New York Headache Center

Pain of migraine can be localized to the face and around the mouth according a two recent reports. Dr. Gaul and colleagues reported in journal Cephalalgia on two patients who had dental pain as well as typical migraine symptoms, including throbbing, sensitivity to light and noise and in one of the patients visual aura (flickering colorful lights) preceding the attack. This report confirms the fact that pain of migraine can occur anywhere in the head, including teeth, eyes, ears, forehead, top or back of the head.

The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. The United States Food and Drug Administration (FDA) has approved a new formulation of Imitrex Injection that allows a convenient way for patients to take a 4mg dose using the Imitrex STATdose System®. Imitrex Injection is indicated for the acute treatment of migraines with and without aura in adults. We find that Imitrex injections are very underutilized, mostly because doctors don’t offer them as an option to their patients. Surprisingly, surveys indicate high acceptance of injections by patients. This should not be so surprising at all considering how disabling migraines can be. The ideal candidates for injectable Imitrex include patients who have severe nausea, those who wake up with a severe attack and need prompt relief, patients for whom oral triptans do not provide adequate relief and those with cluster headaches. We typically prescribe 6 mg injections and use 4 mg ones for patients who are very sensitive to drugs, have small weight or have side effects from 6 mg.

It is not clear how Botox relieves migraine headaches.

Oliver Dolly, an Irish researcher who devoted many years of his work to the study of botulinum toxin, has just published results of a new study which may help explain this question. Twelve years ago when I started using Botox for the treatment of headaches the only possible explanation for the way it worked was that it relaxed tight muscles. It is true that during a migraine attack muscles go into a contraction and many patients find some relief by massaging their temples, back of their head and neck. However, some people reported to me that injecting Botox relieved their headaches in the temples, forehead and back of the head, but not on the top of the head. I did not inject the top of the head because there are no muscles there. When I did inject those areas to my surprise pain on the top of the head improved as well. This has been also observed by many of my colleagues around the country. Dr. Dolly’s experiment showed that in addition to relaxing muscles, Botox prevents the release of CGRP (a chemical messenger - neurotransmitter) from nerve endings and stops painful messages from being transmitted along the nerves. It appears that relaxing muscles may be less important than stopping nerves from sending pain messages to the brain.

Depression (and anxiety) is 2-3 times more common in those suffering from migraines than in people without migraines. Depression is not caused by migraines because patients who develop depression first are 2-3 times more likely to develop migraines than people without depression. It is likely that abnormalities in the function of certain brain chemicals (serotonin, norepinephrine and other) that cause one condition predispose people to develop the other one as well. Certain types of antidepressants prevent migraine headaches even in patients who have none of the signs of depression. It appears that treatments that work for depression can help with migraines as well. At the NYHC we showed this to be true for an experimental treatment using vagus nerve stimulation. We have always advised our patients that one of the best preventive treatments for migraines is to engage in aerobic exercise for 20-30 minutes five days a week. Possible reasons why this treatment works include relief of stress, improved blood circulation in the brain and the release of endorphins - natural painkilling substances. We did not have scientific studies to prove that we were right, but the majority of patients who followed this advice improved. Now we have a scientific study that indirectly supports this treatment. The study by James Blumenthal and his colleagues, published in the journal Psychosomatic Medicine, included 202 men and women who were diagnosed with major depression. They were randomly assigned to one of four groups: one that worked out in a supervised, group setting three times per week; one that exercised at home; one that took the antidepressant sertraline (Zoloft); and one that took placebo pills. After 16 weeks 47 percent of patients on the antidepressant recovered from depression. The same was true of 45 percent of those in the supervised exercise group and 40% in the home-based exercise group. In the placebo group 31 percent of patients improved.

The bottom line - exercise can help your depression and your migraine headaches.

It is no big news that acupuncture helps migraine patients. Nevertheless, it is good to see yet another study confirming this. Maybe, once the health care mess is straightened out and common sense prevails, the insurance companies will notice all these studies and start paying for acupuncture. The latest study published in the September issue of journal Headache was controlled and randomized, that is it was scientifically sound. The Italian researchers led by Dr. Facco compared true acupuncture with sham acupuncture and no preventive treatment. They found that three and six months after the start of treatment patients in the true acupuncture group did significantly better.

A study just published by Dr. Mathew and his colleagues in the journal Headache reports that patients with chronic migraine headaches responded to Botox better than patients with chronic tension headaches. Patients who had headaches predominantly on one side and those with scalp tenderness had a better response to Botox. Scalp muscle tenderness was also a predictor of response in chronic tension headaches. Overall, Botox was highly effective in patients with chronic migraine - 76%, (54 out of 71 patients) obtained relief. Of those 54 patients 37 or 69% had one-sided headaches. Having headaches on both sides does not preclude success with Botox - 17 patients with bilateral headaches also responded. This study confirms what I have observed in my 12 years of treating thousands of patients with Botox - it is a highly effective and safe treatment for frequent migraine headaches.

Prolapse or herniation of the upper cervical disc is known to cause not only neck pain but also so called cervicogenic headaches. Dr. Diener and his German colleagues reported (in journal Cephalalgia) on 50 patients who had prolapse of lower cervical disks and used as controls 50 patients with lumbar disk herniations. They found that 12 out of 50 patients with lower cervical disk herniations developed a headache and in 8 out of 12 headache stopped within a week following surgery. Only two of the patients with lumbar disk herniations developed a headache. Three months after surgery seven of 12 had no headaches and three were improved. It is not very surprising that these patients had headaches - neck muscles overlap all along the neck and form a supporting collar for the cervical spine. Muscle spasm in the lower neck that accompanies a herniated disk will often cause this spasm spread up the neck and cause a headache. Even patients with migraines at times develop a migraine attack from spasm of muscles in the neck or even shoulders. When treating these patients, both with migraines and cervicogenic with Botox injections are usually given not only into the muscles around the head, but also in the neck and shoulders. This makes Botox treatment significantly more effective.

A study just published in the British medical journal Lancet reports on the effect of food colorings in children. This study found that food colorings cause symptoms of attention deficit disorder in young children. Many of my patients report that food colorings, and more often food preservatives, trigger their migraines. The role of colorings, preservatives and sugar substitutes in causing migraine headaches has not been evaluated as rigorously as it was done in this Lancet study of children and remains controversial. However, this study clearly indicates that food colorings can have a negative effect on the brain, which makes it very likely that some migraine sufferers may benefit from eliminating colorings (and preservatives and sugar substitutes) from their diets.

Dr. Tietjen reports in the current issue of Neurology on a survey performed at six headache clinics. A total of 949 women with migraine completed the survey: 40% had chronic headache (that is headaches occuring on more than 15 days each month) and 72% had “very severe” headache-related disability. Major depression was recorded in 18%. Physical or sexual abuse was reported in 38%, and 12% reported both physical and sexual abuse in the past. Migraineurs with current major depression reported physical and sexual abuse in higher frequencies compared to those without depression. Women with major depression were more likely to report sexual abuse occurring before age 12 years and the relationship was stronger when abuse occurred both before and after age 12 years. Women with major depression were also twice as likely to report multiple types of maltreatment compared to those without depression. Similar findings have been reported in patients with chronic pain other than headaches. Brains of migraine sufferers have been found to be more excitable than brains of people without migraines. It is likely that trauma of abuse makes the nervous system even more excitable and more prone to developing chronic pain and headaches.

Hemiplegic migraine can be safely treated with triptans (drugs like Imitrex, Maxalt and other).

This is the conclusion of a study published in the September issue of journal Cephalalgia. A group of Finnish doctors gave triptans to 76 patients who suffered from hereditary and non-hereditary forms of hemiplegic migraine - migraine that is accompanied by temporary paralysis of one side of the body. They found that triptans worked well and none of the patients had strokes or any other serious reactions. According to the FDA, triptans are not to be given to patients suffering from hemiplegic migraine because they potentially could cause a stroke. No strokes have ever been reported, but it was thought that constriction of blood vessels in the brain during hemiplegic migraine is responsible for the weakness and giving triptans could worsen this constriction and cause a stroke. In the past several years we have learned that weakness is caused by a disturbance of brain neurons rather than constriction of blood vessels. Many headache specialists use Imitrex and similar drugs in patients with hemiplegic migraine and several years ago Drs. Klapper and Mathew have already reported on their positive experience in a small group of patients.