New York Headache Center

High homocysteine levels increase the risk of cardiovascular disease (strokes and heart attacks) and can be reduced by folic acid and vitamin B12 (cyanocobalamine).   A study by Spanish doctors published in Headache found elevated homocysteine levels in patients who have migraines with aura.  Patients who have migraine with aura are known to have increased risk of cardiovascular disease and it is possible that elevated homocysteine levels are at least in part responsible for this risk.  I routinely check homocysteine, vitamin B12 and folic acid levels in all of my patients.  One caveat is that vitamin B12 levels are not very reliable - you may have a normal level, but still be deficient.  While laboratories consider a level of over 200 to be normal, clinical deficiency is often present at levels below 400.  A single case report has been published of a severe deficiency with neurological symptoms and a vitamin B12 level of over 700.  This patient lacked the ability to transport vitamin B12 from his blood into the cells.  Injections of high doses of vitamin B12 corrected the problem.  Oral magnesium supplementation is not as effective as injections because vitamin B12 is poorly absorbed in the stomach.   Other ways to get vitamin B12 is by taking it sublingually (under your tongue) or by a nasal spray (it requires a prescription and is fairly expensive).  Many of my patients a willing to self-inject vitamin B12, which they do anywhere fro once a week to once a month.   Vegetarians are more likely to be deficient since meat (and liver) are the main sources of vitamin B12.  Smokers are also at a high risk because cyanide in smoke binds to vitamin B12.

Medications used for the preventive treatment of migraine headaches can cause weight loss, but more often cause weight gain.  An interesting study by Dr. Bigal and his colleagues, just published in Cephalalgia looked at this effect of drugs in 331 patients.  They found that 16% of them gained weight (5% or more of their baseline weight) and 17% lost weight.  The various treatments given to these patients were equally effective in both groups.  However, not surprisingly, those who gained weight had elevation of their cholesterol, blood glucose, blood pressure and pulse.  Patients who have migraine headaches with aura (about 15-20% of migraine sufferers) already have an increased risk of strokes, so adding additional risk factors for both strokes and heart attacks should be especially avoided in this group.  The only preventive migraine drug which consistently lowers weight in many patients is topiramate (Topamax).  This drug is now available in a generic form, making it much less expensive.  While topiramate does lower weight and helps prevent migraine headaches only half of the patients stay on it.  For the other half it causes unpleasant side effects (memory impairment and other) or it does not work.

Trigeminal neuralgia is an extremely painful condition which causes severe electric shock-like pain in one or more branches of the trigeminal nerve.  The 3 branches are mandibular, in the lower jaw, maxillary, in the upper jaw, and ophthalmic in the upper face.  It is more common in the elderly and is caused by compression of the trigeminal nerve by a hardened blood vessel inside the skull, near the brainstem.   Treatment consists of trials of different medications, which work for most patients, but a small percentage require a partial destruction of the nerve (with radiofrequency heat) or surgery.  Surgery consists of opening the skull and placing Teflon insulation between the nerve and the blood vessel.  Medications that are used for trigeminal neuralgia inlcude epilepsy drugs, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), and a muscle relaxant, baclofen (Lioresal).  A recent report suggests that a newer epilepsy drug, pregabalin (Lyrica) is also effective.  However, carbamazepine, phenytoin, and baclofen are available in a generic form, which makes them much less expensive than the other, branded products.