Archive
April, 2012 Monthly archive

Botox injections relieve pain of trigeminal neuralgia, according to a new study just published in Cephalalgia, a leading headache journal. Trigeminal neuralgia is an extremely painful condition which manifests itself by intense electric shock-like pain on one side of the face. The pain is triggered by speaking, chewing and often without any provocation. Persistent pain can lead to malnutrition from the inability to chew and to severe depression and despondency. Epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), and other types of drugs often relieve the pain, but not always and at times the drugs can cause intolerable side effects.
Research on the mechanism of action of Botox has shown that it may be blocking sensory nerves and this led me to try Botox for a few of my patients with conditions other than chronic migraines and other headaches. Several patients with post-herpetic neuralgia (shingles) and a few with trigeminal neuralgia responded very well.
This rigorous double-blind, placebo-controlled study in Cephalalgia by Chinese researchers involved 42 patents with trigeminal neuralgia, of whom 40 completed the study. Among the patients who received Botox injections, 68% had significant improvement compared to only 15% of responders in the group tht received placebo. This study strongly suggests that Botox is an effective treatment for some patients with trigeminal neuralgia. The advantage of Botox is that it has significantly fewer side effects than oral drugs.

Read More

Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been established. A recent study showed that even low levels of particulate matter can increase the risk of a stroke. Doctors looked at 1,705 patients who were admitted to the hospital with an acute stroke and checked pollution records on the days these strokes occurred. They found that strokes were more common within 12 hours of the rise in the level of pollution. The correlation was linear – the higher the pollution, the higher the risk of stroke. The risk of stroke was elevated even at pollution levels considered “satisfactory”.

Read More

Mal de debarquement syndrome (MdDS) or disembarkment syndrome is a rare condition which often, but not always, occurs after getting off a ship. Many people have “sea legs” after getting off a boat, but in most this sensation of still being on a rocking boat quickly subsides. Very few unfortunate people continue to have this sensation for months and even years. Last week I happened to see two patients with this condition. It was not entirely a coincidence since both read online report by a patient whom I helped. One woman I saw today said that she feels that her life was taken away from her. Despite her symptoms, she was able to hold a full-time job and care for her 3 children. However, the second patient with the worst case of MdDS I’ve seen, demonstrated how debilitating this seemingly minor disorder can be. She had to quit her job, became very anxious and depressed, which never happened to her before this illness. She also reported feeling very tired, could not think clearly, complained of difficulty breathing, diarrhea, constipation, and had many other debilitating symptoms. When I examined her, she was unable to stand with her feet together and eyes closed and could not walk a straight line, heel-to-toe. Almost all patients I’ve seen with MdDS had extensive testing, which was normal. Vestibular rehabilitation seems to help a few, as does acupuncture, or medications such as Klonopin or clonazepam (which seems to be the most commonly prescribed drug). Most of the patients with MdDS also suffer from headaches, often migraines. Even if they don’t have headaches, they are referred to me because the ENT or the primary care doctor thinks that this condition may be related to migraines. It is true that migraine sufferers are more likely to have disorders of the inner ear and difficulties with balance and coordination.
Our research has shown that up to 50% of migraine sufferers are deficient in magnesium and this deficiency is not detectable by routine magnesium test. Other symptoms suggestive of magnesium deficiency include coldness of extremities, or just being cold most of the time, leg or foot muscle cramps (often occurring at night), brain fog or spaciness, difficulty breathing, and other symptoms. Most of the patients with MdDS I’ve seen had many of these symptoms and what made a dramatic difference for more than half was an infusion of magnesium, often combined with a vitamin B12 injection (another common deficiency). Some patients were already taking oral magnesium supplement, but it did not make a difference. This is not unusual because some people have either a genetic inability to absorb oral magnesium or have gastro-intestinal disorders (irritable bowel syndrome, diarrhea, etc) which impair magnesium absorption. Some people need to have repeated monthly infusions of magnesium.
Another common contributing factor to this syndrome is neck muscle spasm, which alone can be responsible for a sense of dizziness, but more often just makes MdDS worse. Treatment of neck muscle spasm can produce significant improvement.
So, what happened to my two patients from last week? The first one felt only a little better right after the infusion and I asked her to call me back in a week or two, while the second one had a dramatic improvement: she could stand still without swaying with her eyes closed and walked a straight line without difficulty. We’ll see if this improvement will last. I suspect that it will. I also encouraged her to slowly get off clonazepam and an antidepressant she was taking, but to continue seeing a social worker for psychotherapy. I recommended to both patients several supplements, including CoQ10, 300 mg daily and 6 grams of omega-3 fatty acids.
If magnesium is ineffective, medications, such as gabapentin (Neurontin), memantine (Namenda), and tizanidine (Zanaflex) can help without causing habituation seen with clonazepam. For neck muscle spasm, isometric neck exercises that strengthen neck muscle can help. I also treated one patient who improved when I combined magnesium infusions with weekly acupuncture sessions. Acupuncture tends to be more effective with more frequent sessions, 2-3 times a week, which is impractical for many because of the time and cost involved.

Read More

Risks involved in using Chinese herbs are highlighted in the just released AFP report, which you can read on Yahoo News. Here is an edited quote from this story: The samples analyzed for this study included herbal teas, capsules, powders and flakes were tested by scientists at Australia’s Murdoch University. 68 different plant families that were detected in the 15 samples can be toxic if taken in the wrong doses, but the packaging did not list the concentrations of the elements inside.
I am a big proponent of alternative and complementary medicine, recommend herbs, and am a certified acupuncturist. I think acupuncture and many herbal products have a place in the modern medicine because they’ve been shown to be effective. However, many people who go to acupuncturists are often given Chinese herbs along with acupuncture. Unfortunately, there is very little or no quality control in the production of the Chinese herbs. The most dramatic example of this problem was described in the New England Journal of Medicine in 2000 – an herb people were taking for weight loss was contaminated by a toxic plant which caused kidney failure and urinary cancer in 18 of 105 patients. China (just like India, Russia, etc) still has extreme levels of corruption, which means that we cannot rely on their herbal products unless they are first tested in an American laboratory for purity. For now, stick with herbal products made in the US or Western Europe. Feverfew, boswellia, ginger, valerian root, and other are available from major manufacturers, such as Solgar, GNC, Nature Made, and other.

Read More

We should not complain about our health care system. People in such advanced European countries as Netherlands have it much worse. I just saw a 27-year-old Dutch woman with chronic migraines who has been coming to see me for Botox injections every three months for the past 3 years. Three years ago she was told by her neurologist to quit law school because even if she was able to graduate, her migraines will prevent her from being able to hold a job. She is graduating from law school this June. Her doctors also told her not to take sumatriptan (called Imigran in Europe and Imitrex in the US) more than once or twice a week and take only aspirin on other days. This approach made her unable to function on the five days when she did not take sumatriptan, but even with sumatriptan her headaches were still disabling. Botox injections produced a significant improvement in the severity of her attacks, although not in the frequency. However, now sumatriptan provides complete relief and she can function normally. She tried to find a way to get Botox injections in Holland and offered to pay the doctor. He was not able to do it because medicine is socialized in Holland and he could not accept payment for procedures not covered by the health service. She turned to the government and offered to reimburse the health service for Botox, but they also refused. She is fortunate in that she is able to afford to come to New York every three months and buy as much sumatriptan as she needs to function normally.
Things are not much better in the UK and other European countries. The UK approved the use of Botox for chronic migraine before it was approved in the US. However, their national health service also refuses to pay for it. My Italian colleagues have told me that as a society they’ve decided that Botox was too expensive to be used for the treatment of migraines, despite the evidence that it works. I should note that just like many other drugs, Botox is significantly cheaper in Europe than in the US.

Read More

Muscle relaxants can be surprisingly effective for the prophylactic treatment of migraine headaches. It is surprising because migraine is a brain disorder and not a disorder of muscles. However, studies have shown that during a migraine attack muscles are in fact very contracted and that is probably why people find some relief by rubbing their temples and the back of the head. We also thought that Botox works by relaxing these tight muscles, but it turned out that it also works on nerve endings. Muscle relaxants also do more than just relax muscles – they actually work on brain mechanisms of migraines. Not all muscle relaxants help migraines and the most evidence exists for tizanindine (Zanaflex). A double-blind study was done by Dr. Alvin Lake and his colleagues and it showed very good efficacy and few side effects. The target dose was 8 mg three times a day, but the average dose was 18 mg a day. The main side effect of this drug is sedation, but otherwise it is fairly benign. Baclofen (Lioresal) is another muscle relaxant that has been subjected to a double-blind study and was found to be effective for the prevention of migraine headaches. The drug was also given three times a day with a total dose ranging from 15 to 40 mg a day. The main side effect of baclofen is also sedation. Other muscle relaxants, such as metaxalone (Skelaxin), cyclobenzaprine (Flexeril), clonazepam (Klonopin), and other have helped some patients, but there are no scientific studies to prove their efficacy in migraine.

Read More

A throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a year seemed to indicate a typical chronic migraine headache in a man I saw last week. His headache did not respond to pain medications, short courses of steroids and sinus surgery. The MRI scan of the brain and neurological examination was normal. The only unusual part was that this was a 66-year-old man who never had any headaches before and who had no family history of headaches. Migraines can begin as early as infancy and as late as 50′s, but it is extremely unusual to start having migraines for the first time in the 60s. Headaches that occur in later years are more likely to be due to conditions such as brain tumors (primary – glioma or meningioma, or secondary due to metastases from breast, lung and other tumors), subdural hematoma, or inflammation of blood vessels, which was the case in this 66-year-old man. He suffered from temporal arteritis, also called giant cell arteritis. The diagnosis is confirmed by blood tests (elevated ESR and CRP) and biopsy of the artery. Treatment is usually very effective and typically consists of a steroid medication such as prednisone. Unfortunately, many patients with temporal arteritis need to stay on at least a small amount of this medicine for many years if not the rest of their lives and this drug has many potential serious side effects. However, if left untreated temporal arteritis can cause strokes and blindness, so it is very important to diagnose and treat it as soon as possible.

Read More

I just saw a man with chronic cluster headaches whom I’ve been treating for the past 5 years. He had tried various treatments and still remains on verapamil which provides partial relief, but he finds excellent relief from monthly intravenous infusions of magnesium and Botox injections given every 2 to 4 months. He sometimes needs a magnesium infusion every three weeks. He occasionally takes sumatriptan (Imitrex) injections as needed for breakthrough headaches, but many of his remaining attacks are mild and are relieved by rizatriptan (Maxalt) tablets or zolmitriptan (Zomig) nasal spray. Botox is not approved by the FDA for the treatment of cluster headaches, only for chronic migraines. However, there are several case reports of successful use of Botox in patients similar to mine. I’ve treated several other cluster headache patients with Botox with good results, but this is the only one who has been receiving Botox for three years (he has had 15 treatments to date). As far as the use of intravenous magnesium, we’ve published an article showing that 40% of patients with cluster headaches are deficient in magnesium and respond to intravenous infusions.
Cluster headache
Photo credit: IHS-Classification.org

Read More

Weather is a common trigger of migraine headaches. Review of studies linking weather to migraines suggests that there are three weather-related triggers. It is high humidity, high temperature, and drop in barometric pressure. Some migraine sufferers, just like many people with arthritis, can predict rainy weather. We can speculate that the drop in barometric pressure causes blood vessels inside the skull to dilate and trigger a migraine. This happens because of faulty regulation of blood vessels in those with migraine. This is also probably the reason why migraines are sometimes caused by exercise or sexual activity – blood vessels dilate excessively and trigger a migraine. High altitude headache or mountain sickness is another example of headaches caused by low barometric pressure. In fact, one study showed that people living at high altitudes, specifically in Denver, are more likely to have mgraines than those living at sea level. Treatment of barometric pressure headaches involves the usual approaches to migraines – regular exercise, biofeedback, magnesium, CoQ10, Botox, and drugs. Diamox (acetazolamide) is a diuretic drug that is particularly effective for mountain sickness and in some patients can also prevent weather-related headaches.
It is not clear why high humidity causes headaches, but high temperature may lead to a) dehydration, which is a trigger of migraines for many and b) again, dilatation of blood vessels which the body uses to cool itself by bringing more warm blood to the surface (this is why we look red in the heat).
There is an easy way to figure out if your headaches are triggered by weather – download our free app into your iPhone or iPad. Headache Relief Diary (also known as Migralex Diary) automatically downloads barometric pressure, humidity and temperature at the time of your headache. Just enter your zip code once and enter your headache information every time you get one and after a month or two you may be able to find your migraine triggers, including those related to the weather.

Read More

Headache is one of the most common complaints reported by patients suffering from AIDS, according to a new study by researchers from the University of Alabama. They evaluated 200 patients with HIV/AIDS and discovered that 107 or 54% of them had headaches. Only 4 of these patients had a serious underlying cause, while 88, or 44% had migraines and the rest had tension-type headaches. This is a much higher incidence of migraines than in the general population, where only 12% have migraines. The severity of HIV (CD4 cell count) correlated with the headache severity, frequency, and disability. The findings of this study suggest the importance of diagnosing and treating migraines in this population which already has reduced quality of life and which migraines make even worse.

Read More