug skyrocketed from 10 to up to $130 for a single dose.

Scarcities of raw materials, disruptions to manufacturing plants (eg, hurricane damage), insufficient FDA staff to provide prompt approval for production facilities, industry consolidation, and decisions to stop producing a marginally profitable or unprofitable product have all been cited as shortage reasons.

According to the Healthcare Supply Chain Association the costs of 10 drugs widely prescribed among the general public have jumped up to 8000% in as little as one year (2013–2014). For example, a single tablet of an antibiotic doxycycline went from $0.04 to over $3.60 and the new cost of Isuprel, a heart medication went from $180 to $2700 for a single ampule.

The medical community has been trying to address the problem of shortages and high costs through various organizations and the congress, but to no avail. Actually, the government is to blame in some cases. Besides the FDA staff shortages, low payments by the government (and insurers) that do not cover the cost of production is another common reason. When all pharmaceutical companies stop manufacturing a non-profitable or money-losing drug, one company jumps back in and because it is the only one making this medicine, they can charge exorbitant amounts for a generic drug.

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Solar activity is high again – NASA’s Solar Dynamics Observatory reported a flare on October 1. And in the past two weeks we’ve been seeing many more patients whose cluster headaches returned. The last time we had a surge in the number of cluster patients was last October, when solar activity was also high (see this post).

Unfortunately, there is not a lot we can do about the solar activity, but we do have many treatment options for cluster headaches. These include intravenous magnesium (40% of cluster headache sufferers are deficient), occipital nerve blocks, steroids, daily prevention with verapamil, Botox injections, oxygen inhallation, nasal spray of zolmitriptan (Zomig NS), and sumatriptan (Imitrex) injections. For most cluster patients one more often several of these treatments provide good relief. If these are ineffective, we also use drugs such as lithium, topiramate, and even an herbal supplement, Boswellia.

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A report describing delivery of magnesium through the skin for the treatment of fibromyalgia has just appeared in the Journal of Integrative Medicine. The title of the report is, Effects of transdermal magnesium chloride on quality of life for patients with fibromyalgia: a feasibility study. It was conducted by doctors at the Mayo Clinic, which carries a certain amount of legitimacy. However, close reading of this report shows shockingly poor quality of this study.

It is true that magnesium deficiency has been found in patients with fibromyalgia (especially if levels other than serum or plasma are measured, i.e. ionized or RBC) Fibromyalgia is a syndrome of unknown cause, which is characterized by chronic pain, fatigue, depression, and sleep disturbances. Some studies have found that the lower the level of magnesium, the more symptoms patients were having. There is an association between fibromyalgia and migraine headaches and those of our patients who have both conditions often report relief of both migraines and fibromyalgia with oral magnesium supplementation or intravenous infusions.

Several companies promote products that promise to deliver magnesium into the body through the skin. The oldest one is Epsom salts, which is magnesium sulfate. Taking a warm bath with Epsom salts surely feels relaxing, but there is no evidence that magnesium penetrates through the skin.

The Mayo clinic study enrolled forty postmenopausal female patients with the diagnosis of fibromyalgia. Each was given a spray bottle containing a 31% solution of magnesium chloride (and “a proprietary blend of trace elements”) and asked to apply 4 sprays per limb twice daily for 4 weeks. They were also asked to complete various questionnaires. Only twenty-four patients completed the study, with 4 dropping out because of skin irritation. At week 2 and week 4 most were significantly improved.
The authors concluded that their study “suggests that transdermal magnesium chloride applied on upper and lower limbs may be beneficial to patients with fibromyalgia”. This was a very small and unblinded study with many dropouts, which means that no conclusions can be made. It is very surprising why the authors did not measure magnesium levels before and after the treatment, which would make the study much more valuable.

The company that sponsored the study has a product they’d like to sell to the unsuspecting public and it will certainly use this “study” and the Mayo Clinic name to sell their miracle spray. The Mayo Clinic is a highly respected institution and I hope they will not allow its name to be associated with such poor quality marketing studies.

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Zecuity, a skin patch containing a migraine drug sumatriptan was approved by the FDA almost two years ago, but it became available (by prescription) only last month (see my previous post about Zecuity). The product is not available in retail pharmacies, only from a specialty pharmacy. The doctor who prescribes the patch will usually provide information on where to get it. Otherwise, go to, where you can find a section entitled Migraine Support Solutions. At this site you can verify that your insurance covers this product, get it shipped to you, and then get information on how to apply the patch. A discount coupon is also available on the site and it promises that the copay will be as low as $15. That is a good thing, because it looks like (on each patch costs $300. Yes, not $30, but $300 a piece, or $1,200 for a box of 4. I don’t think too many people will be buying this patch if their insurance does not cover it.

So, who is the best candidate for Zecuity? Half of migraine sufferers experience nausea and/or vomiting with their attacks. This makes the absorption of oral drugs, such as triptans (Imitrex, Maxalt, Zomig, etc) so slow as to make them ineffective. In such patients we try to bypass the stomach, which until now was possible to do with a nasal spray, suppository, or an injection. Sumatriptan (Imitrex) is available in the US in tablets, nasal spray and self-administered injections. Nasal spray of sumatriptan is not very effective, but injections work better than tablets. Relief from an injection can occur in as quickly as 10 minutes, but injections can cause more side effects, which are mostly unpleasant rather than dangerous. Obviously, most people would rather not get a shot. One form of injectable sumatriptan delivers the medicine through the skin without a needle (Sumavel), but not without pain see this post.

One other triptan, zolmitriptan (Zomig) is available in a nasal spray and it is more effective than sumatriptan nasal spray, but it is not available in a generic form, making it less accessible because of the high cost and restricted insurance coverage.

The perfect patient for Zecuity is someone who experiences nausea and/or vomiting with their migraine attacks and who does not respond to tablets and has side effects from or aversion to injections. Zecuity provides good relief for such patients with the main side effect being skin irritation from the patch. The patch is fairly large, the size of a palm. It uses a miniature battery to generate an electric current, which helps drive the medicine through the skin. Iontopheresis is the name of this process. Iontopheresis has been known for decades, but Zecuity is the first product approved by the FDA to utilize this technology.

Disclosure – Teva Pharmaceuticals, manufacturer of Zecuity pays me to give lectures about Zecuity to doctors.

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Epilepsy and migraines share many features and those with epilepsy have a higher risk of developing migraines, while those with migraines are more likely to develop epilepsy. Anti-epilepsy drugs are commonly used for the preventive treatment of migraines.

A study just published in Neurology by Hong Kong researchers investigated the effectiveness of mindfulness-based therapy and social support in patients with drug-resistant epilepsy.

It was a blinded and randomized trial. Sixty patients with drug-resistant epilepsy were randomly allocated to mindfulness therapy or social support (30 per group). Each group received 4 biweekly intervention sessions. They measured quality of life, as well as seizure frequency, mood symptoms, and neurocognitive functions.

Following intervention, both the mindfulness and social support groups had an improved quality of life, but significantly more patients in the mindfulness group had a clinically important improvement. Significantly greater reduction in depressive and anxiety symptoms, seizure frequency, and improvement in delayed memory was observed in the mindfulness group compared with the social support group.

The authors concluded that even short-term mindfulness therapy in patients with drug-resistant epilepsy provides significant benefits.

It is surprising that even seizure frequency was reduced, although stress and lack of sleep can definitely increase seizure frequency. The study did not evaluate the quality or duration of sleep, but mindfulness meditation is know to improve sleep. It also improves migraine headaches (see my previous post).

To start meditating you can download a very popular app, Headspace or read a book by BH Gunaratana, Mindfulness in Plain English or download free podcasts at

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About 12% of the population suffers from migraines. In addition to high rates of migraine-related disability, migraineurs are at a higher risk than the general population of additional disability related to depression, anxiety, irritable bowel syndrome, fibromyalgia, and other conditions.

Fibromyalgia is a disorder of the central nervous system with increased brain excitability. It often manifests itself not only with muscle pains, but also fatigue, memory problems, and sleep and mood disturbances. Various studies estimate that anywhere from 2% to 8% of the general adult population suffers from fibromyalgia. Just like with migraine, women are more often affected than men. The likelihood of coexisting fibromyalgia increases with increasing frequency and severity of migraine attacks.

Both migraine and fibromyalgia have been individually linked with increased risk of suicide. However, it is not clear that the risk is more than additive.

A study just published in Neurology, reports that patients with migraine and coexisting fibromyalgia have a higher risk of suicidal ideation and suicide attempts compared with migraine patients without fibromyalgia.

The study looked at 1,318 patients who attended a headache clinic. Of these patients, 133 or 10% were found to also have fibromyalgia. Patients with both conditions had more frequent, more severe, and longer-lasting migraine attacks as well as higher use of abortive medications.

Compared with migraine patients who did not have fibromyalgia, those with fibromyalgia were more likely to report suicidal ideation (58% vs 24%) and suicide attempts (18% vs 6%).

This report suggests that migraine and fibromyalgia may magnify the risk of suicide compared with the risk of the individual conditions. However, because this data comes from a specialty headache clinic, many patients were severely affected by their migraines, with more than 35% having chronic migraine. It is likely that the results would be less dramatic among migraine sufferers in the general population. Almost half of the estimated 35 million migraine sufferers in the US do not consult a physician. Most of them suffer from milder migraines than those who do consult a doctor.

This study suggests that patients with migraine should be evaluated for other chronic pain conditions and for their mental health well-being. In particular, patients with chronic migraine should be screened for other painful conditions and mental illness. And patients with fibromyalgia should also be evaluated for migraine and potential suicide ideation. Patients often do not appear depressed, but simple questions can detect depression, which can lead to effective treatment. Our initial evaluation at the New York Headache Center includes two questions which are highly indicative of depression: 1. Have you been bothered a lot in the last month by feeling sad, down, or depressed? 2. Have you been bothered a lot in the last month by a loss of interest or pleasure in your daily activities?

Antidepressants have been proven to be effective for the prevention of migraines even in the absence of depression and are the best choice for people suffering from both conditions. Prozac, Lexapro and other SSRI antidepressants do not help migraines or pain, but SNRIs such as Effexor, Cymbalta, and Savella or tricyclics such as Elavil, Pamelor, and Vivactil do relieve pain and depression.

Magnesium deficiency is common in both migraines and fibromyalgia and we recommend an oral supplement to all patients. Some patients do not absorb magnesium and respond very well to monthly intravenous infusions of magnesium. Both their migraines improve as do fibromyalgia symptoms.

One interesting difference between migraines and fibromyalgia is the response to Botox. Botox is proven to be highly effective for the prevention of migraines and it works very well to relax spastic muscles. However, Botox appears to be ineffective for the treatment of muscle spasm in fibromyalgia. It is possibly explained by the fact that Botox interferes with the function of acetylcholine, a neurotransmitter involved in contracting healthy muscles. In fibromyalgia, studies suggests a deficit in acetylcholine, so further blocking it would be ineffective or even make the muscle pain worse (which I’ve seen in a few patients).

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