New York Headache Center

Aspirin is as effective as Imitrex (sumatriptan) in the treatment of migraine headaches with fewer side effects, according to an authoritative Cochrane review published earlier this year.  The review examined 13 high-quality studies which involved 4,222 patients.  Having such a large number of patients in well-conducted studies makes the data highly reliable.  Some of the studies utilized 900 mg of aspirin and some 1,000 mg, some with and some without a nausea medicine, metoclopramide (Reglan).  Aspirin was compared to both Imitrex, 50 or 100 mg and placebo.   The authors concluded that “there are no major differences between aspirin with or without metoclopramide and sumatriptan 50 mg or 100 mg. Adverse events with short-term use are mostly mild and transient, occurring slightly more often with aspirin than placebo, and more often with sumatriptan 100 mg than with aspirin.”  In a previous post I mentioned the review of 16 studies of naproxen sodium (Aleve) for the treatment of migraines.  That review found that aspirin was more effective for the treatment of migraines than naproxen sodium (Aleve).  So far, aspirin seems to be the best drug for the initial treatment of migraine headaches.  However, there are many sufferers with severe migraines who do not respond to aspirin and there is a clear need for prescription drugs, such as Imitrex, although they do have a higher risk of side effects.  New migraine drugs are being developed with the goal of reducing the incidence of side effects, while improving their efficacy.  One of the new category of drugs being developed are CGRP antagonists, but they are at least 2 years away from becoming available.

Vertigo and dizziness are common in migraine sufferers.  It is much less common for vertigo to be the only symptom of migraines.  This seems to be the case with vertigo that begin at menopause, according to a recent report presented at the last meeting of American Academy of Neurology.  The report describes symptoms in 12 women, so its conclusions cannot be accepted as definitive.  All of the women had history of menstrual migraines and all had a normal ear-nose-throat examination and a normal MRI scans.  They all suffered from vertigo for at least a year.  Treatment with standard migraine medications and hormonal therapy reduced attacks of vertigo by 50% and was more effective than non-hormonal treatment alone.  It is not surprising that the hormonal therapy helped because some women with menstrual attacks also improve with hormonal therapy, such as continuous contraception.  This report should raise awareness of the fact that menopausal women with vertigo may be suffering from migraines and may respond to hormonal and migraine therapies.

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.

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.

Vertigo is a common complaint of migraine patients.  Ear-nose-throat specialists at the University of Pisa examined 22 patients with migraine headaches who complained of vertigo and 22 who did not, as well as 22 control subjects without migraines.  They found that in both groups of patients with migraines a third had abnormal vestibular function on laboratory testing.  In half of the patients in both groups the abnormality was in the inner ear (peripheral dysfunction) and in half in the brain (central dysfunction).  This study confirms that both central and peripheral vertigo are common in migraine patients, whether they complain of vertigo or not.  The most important question patients ask is what can we do about it.  Fortunately, once migraines are brought under control, vertigo also subsides.

A recent study by Dr. Bigal and his colleagues just published in Neurology compared more than 6,000 migraine sufferers with over 5,000 matched control subjects without migraines.   They discovered that people with migraine with aura and to a lesser extent those with migraine without aura are significantly more likely to have strokes, heart attacks, hypertension, poor circulation, diabetes, and high cholesterol.  This clearly does not mean that migraine causes all these diseases, but only that if you have one you are more likely to have the other.  It is important to recognize this association in migraine sufferers in order to regularly screen them for these conditions.  We know that controlling diabetes, high blood pressure, and high cholesterol can prevent strokes, heart attacks and poor circulation in extremities.  We also recommend that women who have migraine with aura should not take estrogen-based oral contraceptives or hormone replacement therapy since estrogen in these women also increases the risk of strokes.  All migraine suffererss (and everyone else) should not smoke and exercise regularly, which also reduces the risk of the conditions mentioned above.

During pregnancy, two thirds of women stop having migraine headaches.  However, one third continues to have them, and sometimes even worsen during pregnancy.   As a general rule, only acetaminophen (Tylenol) is considered safe, but for most migraine sufferers it is completely ineffective.  Codeine is also benign, but it also either does not work or causes side effects, such as nausea and sedation.  Triptans, such as sumatriptan (Imitrex), rizatriptan (Maxalt), and other are very effective for migraines, but are not proven to be as safe.  Pregnancy registries in the US have information on over 1,500 women who took a triptan during pregnancy and so far the drugs look safe for the baby.  A new study from Norway in the February issue of Headache reports on another 1,535 women who took triptans during pregnancy and compared them to 68,000 women who did not.  This study also found no increased risk of congenital malformation, even if triptans were taken in the first trimester.  Women who took triptans in the second and third trimester also had healthy babies, but they had a slightly increased risk of atonic uterus and bleeding during labor.

Migraine and migraine medications do not appear to cause cognitive decline, according to a Dutch study just published in Headache.  After 6 years of follow-up there was no difference between those who suffered from migraines and healthy controls.  Taking migraine medications also did not have an effect on cognitive function.  This is very reassuring, especially because a recent study in rats suggested brain damage from what the researchers felt was a process similar to migraine.

Migraines in blind people are made worse by light, according to Dr. Burstein and his associates at Harvard.  Rami Burstein is one of the leading headache researchers who often asks questions no one else thought to ask.  More importantly, he often finds the answers.  When he mentioned to me that he wants to find out why bright light makes headaches worse (so called photophobia), I immediately thought of a blind patient I was treating.  She was very interested in helping Rami discover the answer and helped him recruit many other blind migraine sufferers.  After several years of work, his finding were published today in Nature Neuroscience.  A recent discovery showed that in addition to rods and cones in the retina (cells that allow us to see), there are cells which react to light, but their input goes to non-visual parts of the brain.  These cells regulate sleep-wake cycle and, according to Rami Burstein’s research, also magnify pain perception in headache patients.

The fact that two out of three pregnant women stop having headaches during pregnancy is well established, however a study by Norwegian researchers published in Headache provides some additional details.  Women with headaches who are pregnant for the first time tend to have fewer headaches than non-pregnant women or women during subsequent pregnancies.  This is especially true in the third trimester.   Non-pregnant women who had never been pregnant were less likely to have headaches than women who had been.  If a woman does have headaches during pregnancy, the initial treatment should consist of non-drug therapies, such as biofeedback or meditation, magnesium and other supplements, acupuncture, and if headaches are frequent, Botox injections.