Alternative Therapies

Deficiency of coenzyme Q10 (CoQ10) is the second most common deficiency in migraine sufferers after magnesium. Fully one third of migraine sufferers are deficient in CoQ10, according to a study by Dr. Andrew Hershey and his colleagues published in the journal Headache. They tested 1,550 children and adolescents and a study in such a large population tends to be very reliable. Supplementing these children with 1 to 3 mg/kg of CoQ10 produced significant improvement not only in CoQ10 levels but also in the frequency of attacks (from 19 a month to 12) and the disability (the disability score dropped from 47 to 23).

This deficiency is present in adults as well, as was shown in another study by a Swiss neurologist, Dr. Peter Sandor and his colleagues. They gave 100 mg of CoQ10 three times a day or placebo to 42 adult migraine sufferers and discovered that a 50% drop in migraine attack frequency occurred in 48% of patients on CoQ10 and only 14% of patients on placebo.

The Hershey study was done in a more logical way – determine who is deficient and give them CoQ10. If you give CoQ10 to those who need it and those who don’t, the results of the study and in practice will not be as impressive. Although CoQ10 is not expensive ($7 a month for 200 mg a day) and is very safe, why supplement to someone who does not need it? Although the blood test for CoQ10 is fairly expensive ($158 at Labcorp), it is usually covered by most insurance plans. It is important to ask your doctor what the actual blood level was because the laboratories will report as normal values between 0.37 and 2.2 (Labcorp) or 0.44 and 1.64 (Quest Diagnostics), studies have shown that the level should be at least 0.7.

As far as side effects, a few of my patients developed insomnia, possibly because CoQ10 is involved in energy generation, so I always advise taking it in the morning. While Sandor gave his patients 100 mg three times a day, in Hershey’s study the benefit appeared at lower doses. I usually recommend 100 to 200 mg (depending on body weight and how low the level is), to be taken once, in the morning.

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Magnesium deficiency is found in up to 50% of migraine sufferers, 40% of those with cluster headaches, 45% of the elderly diabetics, and in a high percentages of people with other chronic diseases. Magnesium has been shown to relieve migraine and cluster headaches, post-concussion syndrome, lower blood pressure, prevent irregular heart beats, and improve breathing in asthmatics.

A new study by Dutch researchers published in the leading neurology journal, Neurology reports on an association between magnesium and dementia (Alzheimer’s and other types). Brenda Kieboom and her colleagues measured magnesium levels in almost 10,000 people without any evidence of dementia and followed them for an average of 8 years. The average age at the start of the study was 65. Only 2 subjects had magnesium level above normal and 108 below normal.

The surprising discovery, which was suggested by previous contradictory studies, is that people with both low normal and high normal levels (lowest and highest quintile of the normal range) were at an increased risk of developing dementia.

There are two hypotheses as to why low magnesium levels could predispose to dementia. One is that magnesium blocks NMDA receptor, which is involved in the development of dementia, traumatic brain injury, pain, migraines, and other conditions. The second theory is that magnesium deficiency promotes inflammation, which is found in brains of patients with dementia (and migraines). The authors did not offer any theories as to why high normal magnesium levels were also associated with the development of dementia.

The researchers admit several weaknesses of their study, including poor correlation between serum magnesium levels and the total magnesium in the body and the reliance on a single measurement of magnesium level. The study does have many strengths, including large number of subjects, correction for a variety of confounding factors (education, weight, smoking, alcohol, cholesterol, kidney function, stroke, and other). The fact that this correlation was found as early as 4 years after the initial assessment also suggests a real correlation.

Although, correlation does not mean causation, it is prudent to keep your magnesium level in the middle of normal range. We rarely see high or high normal magnesium levels in our migraine patients and in this study only 2 out of almost 10,000 people had higher than normal levels and 108 had lower than normal levels. Ideally, everyone who suffers from any medical condition or has a family history of dementia, should have their magnesium level checked. The more accurate test is not the serum level, but the RBC magnesium level.

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Excessive consumption of marijuana can lead to bouts of severe nausea and vomiting, which in medicalese is called cannabinoid hyperemesis syndrome (CHS). With many states legalizing medical and recreational marijuana, there has been an increase in ER visits and admissions to the hospital for severe vomiting. This is often misdiagnosed as cyclic vomiting syndrome (CVS), a condition which is more common in children than adults and is related to migraines. CVS, which is mentioned in a previous post, is often relieved by sumatriptan (Imitrex).

Unfortunately, people who overindulge in pot, do not realize that it is responsible for their symptoms and end up undergoing endoscopies, MRI scans and other procedures. Taking a hot shower is known to relieve pot-related vomiting, but hot shower also works for some patients with CVS, so this does not help in differentiating the two conditions. German researchers tried to find a reliable way to differentiate CHS and CVS and concluded that the only way to tell these apart is to completely stop marijuana. They do note that CHS can develop after years of using marijuana and that after marijuana use is stopped, it may take several days and up to a couple of months for symptoms to subside.

So far, we’ve prescribed medical marijuana to a couple of hundred patients with headaches, migraines, and nerve pain and have not seen such a problem. It is possible that the amount used for medicinal purposes is too small to cause CHS. The cost of medical marijuana is relatively high and could be preventing its overuse.

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Psychological factors play a major role in migraines. This is not to say that migraine is a psychological disorder – we have good genetic and brain imaging studies confirming its strong biological underpinnings. The divide between biological and psychological is very artificial since we know that physical illness leads to psychological problems and the other way around. Stress is obviously one of the major triggers of migraines and we know that people with migraines are at least twice as likely to develop anxiety, depression, and other mental disorders. These are not cause-and-effect relationships because anxiety and depression can precede the onset of migraines. The connection is probably due to shared underlying problems with serotonin, dopamine, and other neurotransmitters.

We have strong evidence that addressing psychological factors involved in migraines through biofeedback, meditation, and cognitive therapy can lead to the reduction of migraine frequency, severity, and disability. Studies in chronic pain patients have shown that people with external locus of control (thinking that uncontrollable outside chance events are major contributors to pain) have more disability than people with internal locus of control (those who feel that their actions are contributing to pain and that active involvement in treatment can relieve pain).

Chronic migraine sufferers (defined as those with 15 or more headache days each month) are known to have greater disability than those with episodic migraines. In a recent study by researchers at the Yeshiva University and Albert Einstein College of Medicine, 90 chronic migraine patients were evaluated for psychological symptoms. Of these 90 patients, 85% were women, their mean age was 45, and half reported severe migraine-related disability. They were twice as likely to be depressed and to have external locus of control. The half with severe migraine-related disability were 3.5 times more likely to have anxiety and depression and were twice as likely to have a symptom described as catastrophizing. Catastrophizing is defined as having irrational thoughts about pain being uncontrollable, leading to disability, loss of a job, partner, ruined life, etc.

The good news is that many studies show that with cognitive therapy locus of control can be shifted from external to internal, catastrophizing can be reduced or eliminated, and disability diminished. This may not eliminate migraines or chronic pain, but can make you less anxious and depressed, and much more functional. Cost and access to therapy can be a problem, but studies suggest that even online therapy can be very effective.

Besides psychological approaches, regular aerobic exercise (stationary bike is easiest for migraine sufferers), certain supplements and prescription drugs can also help. Supplements that can relieve anxiety and depression include SAMe, omega-3 fatty acids (fish oil), methylfolate, and other. Some antidepressant medications relieve not only anxiety and depression, but also provide relief of migraines even when psychological factors are absent. These include so called SNRIs (duloxetine or Cymbalta, venlafaxin, or Effexor, and other) and tricyclics (amitriptyline, or Elavil, protriptyline, or Vivactil, and other). The most popular group of antidepressants, the SSRIs (fluoxetine, or Prozac, escitalopram, or Lexapro, and other) do help anxiety and depression, but have no pain or headache-relieving properties. Obviously, all drugs have potential side effects and for most patients it makes sense to try non-drug treatments first.

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Curcumin, which is one of the ingredients in turmeric, has long been touted for many of its anti-inflammatory and anti-cancer properties. A study presented at the 2017 Alzheimer’s Association International Conference showed that curcumin improves memory in healthy adults without Alzheimer’s disease.

This double-blind study was performerd by Dr. Gary Small and his colleagues at UCLA and it involved 40 men and women with a mean age of 63. Half of these subjects received 90 mg of Theracurmin brand of cucurmin twice a day, while the other half was given placebo for a period of 18 months. Researchers administered both verbal and visual memory tests and also measured brain deposits of amyloid plaques and tau tangles using special imaging methods (PET scans). These deposits are found in the brains of patients with Alzheimer’s.

The scores for both types of memory improved in the curcumin group, but not in the placebo group. Curcumin also prevented buildup of amyloid plaques and tau tangles in the brains. Daily curcumin also improved attention and mood.

Four patients in the curcumin group and two in the placebo group had stomach pains and nausea. These were the only side effects.

The authors concluded that “This relatively inexpensive and nontoxic treatment may have a potential for not only improving age-related memory decline, but also as a prevention therapy, possibly staving off progression, and eventually future symptoms of Alzheimer’s disease.”

There is less clinical evidence for the use of curcumin for the prevention of migraines. A recent study, published in the journal Immunogenetics, Iranian researchers reported that a combination of omega-3 fatty acids and curcumin reduced the production of TNF. TNF is a protein that is involved in sending messages between cells, which leads to increased excitability of neurons, neuroinflammation, and pain. The study involved 74 patients with migraines, who were divided into 4 groups – placebo, curcuming, omega-3, and combination of omega-3 and curcumin. The combination produced not only a reduction in TNF levels, but also fewer migraine attacks than seen in the other 3 groups.

Curcumin is not very well absorbed and several companies have tried to improve its absorption using various methods. The UCLA study utilized Theracurmin, which is an ingredient in several brands of curcumin. Another type, Longvida also seems to be better absorbed and is also used by several manufacturers.

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Ketamine is a medicine that is sometimes given intravenously for anesthesia. It is a controlled drug because it can induce euphoria and is potentially addictive. In a previous post I mentioned several anecdotal reports about the beneifical effect of ketamine for a prolonged migraine aura, hemiplegic migraine and other types of headaches.

A presentation at the recent annual meeting of the American Society of Anesthesiologists described the results of ketamine infusion on severe migraines in patients admitted to the Thomas Jefferson University Hospital in Philadelphia from 2014 to 2016. 48 of the 61 patients (77%) responded to this treatment, meaning that their pain levels improved by at least 2 points on a 1 to 10 scale. On average, the infusion had to be given for 5 days. Side effects included sedation (51%), blurry vision (38%), nausea or vomiting (38%), hallucinations (28%), vivid dreams (13%), and low blood pressure (5%). The authors described the adverse effects as mild in nature and only 1 patient discontinued treatment. However, having hallucinations, drop in blood pressure or vomiting does no sound like mild side effects to me. On the other hand, these were patients whose migraine did not respond to other treatments and they needed to be hospitalized, so these side effects could in fact be acceptable if the treatment ultimately provides relief.

Review of patient records admitted to the same hospital between 2006 and 2014 showed the mean headache pain rating using a 0-10 pain scale dropped from 7 on admission to 4 on discharge. The majority (55 out of 77, or 71%) of patients responded by the same definition of an at least 2-point improvement in headache pain at discharge. Only a quarter of responders maintained this benefit at their follow-up office visit. The mean length of infusion was also 5 days. And again, most patients tolerated ketamine well with “very few serious side effects”.

Anecdotal evidence also exists for the use of ketamine infusions to treat depression. There are some outpatient clinics that offer ketamine infusions for chronic pain and depression and a few of my patients have gone there, but unfortunately with little success.

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There is little doubt that stem cells, along with genetics and computer science will revolutionize medicine. There are more than a dozen journals devoted to stem cell research and many general and speciality medical journals also publish research on stem cells, which means that a couple of hundred articles are published every month. At first, the research was stymied by the controversy about the fetal sources of stem cells. For the most part this problem has been circumvented by the discovery of other sources, such as umbilical cord, placenta, fat tissue, and other.

In neurology, multiple sclerosis, spinal cord injuries, and strokes have been the main targets of stem cell research. The latest study of stem cells for stroke victims conducted at Stanford by Gary Steinberg and his colleagues produced very encouraging results. This trial included only 18 patients, but they all had their stroke anywhere between 6 months and 3 years before the study – past the usual time where further recovery is expected. Improvement occurred in the majority of patients and the improvement was not affected by the age of the patient or the severity of the stroke. Although stem cells were injected directly into the brain through a small hole that was drilled in the skull, there were no serious complications or side effects. The researchers also noted that stem cells did not replace damaged cells but rather stimulated patients’ own repair mechanisms. This is at odds with the original idea that stem cells by their nature could turn into nerve cells or any other cells in the body to replaced damaged cells.

This stimulating (and anti-inflammatory) effect of stem cells was our reason for conducting a small pilot study of stem cells in patients with refractory chronic migraines, which was described in a previous post. We did not inject cells into the brain, but into the muscles around the head and neck. Three out of 9 patients showed some improvement. We used patients’ own cells extracted from their fat tissue, while the stroke study used cells derived from the bone marrow of a donor. The future of stem cell research clearly lies in the use of such off-the-shelf cells, which have been shown to be safe and are probably more effective than fat-derived cells.

Stem cell lines are being developed to treat different medical conditions – Asterias for spinal cord injury, Pluristem for radiation damage, and many other.

The same team of researchers and SanBio, Inc. the Japanese company that developed these stem cells are conducting another larger controlled trial. You can email for information about participating in this trial.

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Chronic pain is known to alter the structure of the brain. Mayo Clinic researchers used MRI scans to examine brains of 29 patients with post-traumatic headaches and compared their scans to those of 31 age-matched healthy volunteers. The average frequency of headaches was 22 days a month. Patients with post-traumatic headaches were found to have thinning of several areas of their cerebral cortex which are responsible for pain processing in the frontal lobes. Cortex covers the surface of the brain and contains bodies of brain neurons. Drs. Chiang, Schwedt, and Chong, who presented their findings at the annual meeting of the International Headache Society held last month in Vancouver, also discovered that the thinning was correlated with the frequency of headaches.

This study did not address possible treatments, but it would make sense that with better control of headaches, this brain atrophy might be reversible. To treat post-traumatic headaches we often use Botox injections, which have been shown to help posttraumatic headaches. Even though Botox is approved only for chronic migraines, many patients with post-traumatic headaches do have symptoms of migraines and can be diagnosed as having post-traumatic chronic migraines (without such a designation insurance companies may not pay for Botox). We also check RBC magnesium, CoQ10 and other vitamin levels, which are often low in chronic headache sufferers and if corrected, can lead to a significant improvement. Epilepsy drugs and anti-depressants can also help.

While the above mentioned treatments can help headaches and potentially could reverse brain atrophy, there is only one intervention that has been shown to increase the thickness of the brain cortex on the MRI scan. This intervention is meditation. And this effect was demonstrated in several studies. An 8-week course of mindfulness-based stress reduction led to a measurable increase in the gray matter concentration of certain parts of the brain cortex. A pilot study of migraine sufferers showed that meditation has a potential not only to restore thickness of the brain, but also to relieve migraines.

In one of my previous blog posts that described a sceintific study of meditation, I mentioned several ways to learn meditation: Free podcasts by a psychologist Tara Brach an excellent book, Mindfulness in Plain English by B. Gunaratana, and several apps – Headspace, 10% Happier, and Calm. You can also take an individual or a group class, which are widely available.

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Biome, or the collection of bacteria living in our bodies has been receiving belated and well deserved attention. The discovery that bacteria living in our intestines can cause cerebral cavernous malformations or CCM (see photo) is quite dramatic. But there is no need to panic since this is a rare condition. However, it does indicate that gut bacteria can have a major impact on our brains.

It was a serendipitous discovery by Dr. Mark Kahn, professor of medicine at U. Penn, who studied mice with CCM. He noticed that mutant mice prone to CCM stopped developing holes in their brains after being moved to a new building. The exception was mice who developed an abscess after having their intestines accidentally stuck with a needle during a routine injection. Dr. Kahn and his colleagues identified a specific bacterium, Bacteroides fragilis, which was responsible for the development of brain caverns.

This finding may explain why there is such a wide variety of presentations in people who have the familial form of CCM. Some have no lesions even when they are 70, while others have hundreds of them at age 10. Just like mutant mice, humans seem to need an additional trigger to start developing CCMs. This finding provides a clear path to developing an effective treatment and perhaps, just a simple probiotic could keep such patients healthy.

In fact, a probiotic containing 14 different strains of bacteria (Bio-Kult, made in UK) is effective in preventing migraine headaches, according to a study presented by Iranian doctors at the recent International Headache Congress in Vancouver. Fifty patients were recruited into this study with half taking the probiotic and the other half, placebo. After 8 weeks, patients on the probiotic had fewer days with migraine and the pain was milder when compared to those taking placebo.

The big question is, what other brain disorders are triggered or worsened by our gut bacteria. We have more bacterial cells living in our bodies (about 39 trillion) than we have of our own cells (about 30 trillion) and scientists are finally beginning to study them. I Contain Multitudes: The Microbes Within Us and a Grander View of Life, is a fascinating and well-written book by Ed Yong on this subject.

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A new study by Swiss researchers compared the effect of high intensity interval training (HIT) with moderate intensity continuous training (MCT) and with no exercise at all on the number of migraine headache days.

The results were presented at the International Headache Congress held in Vancouver last month. Not surprisingly, both types of exercise reduced the number of migraine headache days, but HIT was more effective. In the study, patients in HIT group did 4 periods of intensive exercise (90% of maximum intensity) each lasting 4 minutes, separated by periods of 3 minutes at 70% of maximum. The moderate intensity exercise was done at 70% for 45 minutes. Both groups performed these exercise twice a week.

A previous study has established that exercising for 40 minutes 3 times a week is as effective as relaxation training or taking a preventive migraine drug topiramate. Topiramate however has many potential side effects, including some serious ones. A Swedish study of 46,648 people established a strong inverse correlation between physical activity and the frequency of headaches.

HIT has been gaining in popularity since the 1980’s because it provides all of the benefits of exercise in a shorter period of time.

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Bright light bothers many migraine sufferers and in some, a flash of bright light, such as sun reflecting off a window glass or water can instantly trigger a severe migraine. Sensitivity to light may be color dependent, according to a presentation by Japanese researchers at the International Headache Congress held in Vancouver earlier this month.

Dr. K. Niwa and his colleagues in Tokyo studied 936 patients with chronic headaches aged between 12 and 77. They compared 546 patients with episodic and chronic migraines with 392 patients with episodic and chronic tension-type, cluster, new daily persistent and other types of headaches. They exposed these patients to yellow, white, gray, blue green, and red ambient light. They measured the degree of discomfort on a 6-point scale, ranging from none to unbearable.

White, blue, and red lights aggravated discomfort both during a migraine attack and between attacks. Green light reduced discomfort between attacks of migraine and reduced pain intensity during a migraine, regardless of the presence or absence of light sensitivity. This was true for patients with both episodic and chronic migraine headaches. Those with chronic tension-type headaches had only mild discomfort from white light, while patients with all other types of headaches had no positive or negative reaction to various colors of ambient light.

This study confirmed previous reports (and our patients’ experience) that blue and white light worsens migraine pain. The more important finding is that green light seems to be very beneficial. Considering the low cost of this treatment, migraine sufferers, especially those with light sensitivity, may want to buy a green light bulb or sunglasses with green lenses. Some of our patients have a preference for different colors, including bright orange, which eliminates blue light. One of my previous blog posts mentioned research looking at individualizing color selection of eyeglass lenses. This customized service is not yet available and is likely to be expensive. However, several companies sell glasses with FL-41 tint that is specifically designed for migraine patients. Theraspecs is one and Axonoptics is another. The Fl-41 tint can also be applied to any lens.

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Researchers at Northwestern University in Chicago examined possible correlation between magnesium level on admission to the hospital with the size of a stroke due to bleeding as well as functional outcomes. Their findings were published in Neurology.

290 patients presenting with a non-traumatic intracranial hemorrhage had their demographic, clinical, laboratory, radiographic, and outcome data analyzed and assessed for associations between serum magnesium levels and initial hematoma volume, final hematoma volume, in-hospital hematoma growth, and functional outcome at 3 months.

Lower admission magnesium levels were associated with larger initial bleeds and larger final hematoma volumes. Lower admission magnesium level was associated with worse functional outcomes at 3 months after adjustment for age, initial hematoma volume, hematoma growth, and other factors. The evidence indicates that the beneficial effect of magnesium is due to the reduction in hematoma growth.

The authors concluded that having higher magnesium level can reduce the size of a bleed in the brain.

Unfortunately, magnesium is not a part of the routine blood tests included in the so-called comprehensive metabolic panel. This panel does include potassium, sodium, calcium and other tests, but magnesium needs to be ordered by the doctor separately. Very few doctors do and this can be detrimental to your health. Not only strokes are bigger, but many other much more common health problem can stem from magnesium deficiency. Readers of this blog know well that magnesium deficiency is very common in migraine patients and that taking magnesium (or getting an intravenous infusion) can provide dramatic relief.

Magnesium also helps asthma, palpitations, muscle cramps, PMS, brain fog, and many other symptoms. The next time you have any kind of a blood test, ask your doctor to add a magnesium test, preferably “RBC magnesium”, which is more accurate than “serum magnesium”. If you have any of the above symptoms, you can just start taking 350-400 mg of magnesium glycinate, which is the daily recommended allowance for magnesium.

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Omega-3 polyunsaturated fatty acids (PUFA) which are found in fish oil, have been studied in a wide variety of diseases, ranging from Alzheimer’s disease to Herpes Zoster (shingles). Omega-3 PUFA have proven anti-inflammatory and neuroprotective properties and have been used to treat rheumatoid arthritis, Crohn’s disease, ulcerative colitis, psoriasis, lupus erythematosus, multiple sclerosis, as well as migraine headaches.

A new study just published in Neurology showed a strong beneficial effect of Omega-3 PUFA in the treatment of diabetic nerve damage, or diabetic sensorimotor polyneuropathy in patients with type 1 diabetes. After one year of taking 750 mg of EPA and 560 mg of DHA (two of the main omega-3 fatty acids) there was a significant improvement in the nerve function.

Omega-3 PUFA are proven to help patients with coronary artery disease, while in many other conditions, including migraines, the evidence is not as strong. However, considering that we have a very large amount of data showing a benefit in a wide variety of conditions and that Omega-3 PUFA are very safe and inexpensive, it is reasonable to try EPA with DHA for any auto-immune or inflammatory condition, as well as depression.

Eating fatty fish, such as salmon and sardines 2-3 times a week can be sufficient for general health, but those with coronary artery disease and other conditions could benefit from a daily supplement. Also, fish often contains mercury, which can cause neurological and other problems. Omax3 and prescription fish oil, Lovaza are my preferred products because they contain no mercury and are highly concentrated, requiring only 1 or 2 pills a day.

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Anxiety is at least twice as common in both children and adults with migraine headaches compared to people without migraines. A new study presented at the recent American Headache Society meeting examined the impact of anxiety on functioning in pediatric migraine population. The researchers analyzed records of 530 kids with migraine and 371 with tension-type headache seen in the pediatric neurology clinic of the Boston Children’s Hospital.

Dr. Lebel and her colleagues discovered that physiological anxiety was associated with more severe functional disability in kids with both migraines and tension-type headaches. Physiological anxiety often manifests itself by sleep difficulties, racing heart, shortness of breath, feeling shaky, fatigue, and other. The other two types of anxiety, worry and social anxiety did not seem to lead to more disability.

This study confirms the importance of cognitive and behavioral treatments, such as progressive relaxation, biofeedback, meditation, and cognitive therapy. Kids are very good at these techniques and they are particularly receptive to smartphone-based apps. For meditation, I recommend 10% Happier and Headspace. offers free podcasts for meditation and provides very inexpensive and scientifically proven cognitive-behavioral therapy.

At the NY Headache Center we always try to avoid drugs, especially in children. In addition to cognitive and behavioral techniques, we address sleep, exercise, diet and supplements such as magnesium, CoQ10, and other. If medication is needed, this study suggests that a beta blocker, such as propranolol (Inderal) may be a good choice because in addition to preventing migraines, it reduces physiological symptoms of anxiety (it is also used for performance anxiety). Potential side effects of beta blockers are mostly due to its pressure lowering effect and include fatigue, dizziness, and lightheadedness.

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Stem cells hold great promise in the treatment of many conditions, possibly including migraines. In a post from 3 years ago I’ve written about a report from Australia that described 4 patients with refractory chronic headaches who had a very good response from stem cells. They were given stem cells for other conditions and coincidentally their migraines improved.

Since many patients come to our practice after seeing several other neurologists and headache specialists, we often have to resort to new, non-traditional, and unproven treatments. This is how I started using Botox 25 years ago (the FDA approved it for migraines only 6 years ago).

After reading the Australian report I decided to try stem cell treatment in some of my most refractory patients. Only patients who failed to respond to Botox and at least 3 preventive drugs were offered to participate in this pilot study. The only type of stem cells that the FDA allows to be injected are cells taken from patient’s own body without altering them. The richest source of stem cells in our bodies is fat. My colleague, Dr. Kenneth Rothaus who is a plastic surgeon, performed a liposuction to obtained fat tissue, from which we separated active cells.

We enrolled 9 patients and 3 did have significant temporary improvement. The results are obviously not dramatic, but it is possible that in less severely affected patients this treatment could work better. More importantly, using stem cells from an umbilical cord or placenta is more likely to be effective as these are younger and more active stem cells. There are many companies researching these cells for various indications, but not yet migraines. The reason why stem cells should help at least some migraine sufferers is the fact that they have strong anti-inflammatory properties while migraine involves neurogenic inflammation.

The results of our pilot study were just published in Case Reports in Neurology.

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Many migraine sufferers complain about worsening of their migraines when they travel to high altitudes. But do people who permanently live at high altitudes are more likely to have migraines? A report published in the European Journal of Neurology describes a population-based study done in Nepal in which researchers compared the incidence of migraines in Nepalese living at low and high altitudes. A previous study done in Peru suggested such an association between migraine and living at a high altitude.

2,100 Nepali-speaking adults were recruited into this study. More than half, or 1,100 (52.4%) lived above 1000 meters (3,280 feet) and almost one quarter or 470 (22.4%) lived at 2,000 meters (6,560 feet). The researchers took into account the age and the gender of participants. Migraine prevalence increased from 28% to 46% with altitude between 0 and 2,499 meters and thereafter decreased to 38% at 2,500 meters. The likelihood of having migraines was almost two times greater at all higher altitudes compared with those living below the altitude of 500 meters. In addition, frequency and duration of migraine attacks doubled and pain intensity increased by 50% at higher altitudes.

The authors concluded that “dwelling at high altitudes increases not only migraine prevalence but also the severity of its symptoms”.

Acetazolamide (Diamox) can be an effective drug for the prevention of headaches at high altitudes and with barometric pressure drops. Unfortunately, we do not know if taking this medicine long-term is also effective for the prevention of headaches in people living at high altitudes.

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Medical marijuana has been legalized in NY and more than 20 other states. It is approved in NY for several medical conditions, including pain and some of my patients with headaches (about one out of 3), arthritis, and other pains have found it to be very helpful. Some patients use it acutely (as a vaporizer or tincture) and report relief of pain, and/or nausea and for some it allows them to go to sleep and sleep off their migraines. Tablets of medical marijuana can prevent migraines if taken once or twice a day. Most people need products with a low THC/CBD ratio which does not cause euphoria or other cognitive effect.

Despite the requirement by states to have verified amounts of active ingredients, THC and CBD in the medical marijuana products, the efficacy and the side effects vary from manufacturer to manufacturer. This could be in part due to ingredients other than THC and CBD. Fortunately, many researchers are looking into the effect of pure ingredients and their mechanism of action.

Such a study was presented at the recent meeting of the American Headache Society by scientists from the Missouri State University led by Paul Durham. They developed a new animal model of migraine in rats and triggered a process in the rats’ brains that is similar to a migraine in humans. Administering cannabidiol (CBD) suppressed increased sensitivity in the trigeminal nerve and produced other positive effects, suggesting a possible mechanism by which CBD may relieve migraine and other facial pains. The next logical step would be to add small amounts of THC to see if it enhances the effect of CBD (so called entourage effect).

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Searching on Amazon for books on migraines yields over 2,291 items. Do we need another book? Having just read the latest book on migraines, Understanding Your Migraines, the answer is a definite yes.

The book is written by two colleagues who for many years co-directed the Dartmouth Headache Clinic. Dr. Morris Levin is now the Director of the Headache Center and a Professor of Neurology at UCSF, while Dr. Thomas Ward is Professor of Neurology Emeritus at the Geiser School of Medicine at Dartmouth and the editor of the journal Headache. They are clearly highly qualified to write such a book, but qualifications are not enough – you need to be a good writer as well. And in fact, excellent writing style and case-based discussion are two of the major strengths of the book.

The book consists of 17 chapters, which cover diagnosis and our understanding of the underlying causes of this condition. What the readers will find most useful is the treatment approaches. Drs. Levin and Ward go into great detail about various non-drug options, including nutrition, exercise, meditation, acupressure, herbal products, vitamins and minerals. They also present pros and cons of various medications, nerve blocks and describe in detail the most effective and the safest preventive treatment for chronic migraines, Botox injections.

One chapter is devoted to specifics of migraines in pregnancy and another one to children and adolescents. The book also includes individual chapters on tension-type headaches, cluster and other less common headache types, and postconcussion headaches.

The authors also mention an exciting new treatment option, which we expect to be approved by the end of 2018. Four companies are racing to bring to the market CGRP monoclonal antibodies, which act like vaccines against migraines. A single injection will provide 1 to 3 months of relief with very few side effects. It is likely that this treatment will help about 60% of patients with both episodic and chronic migraines. Cluster headache patients might also benefit from these biologic drugs.

Reading so much information can make it difficult to understand how to actually use it and how to talk to your doctor about all these options. The authors successfully tackle this problem by providing many real-life cases and by including a chapter, How to Communicate with Your Medical Team.

I am sure that this book will help many migraine sufferers find relief. You can buy it on Amazon.

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The most satisfying part of our work is that we can help more than 95% of our patients. However, a small number of headache sufferers defy our best efforts and continue to have severe pain, which ruins their quality of life.

I just returned from my second visit to lecture at the Berolina Klinik, a rehabilitation hospital in Germany. It has an outstanding record in rehabilitating chronic headache and other types of patients. I wrote about this clinic after my first visit in 2014.

A report just published in Headache describes a successful rehabilitation program of chronic headache patients in an outpatient setting at the Cleveland Clinic. Drs. Krause, Stillman and their colleagues report on 379 patients who were admitted to the IMATCH (Interdisciplinary Method for the Assessment and Treatment of Chronic Headache) program.

The program lasts 3 weeks, during which patients come to the clinic for 8 hours 5 days a week. Patients are informed that “the primary purpose of treatment is not to reduce pain, but rather to improve their ability to function during pain”. Despite this warning the average pain on admission was 6.1, while on discharge 3.5 and a year later, 3.3. Functional impairment, anxiety, and depression also improved and stayed improved a year after the treatment.

The program is clearly very effective and has an additional advantage of not requiring expensive hospitalization. Most patients stay at a hotel across the street from the clinic.

Here is an outline of the 3-week program:

Medical treatment:

1. History and initial medication adjustments on admission day.
2. Four days of intravenous therapy. Patients meet with the physician daily during infusions.
3. Two brief individual medical appointments per week during the second and third weeks.
4. All patients are drug tested at admission, and subsequent drug testing may be included if staff have concerns about illicit use.
5. Consultation with outside physicians as appropriate.

Psychological treatment:
1. One individual biofeedback session in each of the second and third weeks.
2. One individual psychotherapy session in each of the second and third weeks.
3. Psycho-educational group sessions spread throughout the three weeks. Topics include avoidance of pain displays, diminishing attention to headaches, cognitive-behavioral therapy for management of mood, activity pacing, time management, theories of pain, sleep hygiene, assertiveness training, relaxation training, self-esteem, management of headache flare-ups, and relapse prevention.
4. In the second and third weeks of treatment, patients’ families are requested to participate in a group family meeting, where the necessity of avoiding reinforcement of headache displays and disability is emphasized.

Nursing treatment:
1. Initial assessment, including current medication intake, document allergies, perform an EKG.
2. Patients receive at least 1-2 individual visits with a registered nurse during the second and third weeks of the program.
3. Nursing groups, including pathophysiology of headaches, proper use of a headache diary to track progress, dietary counseling, the impact of headaches and medications on sexuality, and medical communications. Nurses also train the patients in additional relaxation techniques beyond those covered in the psychology groups, and lead group relaxation practice.

Physical therapy treatment:
1. Physical therapy evaluation on their admission day, with particular attention paid to cranio-cervical dynamics. Data are used to develop an individualized, quota-based exercise plan including strengthening, flexibility, and endurance exercises.
2. Beginning on the day after admission, patients participate in daily group exercise sessions, where they learn and practice individually tailored exercise plans.
3. Twice weekly individual physical therapy sessions.

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Preeclampsia and eclampsia are complications of pregnancy which manifest by a severe headache and high blood pressure. If left untreated, they can cause strokes and kidney failure.

Fortunately, these conditions are very responsive to intravenous infusions of high doses of magnesium (5-6 grams at a time, while we give 1 gram to our migraine patients). A study recently published in Neurology suggests that even if preeclampsia is treated effectively, it can lead to persistent brain lesions. The researchers found these small white matter lesions (WMLs) in the healthy controls as well, but not as many as in women who suffered from preeclampsia 5 to 15 years prior to the study. We also see these lesions, which appear as small spots, on MRI scans of patients with migraines. The exact nature of these spots remains unclear, but the leading theory is that they are due to impaired blood flow.

The authors looked at a wide variety of factors that might have predisposed women to preeclampsia and subsequent WMLs, but did not find any. They did confirm previous findings indicating that age and high blood pressure increases the number of WMLs, but those with preeclampsia had more WMLs in the temporal lobes of the brain. They also found a decrease of the cortical volume, which means loss of brain cells on the surface of the brain.

Surprisingly, one of the factors they did not measure was magnesium levels. If preeclampsia responds so well to magnesium, it is possible that these women have chronic magnesium deficiency. Magnesium deficiency predisposes people not only to migraines, but also to heart attacks and strokes. The test that should have been done is red blood cell (RBC) magnesium since 98% of magnesium is inside the cells or in the bones. The most commonly used serum magnesium level measures the remaining 2% and is highly unreliable.

If you’ve suffered from preeclampsia or eclampsia, in addition to reducing other risk factors for vascular problems – control your blood pressure, sugar and cholesterol, stop smoking if you smoke, lose weight, and exercise, you may also want to ask your doctor to check your RBC magnesium level. If the level is low or at the bottom of normal range, take a magnesium supplement. A good starting dose is 400 mg of magnesium glycinate taken daily with food. If subsequent tests show no improvement, the dose can be increased to 400 mg twice a day and even higher.

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Inhalation of pure oxygen under high flow is an effective treatment for an acute cluster headache, although not migraines. Headache is one of the most common symptoms of traumatic brain injury and postconcussion syndrome and there is evidence that oxygen under pressure can help those conditions.

A review article on the use of oxygen to treat mild and moderate traumatic brain injury and postconcussion syndrome was recently published in Neurology. THe authors reviewed 5 previously published studies and concluded that hyperbaric oxygen in fact does help patients with brain trauma and postconcussion syndrome.

While cluster headache patients can breathe in oxygen through a mask from a tank of oxygen delivered to their home, hyperbaric oxygen requires a special room or a chamber. Hyperbaric means that oxygen is under increased pressure, although the authors report that moderate pressure (between 1 and 2 ATA) may be better than high pressure. Even hyperbaric air, that is normal air under pressure, may have beneficial effects.

The authors conclude that, there is sufficient evidence for the safety and preliminary efficacy from clinical data to support the use of hyperbaric oxygen in mild to moderate traumatic brain injury and postconcussion syndrome. They also state that “It would be a great loss to clinical medicine to ignore the large body of evidence collected so far that consistently concludes that hyperbaric oxygen is effective in treatment of brain injuries.”

Fortunately, there are many hospitals and private clinics all around the country that offer hyperbaric oxygen. They often advertise its use for a variety of unproven indications, but if you suffer from a traumatic brain injury, this treatment may be worth trying. A major obstacle though could be the cost of treatment since insurance companies are not likely to cover this treatment.

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The field of marijuana research is starting to take off due to the wider acceptance of medicinal marijuana. The other night I attended a lecture in NYC by the “father of cannabis”, Raphael Mechoulam.

According to Wikipedia, “Dr. Mechoulam is an Israeli organic chemist and professor of Medicinal Chemistry at the Hebrew University of Jerusalem in Israel. Mechoulam is best known for his work (together with Y. Gaoni) in the isolation, structure elucidation and total synthesis of THC (?9-tetrahydrocannabinol), the main active ingredient of cannabis and for the isolation and the identification of the endogenous cannabinoids anandamide from the brain and 2-arachidonoyl glycerol (2-AG) from peripheral organs together with his students, postdocs and collaborators.”

Dr. Mechoulam identified THC in 1964 and in his lecture he lamented the paucity of research into the many potential healing properties of cannabis in the past 50 years. He strongly feels that the two main active ingredients in marijuana, THC and CBD should be tested rigorously in large double-blind studies just like any other prescription drug. This will allow doctors to prescribe a proven medicine, rather than rely on anecdotal reports and go through trial and error, as we are doing now. His research suggests that cannabis ingredients could possibly help a wide variety of conditions, from diabetes and cancer to pain and nausea.

Prescribing medical marijuana is at least possible in New York and 20 other states, so that we do not have to wait, possibly up to 10 years, for a cannabis-based drug to be approved by the FDA (one CBD-containing drug might be approved soon for a rare form of epilepsy).

At this time we have to go through trials of various ratios of THC and CBD and various modes of delivery (inhaled, sublingual or oral) to determine the best treatment for each patients. Another obstacle is the fact that no insurance company pays for medical marijuana. After a year of prescribing medical marijuana for patients with migraine and other painful conditions it is clear that it works for a minority of my patients. However, I prescribe it only after more traditional methods fail, so my results may not be as good as if I used medical marijuana earlier. Our standard approach involves lifestyle changes, regular exercise, dietary changes, magnesium, CoQ10, and other supplements, followed by drugs and Botox injections. These are mostly well-studied treatments and with the possible exception of drugs, should precede the use of medical marijuana. Having said that, For a few of my patients medical marijuana dramatically improved their quality of life and I am very glad that we have this treatment option available.

Dr. Rafael Mechoulam and Dr. Alexander Mauskop
May 4, 2017, NYC

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Migraine sufferers are more likely to have insomnia than people without migraines. Depression and anxiety, which are more common in migraineurs can often lead to insomnia as well. Surveys indicate that 38% of migraine sufferers sleep less than 6 hours, compared to 10% of the general population. Insomnia is more common in patients with chronic migraine compared with patients who have episodic migraines. Chronic migraine is defined as having 15 or more headache days each month with a migrainous headache on at least 8 of those days.

Most people are reluctant to start taking sleep medications because of the reasonable fear of becoming dependent on medicine, having somnolence the next day and other short-term and long-term side effects. Fortunately, non-drug therapies can be quite effective. In some, natural remedies, such as magnesium, valerian root and melatonin work well without any side effects. Another approach is cognitive-behavioral. According to a study by psychologists at the University of Mississippi, behavioral treatments can be effective in relieving insomnia and in reducing headaches in people with chronic migraine.

The researchers compared cognitive-behavioral therapy specifically developed for insomnia with sham treatment. Those in the active group were asked to go to sleep at the same time, try to stay in bed for 8 hours, avoid reading, watching TV or using their cell phone in bed, and not to nap. If they could not fall asleep after 30 minutes, they were told to get up and engage in a quiet activity. Some were also subjected to sleep restriction – not being allowed to sleep for more hours than the patients reported getting prior to treatment, in the hope that this will lead to better sleep in the long term. The sham group was instructed to eat some protein in the morning, eat dinner at the same time, keep up with their fluid intake, perform range of movements exercise, and regularly press on an acupuncture point above the elbow.

After two weeks of this intervention headaches improved in the sham group slightly more than the active group, but six weeks later, headache frequency dropped by 49% in the active group and 25% in the sham group. Improvement in insomnia symptoms strongly correlated with the headache frequency. The cognitive-behavioral group had a significant increase in the total sleep time and the quality of sleep.

This was a relatively small study, but there is a large body of evidence that behavioral therapies do relieve insomnia. And it is no surprise that better sleep is associated with fewer headaches since sleep deprivation is a common migraine trigger. Sleep restriction is the only part of this treatment that has contraindications – it should be avoided in patients with bipolar disorder or epilepsy.

Another simple method, which I’ve used over the years whenever I cannot fall asleep, is visualization. You have to use not only visual images, but engage all of your senses. For example, imagine yourself in a place where you tend to feel relaxed (lying on a beach, on a cool lawn, on a float in a pool, etc). See all the details and also hear the sound of the wind or waves, smell the ocean or the grass, feel the touch of the wind or sand. It takes an effort at first, but use the same image every time and after a while, as soon as you go to that place, you fall asleep in minutes. Here I found more detailed instructions for this method.

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I am certain that you will learn a lot of useful information from listening to the top headache experts in the world. The event is free during the week when it is held (April 23 – 29), but afterwards you will have to pay for full access to all interviews. The Migraine World Summit is in its second year and it again assembled excellent speakers to address a wide variety of headache-related topics. Last year I spoke on non-drug therapies and this year the speakers are again addressing not only medications, but many alternative treatments and self-care. In addition to many leading neurologists, the event features Ping Ho, MA, MPH, a UCLA expert on alternative therapies, meteorologist, Michael Steinberg of Accuweather, Vidyamala Burch, a mindfulness expert, an Australian psychologist, Paul Martin, a geneticist, Professor Lyn Griffiths of Queensland UT (the event is organized by an Australian migraine sufferer Carl Cincinnato, so there are many Australians represented), and over 30 other experts.

Here is a blurb from the organizers:

In it’s first year, The Migraine World Summit became the largest ever conference for migraine patients. In 2017, we’re back with 36 brand NEW interviews where you’ll discover even more about…

What are the best treatments for migraine?
What can I do when I’ve already tried everything?
What are the secrets to finding effective natural alternatives?
How can I cope with the anxiety, judgment and social stigma of chronic migraine?
What new treatments are coming that I should be aware of?
What are the most common challenges that could appear?
The 2017 Migraine World Summit is online and free from April 23 – 29, 2017!

Register for FREE now at the following link:

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Photophobia, or sensitivity to light is one of the most common symptoms that accompany a migraine attack. Many patients remains photophobic even after the headache has resolved. In some, a prolonged exposure to bright light or as little as a momentary reflection of the sun in the window glass or water surface can bring on a severe attack.

It is not unusual for some of my patients to wear sunglasses indoors. Once, when I had a migraine while driving at night I had to put on my sunglasses because the headlights of oncoming cars made the pain worse (luckily, I had a sumatriptan injection with me and as soon as I got off the highway and to a traffic light, I gave myself a shot).

Dr. Kathleen Digre, a professor Neurology and Ophthalmolgy at the University of Utah, whose article on dry eyes and migraines I quoted a couple of years ago, recently stated that staying in the dark may actually make photophobia worse. It may be better to gradually expose yourself to more light when you are not in the middle of an attack.

A small study suggested that people who suffer from photophobia between migraine attacks are more likely to experience anxiety and depression than those without photophobia between attacks and those without migraines. It is not clear if anxiety and depression in these patients is due to more severe migraines.

Treatments for photophobia mentioned by Dr. Digre include botulinum toxin (Botox) injections, nerve blocks, medications such as gabapentin, and a natural supplement, melatonin. I should add that any effective acute and preventive treatment that leads to reduced frequency and duration of the attacks can lead to a reduction in photophobia. Effective treatment is also likely to improve phonophobia (sensitivity to noise) and osmophobia (sensitivity to smells), which are somewhat less common.

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Postconcussion symptoms can be debilitating and can persist for long periods of time, both in kids and adults. Persistence of headaches, dizziness, difficulty concentrating and with memory is often compounded by depression and anxiety. The usual care consists of mild exercises, sleep medications, antidepressants, and other drugs.

A new study published in Pediatrics shows very promising results from cognitive-behavioral therapy (CBT) in teens with post-concussion symptoms. Children aged 11 to 17 years with persistent symptoms for more than a month after sports-related concussion were randomly assigned to receive collaborative care that included CBT (25 kids) or care as usual (24 kids). The children were assessed before treatment and after 1, 3, and 6 months.

Six months after the baseline evaluation 13% of children who received CBT and 42% of control patients reported high levels of postconcussive symptoms. Depression improved by at least 50% in 78% of the CBT group and 46% of control patients. Anxiety symptoms were at the same level in both groups.

CBT has been shown to be effective in children and adolescents with chronic migraines, so it is not surprising that it would also help with postconcussion headaches and other symptoms. And the effect is quite dramatic.

A major obstacle for wider adoption of CBT is the cost and difficulty in finding a qualified psychologist. In a previous post I mentioned two very effective and scientifically verified online programs, ThisWayUp and moodGYM. These do require persistence and discipline, which in case of teens, parents might be able to provide.

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A new electric device is being tested for the treatment of migraine by an Israeli company, Theranica. Transcutaneous electric nerve stimulation (TENS) has been successfully used for the treatment of musculoskeletal disorders for decades. The theory behind it is the so-called gate theory of pain. It is thought that by stimulating larger nerve fibers we can block pain messages sent by smaller pain-sensing nerve fibers.

Cefaly is a TENS device which became available in 2014 and it provides electrical stimulation of the supraorbital nerves in the forehead. Only small studies have been conducted, so it is not clear how well Cefaly relieves migraines. As far as our experience, we at the NY Headache Center usually treat more severely affected patients, so it is possible that the results are better in people with less severe migraines.

The new wireless patch that is being developed by Theranica is applied to the upper arm. The results of the first study of this patch were published in Neurology, the medical journal of the American Academy of Neurology.

The study author, is a well-known neurologist and pain researcher, Dr. David Yarnitsky of Technion Faculty of Medicine in Haifa, Israel. He was quoted saying, “People with migraine are looking for non-drug treatments, and this new device is easy to use, has no side effects and can be conveniently used in work or social settings.”

The patch device is controlled by a smartphone app. It was studied in 71 patients with episodic migraine who had two to eight attacks per month and who were not on any preventive medications for migraines. The device was applied soon after the start of a migraine and kept in place for 20 minutes.

The devices were programmed to randomly give either a very weak stimulation to serve as placebo or different levels of stronger electrical stimulation.

A total of 299 migraine attacks were treated by these 71 patients. Two hours after the start of real treatment, pain was reduced by at least 50% in 64 percent of patients, compared to 26 percent of patients who received the sham stimulation.

Starting treatment early produced better results, which is similar to what we see with all migraine medications as well. None of the participants found the treatment to be painful.

The device is very safe and we hope that the ongoing trial that Theranica is conducting in the US will confirm its efficacy. It is not yet available in this or any other country.

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Naltrexone, along with naloxone are narcotic (opioid) antidotes, that is they counteract the effect of narcotics and are used to treat overdoses with heroin, fentanyl, Percocet, Vicodin, and other opioid drugs. Surprisingly, low doses of naltrexone (LDN) seem to be effective in treating pain. LDN has been also used to treat symptom in conditions such as depression, fibromyalgia, Crohn’s disease, multiple sclerosis, complex regional pain syndrome (which used to be called reflex sympathetic dystrophy), and autoimmune disorders.

Low dose naltrexone is not a typical pain killer, but may be helping pain by reducing inflammation. Instead of opioid receptors, it works on Toll-like receptor 4 (TLR4) receptors on glial cells. Glial cells surround the nerve cells and play important functions in the brain, beyond just a supporting role that had been assigned to them for many years. Opioid drugs are known to promote inflammation through the brain immune system leading to worsening of pain over time. Recent discoveries have shown that the Toll-like receptors are involved in triggering these inflammatory immune events. These discoveries have led many researchers to look at ways to block TLR4, but so far no such drug has been developed. We do have several existing medications that seem to block TLR4. Besides LDN, amitriptyline (Elavil) and cyclobenzaprine (Flexeril) are two other drugs that block TLR4 and that have been used for years to treat pain.

No large controlled studies of LDN for migraines, pain or any other condition have been conducted to date. Despite the fact that the evidence is only anecdotal and that LDN my work purely through the placebo effect, advantages of LDN are that it is inexpensive and safe. Naltrexone is available in 25 and 50 mg tablets, while the amount used for LDN is between 1.5 to 4.5 mg. This means that it can be obtained only from a compounding pharmacy. Naltrexone is not a controlled substance, but it does require a prescription from the doctor.

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Italian researchers published a study in the journal Headache that attempted to correlate the attachment style in children with migraines with headache severity and psychological symptoms.

Attachment style typically develops in the first year of life. The premise of the study was derived from the attachment theory which suggests that early interpersonal relationships may determine future psychological problems and painful conditions. Previous studies have shown that people with insecure attachment styles tend to experience more pain than people with secure attachment style.

The study involved 90 children with migraines. The mean age was 12 years and there were 54 girls and 36 boys in the study. The kids were divided into a group with very frequent headaches (1 to 7 a week) and those with infrequent attacks – 3 or fewer per month. They also grouped them into those with severe pain, which interrupted their daily activities and those with mild pain that allowed them to function normally. The children were tested for anxiety, depression, and somatization (tendency to have physical complaints as a manifestation of psychological distress). They were also evaluated for the attachment style and were assigned into “secure,” “avoidant,” “ambivalent,” and “disorganized/confused” groups.

Interestingly, the researchers found a significant relationship between the attachment style and migraine features. Ambivalent attachment was present in 51% of children with high frequency of attacks and in 50% of those with severe pain. Anxiety, depression, and somatization were higher in patients with ambivalent attachment style. They also showed an association between high attack frequency and high anxiety levels in children with ambivalent attachment style.

The authors concluded: “We found that the ambivalent attachment style is associated with more severe migraine and higher psychological symptoms. These results can have therapeutic consequences. Given the high risk of developing severe headache and psychological distress, special attention should be paid to children with migraine showing an ambivalent pattern of attachment style. Indeed, a prophylactic and psychological therapy could often be necessary for these patients.”

People who have an anxious–ambivalent attachment style show a high desire for intimacy but often feel reluctant about becoming close to others and worry that people will not reciprocate their feelings. It is possible to mitigate the negative effects of the ambivalent attachment style even in adulthood. It does require a major effort and help from a psychotherapist.

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Atul Gawande is a surgeon at the Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School. He is also a very talented writer who has written four books and has been writing for the New Yorker since 1998. I had the privilege of meeting him and found him to be very humble and low-key, despite him being a surgeon, MacArthur “genius” award recipient, famous writer, etc. His last book, Being Mortal should be read by everyone who is dealing with elderly parents, grandparents, or friends.

His last article in the New Yorker, The Heroism of Incremental Care describes how headache specialists approach patients with severe and persistent migraine headaches. Fortunately, these are a minority of our patients, but require our unflagging attention and care. Some tell me that they’ve tried “everything” and ask, “please do not abandon me”. My response is to reassure the person that I will never stop trying to help and also that I’ve never seen anyone who has tried everything – we always find medications, supplements, devices, procedures, and other treatments that the patient has not yet tried.

Just like with the man in Gawande’s story, some patients improve very slowly and over a long period of time, so patience and perseverance are essential. I must admit that we cannot be sure if it is our treatment or just the passage of time that leads to improvement. However, it may not matter since our support helps avoid a sense of helplessness and hopelessness that can lead to depression and a decline in the ability to function.

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Many chiropractors advertise their success in treating migraine headaches. Norwegian researchers conducted a scientific study of chiropractic manipulation for migraine headaches in 104 patients. They divided patients into three groups: one that received real chiropractic manipulation of the spine, one that received a sham treatment that consisted of just putting pressure over the shoulders and lower back, and one that continued their usual medication. The real and sham chiropractic groups received 12 treatment sessions over 12 weeks and all three groups were followed for a year. After 12 weeks patients in all three study groups reported improvement. However, a year later, only the two chiropractic groups still felt better. On average, they had about four migraine days a month, down from six to eight before the treatment started. Patients who just continued their medications lost all of their improvement and their migraine frequency was back where it was at the baseline.

The results published in the European Journal of Neurology suggest that chiropractic is indeed effective in reducing migraine frequency, however, it also suggests that any hands-on treatment is equally effective. This probably explains the popularity of chiropractic, physical therapy, massage, reflexology, Reiki, energy therapies, Feldenkreis, and all other hands-on treatments.

All these treatments are worth trying, but avoid high velocity adjustments when undergoing chiropractic treatment as it carries a small risk of serious side effects (see this previous post). I would also pick inexpensive treatments and pick therapists you feel a rapport with. The treatment should be pleasant and never painful. You should also combine these therapies with a healthy lifestyle, including a healthy diet, regular sleep, exercise, meditation, and supplements.

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Vitamin C deficiency appears to be more common in people with back pain, according to a study just published in the journal Pain by Canadian researchers. Vitamin C (ascorbic acid) is important for collagen formation and collagen is one of the main ingredients of ligaments, tendons, and bones. Recent studies have reported that vitamin C deficiency is common in the general population. The authors “hypothesized that lack of vitamin C contributes to poor collagen properties and back pain”. They used nationwide data from the U.S. National Health and Nutrition Examination Survey from 2003–2004. Information was available for 4,742 individuals older than 20. Low serum vitamin C levels were associated with one and a half times higher prevalence of neck pain and 1.3 times higher prevalence of low back pain, as well as low back pain with pain radiating to below the knee in the preceding three months. Deficiency was also associated with the self-described diagnosis of arthritis or rheumatism and related functional limitations. The authors concluded that the association between vitamin C deficiency and spinal pain warrants further investigation to determine the possible importance of vitamin C in the treatment of back pain patients.

Neck pain is very common in patients with migraine and tension-type headaches, so it is possible that vitamin C could also play a role in the treatment of headaches. My search revealed no studies looking at vitamin C levels in migraine sufferers. It may be worth checking vitamin C levels in those headache patients who do not respond to usual treatments and recommending supplementation to those who are deficient. However, even if I see good responses to vitamin C in my patients, these observations are not going provide true scientific evidence, even if hundreds of my patients report feeling better. This is because besides giving vitamin C, I would continue to recommend regular exercise, healthy diet, meditation, and other vitamins and minerals, all of which could be contributing to improvement. We need a large study to measure vitamin C levels in headache patients, and the deficient patients should be enrolled in a double-blind study to find out if vitamin C can improve different types of headaches.

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Two leading headache experts, Drs. Richard Lipton and Dawn Buse of the Montefiore Headache clinic gave positive comments on the report published in Pain and described in my recent post. Another headache specialist from Texas, Dr. Deborah Friedman was also quoted about this research report in Neurology Today.

“Acupuncture studies are difficult because the blinding is difficult,” Richard B. Lipton, MD, FAAN, the Edwin S. Lowe professor and vice chair of neurology at the Albert Einstein College of Medicine, said. He noted that even comparisons using sham procedures may not entirely blind the patient to whether he or she is receiving a real treatment in which needles are inserted in the “meridian” — the points where energy is said to flow.“ That said, the authors in their review show that acupuncture is very substantially better than usual care. I think in aggregate these data demonstrate that real acupuncture is very helpful to people with episodic migraine in terms of reducing the number of headache days. My longstanding practice has been to arrange acupuncture for patients who ask for it, but not to recommend it otherwise,” Dr. Lipton said. “This review is going to impact what I do. It’s 22 randomized trials, and the Cochrane review is 150 pages. I think this is an important summary of the best evidence. I think it’s quite positive. I want to make my patients better so the imperfect blinding doesn’t matter.”

Dawn C. Buse, PhD, associate professor of neurology at Albert Einstein College of Medicine of Yeshiva University, also found the review persuasive, while noting that the mechanism by which acupuncture works is unknown and may be influenced by factors other than the procedure itself. “This review demonstrates that acupuncture may be helpful in reducing the frequency of migraine attacks and is likely to be well tolerated when compared to pharmacologic treatment,” she said. “We do not know from this review how patients who incorporate both acupuncture and optimized pharmacologic approaches fare. However, we know from meta-analyses of combined behavioral and pharmacologic approaches to migraine management that the combination is superior to either approach alone both in initial and sustained response.” She added: “Evidence suggests that many additional factors unrelated to acupuncture needling including expectations, beliefs, openness to experience, and the quality of the patient-provider relationship may play important roles in the beneficial effects of acupuncture for a particular patient. In addition, it is likely that patients who participate in and as a result report benefit from acupuncture are people who are interested and open to nonpharmacologic approaches. It is likely a patient who is open to nonpharmacologic approaches may also be a patient who will take a more active role in migraine management.” Dr. Buse noted that this type of patient is likely to have better treatment outcomes, no matter what type of treatment, due to higher levels of self-efficacy and willingness to actively engage in all aspects of treatment such as following treatment recommendations for healthy lifestyle habits, exercising, managing stress and healthy sleep hygiene. “Based upon these findings, it is reasonable to suggest that a patient who is interested and motivated to try acupuncture to manage migraine may benefit,” she told Neurology Today. “There are likely to be few if any side effects or risks to acupuncture, other than time and financial expense since acupuncture may not be covered by insurance. In addition, it may be difficult to advise a patient how to find a provider with proper training, skill, and knowledge to provide successful treatment and to know exactly what successful treatment would entail. The body of literature suggests that combined pharmacologic plus behavioral approaches are superior to either one alone, Dr. Buse noted. It may be therefore wise to recommend that patients who are interested in acupuncture combine it with optimized pharmacologic and behavioral treatments for the best chance of treatment outcome with lasting benefits, she said.

Dr. Lipton echoed that comment. “Acupuncture is one of many nonpharmacologic treatments for migraine,” he said. “The nonpharmacologic interventions include education, helping people identify triggers, some vitamins and herbs that are evidence-based, cognitive-behavior therapy and biofeedback. So my broad comment is that we should not restrict what is in our toolbox and consider a range of non-pharmacologic as well as pharmacologic treatments.”

But another reviewer, Deborah I. Friedman, MD, MPH, FAAN, chief of the division of headache medicine and professor of neurology & neurotherapeutics and ophthalmology at University of Texas-Southwestern in Dallas, expressed some reservations about the quality of the data. “Acupuncture is helpful in some patients with episodic migraine, particularly as an ‘add on’ treatment, but the quality of the data from clinical trials is moderate overall. There is a lot of variability in acupuncture technique amongst practitioners,” she said. “Patients who are interested in acupuncture should be referred to reputable practitioners who have had proper training.” She added: “In general, I don’t discourage it, but I rarely suggest it as an option unless the patient asks about it, or if I get the sense that they are interested in natural remedies. I tell my patients that the clinical evidence to support acupuncture treatment for migraine is not strong, with mixed results. However, it is safe and many patients find it useful, particularly those who are attracted to ‘natural’ or non-pharmacological treatments, and those who have not tolerated conventional therapies.” Dr. Friedman said that in the program at University of Texas Southwestern Medical Center, physical therapists are trained to do dry needling. “It seems to benefit many of our patients with refractory head and neck pain,” she said. “I make it clear to my patients that this is not the same as traditional acupuncture, and encourage them to try it once to see if it helps.”

Dr. Linde, one of the authors of the original report, noted in his comments that the problem of blinding affects the study of many treatments that are not pharmacologic in nature. “While the overall quality of a number of trials is actually quite good, one has to keep in mind that apart from sham-controlled trials acupuncture studies are usually not blind. However, this applies to almost all non-pharmacological treatments.”

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Acupuncture for the treatment of migraines has been studied in dozens of clinical trials. A 2012 study mentioned in a previous blog post described a rigorous trial done in 480 patients with highly positive results. The largest, albeit uncontrolled study was done in Germany and involved over 15,000 patients. A well controlled and randomized study of 960 patients comparing acupuncture with sham acupuncture and drug therapy concluded that “…acupuncture is as effective as drug therapy, but …sham acupuncture is as effective as ‘real’ acupuncture.” and “…acupuncture should be offered to patients who do not respond to prophylactic treatment with drugs, terminate drug treatment because of adverse events or have contraindications to drug treatment.”

Most headache specialists recommend acupuncture to their patients even if they believe it works only through the placebo effect. I’ve been a licensed acupuncturist for the past 30 years, but treat a relatively small number of patients with acupuncture. The main reasons are the fact that insurance companies do not pay for it and that it is too time consuming. In the first study mentioned above, which was performed in China, patients were treated five days a week. The minimum frequency of treatments should be once a week. I often recommend that patients find a non-MD acupuncturist (whose rates are usually lower) who is closer to the patient’s home or work place. Another concern with acupuncture is that while it might help during the treatment, the effect might subside once the treatment is stopped.

A study The persistence of the effects of acupuncture after a course of treatment: A meta-analysis of patients with chronic pain, just published in the journal Pain addresses this question.

A group of researchers from the US and Europe examined a large set of information on individual patients from high quality randomized trials of acupuncture for chronic pain. The chronic pain conditions included musculoskeletal pain (low back, neck and shoulder), osteoarthritis of the knee and headache / migraine. Data on longer-term follow-up were available for 20 trials, which included 6,376 patients. In trials comparing acupuncture to no acupuncture control (wait-list, usual care, etc), the treatment effect diminished by a very small amount after treatment ended. They estimated that 90% of the benefit of acupuncture relative to controls would be sustained at 12 months. For trials comparing acupuncture to sham acupuncture, they observed a higher reduction in effect, suggesting about a 50% diminution at 12 months. They concluded that “The effects of a course of acupuncture treatment for patients with chronic pain do not appear to decrease importantly over 12 months. Patients can generally be reassured that treatment effects persist.” They also suggested that studies of the cost-effectiveness of acupuncture should take these findings into account when considering the time horizon of acupuncture effects and that further research should measure longer term outcomes of acupuncture.

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Medical marijuana was legalized in New York in February of this year. Since then, I’ve prescribed it to over 30 patients and about a third of them have found it to be effective. We are planning an observational study to determine which of the three approved types (inhaled, sublingual, oral) and what ratio of active ingredients (THC/CBD) are preferred by migraine sufferers. Doctors who prescribe medical marijuana do have to take an online training course, but the course does not teach about the optimal use because no one has researched this question. There are also regulatory issues to deal with.

Several sets of guidelines have been published by various medical organizations addressing the proper use of medical marijuana, other than dosing and route of administration. Here are some of the recommendations with my comments:

“The doctor should adhere to current standards of practice and comply with state laws, rules and regulations, which may specify conditions for which a patient may quality.”
Migraine is not one of the conditions listed specifically, but it is often accompanied by neuropathic pain, which is listed.

“The doctor’s office should not be located at a marijuana dispensary or cultivation center. The doctor should not receive financial compensation from or hold a financial interest in marijuana-related businesses or be affiliated with them in any way.”
This one is easy for us.

“The physician should not use marijuana either medicinally or recreationally while actively engaged in the practice of medicine.”
I’ve never tried it.

“There should be an established doctor-patient relationship before the doctor considers the use of medical marijuana.”
I prescribe it only to our established patients.

“The doctor should do a physical exam and gather health history, including documentation of previous therapies used by the patient and information on any personal or family history of substance abuse, mental illness or psychotic disorders. The diagnosis should justify the consideration of medical marijuana.”
All of our patients undergo a thorough evaluation.

“The doctor should review other treatment options. The known benefits and risks of marijuana should be presented, along with the warning that, unlike with FDA-approved drugs, there is variability and lack of standardization in marijuana preparation.”
We use medical marijuana only after other non-drug and drug treatments fail.

“If the medical marijuana is chosen, a specific treatment plan for a limited period of time should be agreed on, with details documented in the medical record. The doctor should instruct the patient not to drive or operate heavy machinery while using marijuana.”
Yes, I do that.

“The patient should be seen for follow-up visits to monitor for efficacy and side effects of medical marijuana.”
This is a standard practice with any treatment.

“Patients with a history of mental health problems, substance abuse or addiction should be referred for further evaluation as needed.”
I typically avoid prescribing medical marijuana to such patients.

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We are big proponents of non-drug treatments, including a variety of vitamins, minerals, and herbal supplements. However, potential liver damage by butterbur is why we do not recommend this supplement, even though I was one of the participants in the clinical trial that showed it to be effective in preventing migraines. I also cautioned about risks of some Ayurvedic medications.

A recent report in Hepatology, a journal devoted to liver diseases, suggests that 20% of all cases of liver damage are due to herbal and dietary supplements. The main culprits were anabolic steroids (these are banned in professional sports, but are widely used for muscle building), green tea extract, and supplements with multiple ingredients. Anabolic steroids cause prolonged, but not serious liver injury, which resolves when the supplement is stopped. Green tea extract and many other products cause acute liver damage, similar to that seen in hepatitis. The majority of cases of liver injury are due to products that contain multiple ingredients, which makes it difficult to figure out which of the supplements is responsible. Unfortunately, non-prescription supplements are not regulated by the government. This is mostly because it is a $37 billion dollars a year industry with a powerful lobby in Washington. The authors conclude their report by saying that “the ultimate goal should be to prohibit or more closely regulate potentially injurious ingredients and thus promote public safety.”

Until these products come under FDA’s supervision, you should buy only products made by reputable American and German companies. Germany tightly regulates their supplement industry, so if a product is sold in Germany (and none of the butterbur products are approved there or in Great Britain), it is probably safe to take. Do not buy products made in China where corruption has led to many scandals related to the quality of supplements, drugs, food, and environmental pollution.

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Medical marijuana reduces the number of prescriptions written by doctors, according to a recent study published in Health Affairs. The researchers at the University of Georgia in Athens looked at all prescriptions filled by Medicare participants over a four year period for nine conditions for which medical marijuana is used for. These included anxiety, depression, glaucoma, nausea, pain, psychosis, seizures, sleep disorders and spasticity. They compared 17 states and Washington, DC where medical marijuana was legalized with those where it was not. In states with legalized medical marijuana the number of prescriptions dropped by 0.5% providing estimated savings of $165 million a year. Of all approved indications, relief of pain was by far the most common reason medical marijuana was prescribed for. This was a much more dramatic effect than the researchers anticipated. They expected that the mostly elderly patients on Medicare would be more resistant to the idea of using marijuana than younger people.

In a February post I mentioned that I started prescribing medical marijuana to my patients with migraine headaches who also have neuropathic pain as part of their headache. While medical marijuana is not approved for migraines per se, it is approved for neuropathic (i.e nerve-related pain), which many migraine sufferers do have. Burning or stabbing pain indicates the presence of neuropathic pain. So far, I’ve prescribed medical marijuana to about two dozen patients and as expected, the results are mixed. It works well for some, but not other. Most commonly, patients who’ve had positive experience with recreational marijuana tend to request medical marijuana and they tend to do better than those who’ve never tried it.

Research on medical marijuana is complicated by the fact that there is no standard formulation, which means that there is wide variation in the strains of the plant with varying amounts of active and inactive ingredients. In New York State medical marijuana can be ingested, inhaled through a vaporizer or placed under the tongue. We also have various ratios of tetrahydrocannabinol (THC) and cannabidiol (CBD), which produce different results. Nevertheless, we do plan to do an observational study of 100 migraine sufferers who also have neuropathic pain. We hope to get an indication as to what route of administration and what THC/CBD ratio work best for migraine patients.

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Vitamin B12 was the subject of an article in the New York Times by Jane Brody entitled, Vitamin B12 as Protection for the Aging Brain. However, she mentions that “insufficient absorption of B12 from foods may even be common among adults aged 26 to 49” and that the advice to take a vitamin B12 supplement may apply to young people as well. This is particularly true for vegans and vegetarians, as well as people with stomach problems and those on PPIs – drugs for ulcers and heartburn, such as Prilosec, Nexium, Aciphex, etc.

Vitamin B12 deficiency can cause “fatigue, tingling and numbness in the hands and feet, muscle weakness and loss of reflexes, which may progress to confusion, depression, memory loss and dementia as the deficiency grows more severe”. Severe deficiency leads to peripheral and central nervous system damage (so called subacute combined degeneration), which eventually becomes irreversible and leads to death.

Jane Brody does not mention that besides Alzheimer’s, other chronic diseases, such as multiple sclerosis, diabetes, and cancer are also associated with low vitamin B12 levels. Vitamin B12 with vitamin B6 and folic acid has been shown to help some migraine sufferers

You can ask your doctor to check your vitamin B12 level, but unfortunately it is not reliable. Most laboratories cite as normal blood levels of above 200 or 250, but there are reports of rare cases where severe deficiency is present with a level of 700. I recommend taking a supplement if the level is below 500. In severe cases or in people with stomach problems, a monthly injection is a better choice. Patients can easily self-inject vitamin B12, but it does require a doctor’s prescription. Some of my patients feel the need to inject themselves with vitamin B12 more often than once a month. Whenever they start feeling tired or having other symptoms, they take a shot. Unlike some vitamins, such as B6 and A, vitamin B12 does not cause any negative effects even at high levels. As an oral supplement I usually recommend tablets of methylcobalamin, rather than cyanocobalamin form of vitamin B12 because of better absorption. The usual dose is 1 mg (or 1,000 mcg) daily. If you are deficient and stop taking the supplement, the deficiency can return within a few months.

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Intravenous magnesium relieves acute migraine attacks in patients with magnesium deficiency, which is present in half of migraine sufferers, according to the study we published in 1995 in the journal Clinical Science. Infusions not only treat an acute attack, but also prevent migraines. Oral magnesium supplementation is not as effective and helps less than 50% of patients because some patients do not absorb magnesium. Most people get enough magnesium from food, but some migraine sufferers have a genetic defect which prevents them from absorbing magnesium or a genetic defect that leads to an excessive loss of magnesium through kidneys.

Our experience with thousands of patients suggests that the majority of migraine sufferers who are magnesium deficient do improve with oral supplementation, but about 10% do not. These patients need regular infusions of magnesium and these infusions are often life-changing. Magnesium not only treats and prevents migraines, but also relieves muscle cramps, PMS, palpitations, “brain fog”, and other symptoms.

There are many mentions of magnesium on my blog and on the website, so what prompted another post on this topic is a couple of patients with an unusal experience. I would occasionally see such patients but in the past few weeks, I saw several. These patients tell me that when we give them an infusion of magnesium by “slow push” over 5 minutes they get excellent relief, but when they end up in an emergency room or another doctor’s office where they receive the same amount of magnesium through an intravenous drip over a half an hour or longer, there is no relief.

A likely explanation is that a push results in a high blood level, which overcomes the blood-brain barrier and delivers magnesium into the brain, while during a drip, magnesium level does not increase to a high enough level to reach the brain. Studies have shown that migraineurs not only have a systemic magnesium deficiency, but specifically in their brains. A similar phenomenon has been described with sumatriptan (Imitrex). Researchers discovered that migraine sufferers who did not respond to sumatriptan had a much slower increase in the drug level compared to responders, even though the total amount of the drug absorbed into the blood was the same.

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Recently, a patient of mine reported that cramp bark has significantly improved her menstrual migraines. Cramp bark is a common shrub with red berries. Its bark has been used for over 100 years for muscle cramps, menstrual cramps, fluid retention, and other symptoms. Fortunately, it appears to be very safe and even though no scientific studies have been performed on it, it may be worth trying. I will start recommending it to women with menstrual migraines, menstrual cramping and patients with muscle spasms in their neck and upper back.

The two top herbs I recommend to my migraine patients are feverfew and boswellia. Feverfew has been subjected to scientific studies and seems to help some patients while causing almost no side effects. Boswellia has been reported to help even patients with cluster headaches, but no rigorous studies have been done. However, it is safe and because of its anti-inflammatory properties it can also help joint and muscle aches (see my blog post on Boswellia).

Butterbur, on the other hand is not always safe, so I haven’t been recommending it. Here is one of my blog posts on it.

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Vagus nerve stimulation (VNS) with an electrode implanted in the neck is an FDA-approved treatment for depression and epilepsy, when these conditions do not respond to medications. Since antidepressant and anti-epilepsy medications help migraines, I had six patients (four with migraines and two with cluster headaches) treated with VNS. Two of the four chronic migraine patients and both cluster patients had good relief – results that were published in the journal Cephalagia in 2005. This publication led to the development of gammaCore, a device to stimulate the vagus nerve through the skin, without the need for surgical implantation of an electrode. The New York Headache Center participated in one of the earliest studies of this device and the results were encouraging.

An article published in the current issue of Neurology presents the results of another study of gammaCore. In this first double-blind study 59 adults with chronic migraines (15 or more headache days each month) were given either real VNS or sham treatment for two months. After two months they were all given the real treatment for 6 months. The main goal of the study was to examine the safety and tolerability of this treatment, but the researchers also looked at the efficacy by measuring the change in the number of headache days per 28 days and acute medication use.

Both sham and real treatment were well tolerated with most adverse events being mild or moderate and transient. The number of headache days were reduced by 1.4 days in the real and 0.2 days in the sham group. Twenty-seven participants completed the open-label 6-month phase, which suggests that this treatment might work for half of the patients. However, larger sham-controlled studies are needed to prove that this treatment really works. GammaCore is also being tested for the treatment of cluster headaches. Although it has not been definitively proven to be effective, it is already being sold in some European countries.

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If you are interested in learning to meditate, but don’t know how to get started, go to Dr. Tara Brach’s website for help. It offers her free weekly podcasts that will guide you through the process. Tara Brach is a psychologist and a buddhist, who after college spent 10 years in an ashram studying yoga and meditation. She has a pleasant voice and her podcasts are full of stories, funny anecdotes and short poems that are sure to inspire you.

My wife and I recently attended Tara Brach’s workshop on “Radical Acceptance” at the Omega Institute in Rhinebeck, NY. There were frequent sessions of guided meditation as well as exercises and Q & A sessions. Many participants had listened to her podcasts for years and came to hear her in person. One of the questions was, how do you maintain a regular meditation practice? Tara’s answer was to meditate daily. If you do not have time for a 20 or 30-minute session, do it for a minute or two. I would also recommend reading books such as Living Fully by Shyalpa Tenzin Rinpoche, Mindfulness by Joseph Goldstein, Peace is Every Step by Thich Nhat Hanh, and Tara’s two excellent books, Radical Acceptance and True Refuge.

Meditation can bring you relief of anxiety, migraine headaches, and many medical conditions that are made worse by stress. It can also make your life more enjoyable.

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A new report presented at the last annual scientific meeting of the American Headache Society in San Diego showed that post-concussion symptoms can be helped by an intravenous infusion of magnesium.

Doctors at the department of neurology at UCLA described six patients with a post-concussion syndrome, who were given an infusion of 2 grams of magnesium sulfate. Three out of six had a significant improvement of their headaches and all had improvement in at least one of the following symptoms: concentration, mood, insomnia, memory, and dizziness.

This was a small study, but it is consistent with other studies that show a drop in the magnesium level following a concussion and also studies in animals that show beneficial effects of magnesium following a head trauma.

Our studies have shown that intravenous magnesium can relieve migraine and cluster headaches in a significant proportion of patients.

Considering how safe intravenous magnesium is and how devastating the effect of a concussion can be, it makes sense to give all patients with a post-concussion syndrome if not an intravenous infusion, at least an oral supplement. I usually recommend 400 mg of magnesium glycinate, which should be taken with food. For faster and more reliable effect, we routinely give patients with migraines, cluster, and post-concussion headaches an infusion of magnesium. Patients who do not absorb or do not tolerate (it can cause diarrhea) oral magnesium, come in to for monthly infusions.

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Should you sleep on the right or on the left side? Researchers led by Dr. Helene Benveniste of Stony Brook University discovered that sleeping on the right side provides better drainage of toxins out of the brain, at least in rats. She presented their findings at the meeting of the American Headache Society in San Diego earlier this month.

The lymphatic system, which has been long known to exist throughout the body, was only recently discovered in the brain. It is called a glymphatic system because brain’s glial cells form this network of draining channels. According to the latest studies, our brain does housekeeping by removing waste products when we are asleep. Insomnia has been associated not only with more frequent migraine headaches, but also with an increased risk for Alzheimer’s disease, which is thought to be at least in part due to accumulation of waste products in brain cells.

When you google sleep positions, many sites recommend sleeping on the left side, but no scientific studies have been done to see which position is more beneficial. The rat study mentioned above suggests that sleeping on either side is better than sleeping on your back or on the stomach. Hopefully, Dr. Benveniste and her colleagues will conduct studies in humans, so that we know how to sleep. For now, whatever position you sleep in, try to get enough sleep every night.

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Medication overuse headache (MOH), which is sometimes called rebound headache, is included in the International Classification of Headache Disorders. However, this is one of several headache types whose existence is still debated. After years of indocrination, most neurologists and headache specialists strongly believe that every drug taken for acute treatment of headaches can cause MOH. However, we have good evidence only for caffeine and for opioid (narcotic) pain medications. It is far from proven in case of triptans (sumatriptan or Imitrex, and other) or NSAIDs (ibuprofen or Advil, naproxen or Aleve, and other).

Last week, I attended the annual scientific meeting of the American Headache Society (AHS) and was happy to see that despite an almost universal acceptance of the diagnosis of MOH, the organizers set up a debate on the existence of MOH. The debaters included two top experts in the field, Drs. Richard Lipton of Montefiore Headache Clinic in the Bronx and Ann Scher of the Uniformed Services University in Bethesda. Dr. Lipton and Scher have collaborated on many research projects and have published many important articles on headaches together, so the debate was friendly and based on facts.

Dr. Scher quoted the American Council on Headache Education, an affiliate of the AHS:

“It is important to know that intake of medications for acute treatment should be limited to less than twice a week. Some methods which can prevent the onset of medication overuse headache include following instructions on how to take medications, avoid use of opioid medications and butalbital combination medications and limit use of simple analgesics to less than 15 days a month and triptans less than 10 days a month”.

And then she posed a question: How many are being harmed vs helped by this advice?

While Dr. Lipton quoted scientific articles supporting the existence of MOH, Dr. Scher’s conclusions reflected my clinical experience that MOH is not a proven entity as it relates to triptans and NSAIDs. I see it only in those who overuse caffeine or caffeine-containing drugs (Excedrin, Fioricet, etc) or narcotic pain killers (Percocet or oxycodone, Vicodin or hydrocodone, and other).

Dr. Scher concluded that, “Since the existence of MOH has not been proven (and may be non-provable for practical purposes), one is obligated to remain agnostic about this entity. And the corollary is that there is no evidence that undertreating will prevent headache frequency progression and may harm more people than help”.

In fact, the same headache experts who limit abortive therapies to twice a week, recommend aggressive abortive therapy for migraines because undertreatment of episodic migraine can lead to its transformation into chronic migraine.

She also indicated that “Quality of evidence for medication withdrawal alone as treatment for MOH is poor” and “Medication withdrawal alone is not clearly better than doing nothing and may be worse”. Meaning that in addition to withdrawal of the acute medication, patients should be given prophylactic treatment.

Studies indicate that after one year, 60% and after two years, 70% of those with chronic migraines (15 or more headache days in a month) revert to episodic ones (less than 15 headache days a month) regardless of treatment. In 15% headaches decrease to less than one a week. This is because fortunately, migraines often improve with time on their own.

We have evidence that Botox injections and some preventive medications can make discontinuation of acute medications easier. We always try to stop Fioricet (butalbital, acetaminophen, and caffeine), Fiorinal (butalbital, aspirin, and caffeine), Excedrin (caffeine, acetaminophen, aspirin) with the help of regular aerobic exercise, biofeedback or meditation, magnesium and other supplements, Botox injections, and sometimes preventive medications.

However, we do have several dozen patients whose headaches are controlled by the daily intake of triptans. These patients have tried given prophylactic medications, Botox injections and other treatments, but find that only triptans provide good relief and eliminate migraine-related disability. The most commented on post on this blog (with 175 comments to date) is one on the daily use of triptans.

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Intravenous magnesium infusions may not be as safe in pregnant women as it has been always thought. The FDA recently moved intravenous magnesium from category A into category D (see category definitions below). This came about after the FDA reviewed 18 cases of babies who were born with serious problems after their mothers received intravenous infusions of large amounts of magnesium for 5 to 7 days in order to stop premature labor. The FDA strongly discourages this practice and states that “Administration of magnesium sulfate injection to pregnant women longer than 5-7 days may lead to low calcium levels and bone problems in the developing baby or fetus, including thin bones, called osteopenia, and bone breaks, called fractures.”

However, treatment of choice for eclampsia remains intravenous magnesium. Eclampsia, one of the most serious complications of pregnancy can be treated only with high doses of intravenous magnesium. Without intravenous magnesium eclampsia can lead to epileptic seizures, very high blood pressure, kidney failure and death.

The FDA also recommends that “Magnesium sulfate injection should only be used during pregnancy if clearly needed. If the drug is used during pregnancy, the health care professional should inform the patient of potential harm to the fetus.”

We do treat many patients, including pregnant women, with intravenous infusions of magnesium if they are deficient in magnesium and if their migraines respond to such infusions. Typically, these infusions are given monthly and the amount is only 1 gram, while for preterm labor the dose is 4-6 grams to start and then 2-4 grams an hour as needed. This monthly dose of 1 gram is extremely unlikely to cause any adverse effects. We find that migraines triggered by magnesium deficiency do not respond well to any other treatments and considering the risk of drugs, it is much safer to administer 1 gram of magnesium. This amount of magnesium just corrects the deficiency and does not cause very high magnesium levels, which can be detrimental.

Several other drugs routinely used in pregnancy may also not be as safe as we thought. Acetaminophen (Tylenol) has been considered one of the safest choices. However, recent evidence suggests possible link to attention deficit disorder with hyperactivity (ADHD).

Butalbital, which is an ingredient in the popular headache drugs such as Esgic, Fioricet and Fiorinal is associated with an increased risk of congenital heart defects. Fioricet also contains caffeine, which has negative effects on the fetus and which can cause rebound (medication overuse) headaches.

FDA drug categories in pregnancy

Category A
Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).
Example drugs or substances: levothyroxine, folic acid, liothyronine

Category B
Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.
Example drugs: metformin, hydrochlorothiazide, cyclobenzaprine, amoxicillin, pantoprazole

Category C
Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Example drugs: tramadol, gabapentin, amlodipine, trazodone, prednisone

Category D
There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.
Example drugs: topiramate (Topamax), divalproex sodium (Depakote), lisinopril, alprazolam, losartan, clonazepam, lorazepam

Category X
Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

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Yoga is the most impactful import from India to the US. Yoga has many documented health benefits, including relief of headaches. I have been practicing Bikram yoga about twice a week for nearly 12 years. About a year ago I started having some neck and left upper back pain. I thought that strengthening neck exercises, meditation, occasional massage, which is what I recommend my patients, would eliminate the pain (I probably should have also gone for physical therapy). The pain was never severe and would temporarily improve with massage, but because it persisted and became annoying, I decided to try chiropractic.

Many doctors’ attitude towards chiropractors is dismissive, disdainful or worse. When I tried to google the number of chiropractic manipulations done in the US, the first item that popped up was Medscape’s Deaths After Chiropractic: A Review of Published Cases (there were 26 cases in that report). I have personally treated an elderly patient who developed a subdural hematoma (bleeding inside the head) after chiropractic manipulation. My usual advice to patients has been to go for physical therapy and massage instead of chiropractic. If a patient really wants to see a chiropractor, I advise asking not have any high velocity adjustments. This adjustment is done by suddenly turning and lifting your head to one side and it is responsible for most of the complications. I also tell patients that a good chiropractor will always give you exercises to do, while those who don’t, just want you to keep coming for adjustments for years. Many people feel immediate relief from chiropractic, but it lasts only a few days and they have to go back for another treatment. In fact, regular stretching done by a chiropractor can loosen the ligaments around the cervical spine and cause habitual subluxation of the joints. Subluxation is a partial joint misalignment, which a chiropractor can fix, but repeated adjustments stretches the ligaments and make it easier for the joint to misalign again.

So, why did I take a chance with my neck if not life? First, I wanted to experience what a chiropractic manipulation is like (I’ve also tried Botox, intravenous magnesium, TMS stimulation, and other treatments I offer my patients). Second, I ran into (or rather gave a TV interview to) Lou Bisogni, a chiropractor who is the chiropractor for the New York Yankees. If Joe Torre, Yogi Berra, Wade Boggs, Derek Jeter, and other top Yankee players (dozens of their signed photos are on the office walls) have been entrusting their bodies to him, then obviously he must be very good.

Because my pain has lasted for almost a year, Bisogni first X-rayed my neck. I was not surprised to see that my C5-6 cervical disc was mildly degenerated and the C5 vertebra slipped slightly forward over the C6. This misalignment was what must have prevented my pain from going away. Treatment of such mild misalignments is what chiropractors are probably best at. I did tell him that I did not want high velocity adjustments and he reassured me that he wasn’t going to do any. Many chiropractors are fully aware of the risks and do avoid this type of adjustment. Instead, Bisogni would first apply TENS (transcutaneous electric nerve stimulation – an old technique often used by physical therapists as well), ultrasound, or massage, followed by a brief and gentle adjustment. The adjustment was so gentle and brief (5 minutes or so) that I was a bit skeptical about its efficacy. But to my surprise, after 5 – 6 sessions my pain dramatically improved. It is not completely gone, so I will go for a few more sessions.

I did cut back on Bikram yoga to once a week (but added some weight training instead) and modified my routine when I do it. It is possible that extreme flexion and extension of my neck, which is part of some yoga positions (rabbit, camel, pranayama breathing), might have caused my neck problem. So, I avoid flexing and extending my neck all the way as far as I can. Many yoga instructors push their students to achieve a full expression of the pose, but if your neck hurts or feels uncomfortable, tell the instructor that you’d rather not take a chance with your neck. You should definitely avoid head stands (unless you can do them without putting any pressure on your head and support yourself on the forearms) and shoulder stands, which put excessive pressure on your cervical spine. Also, the high heat in Bikram studios can be a headache trigger for some migraine sufferers and I usually recommend to my patients doing yoga at room temperature.

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I have not been aware of any research indicating a link between salt intake and migraines. A study just published in the journal Headache by researchers at Stanford and UCLA looked at this possible connection.
This was a national nutritional study that examined sodium intake in people with a history of migraine or severe headaches.

The study included 8819 adults with reliable data on diet and headache history. The researchers classified respondents who reported a history of migraine or severe headaches as having probable history of migraine. They excluded patients with medication overuse headache, that is people who were taking pain medications very frequently. Dietary sodium intake was measured using estimates that have been proven to be reliable in previous studies.

Surprisingly, higher dietary intake of sodium was associated with a lower chance of migraines or severe headaches. This relationship was not affected by age or sex. In women, this inverse relationship was limited to those with lower weight (as measured by body mass index, or BMI), while in men the relationship did not differ by BMI.

This study offered the first scientific evidence of an inverse relationship between migraines and severe headaches and dietary sodium intake.

It is very premature to recommend increased sodium intake to all people who suffer from migraines and severe headaches. However, considering that this is a relatively safe intervention, it may make sense to try increased salt intake. I would suggest adding table salt to a healthy and balanced diet, rather than eating salty foods such as smoked fish, potato chips, processed deli meats, or pickles. These foods contain sulfites, nitrites, and other preservatives which can trigger a migraine attack.

People with high blood pressure and kidney or heart disease need to consult their doctor before increasing their salt intake.

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Caffeine is a well-know trigger of migraine headaches and I regularly write on this topic (my last post on this topic – caffeine causing headaches in adolescents – was three years ago). Caffeine can help migraines and other headaches, but in large amounts it worsens them due to caffeine withdrawal, which can occur in as little as 3 hours after the last cup of coffee. One of my patients was an extreme case. He told me that he figured out that his early morning migraines were due to caffeine withdrawal and he would set his alarm clock for 4 AM, so that he could wake up, drink some coffee and go back to sleep without the fear of a morning headache. A continuous intravenous drip of caffeine would also solve his problem. Most people opt for stopping caffeine, albeit it can be a difficult process. Going cold turkey is often easier than a gradual reduction in caffeine intake. To avoid severe withdrawal, prescription migraine drugs, such as sumatriptan (Imitrex), intravenous magnesium, nerve blocks and other interventions may be necessary in a small percentage of patients.

This post was prompted by a just published study that showed a higher risk of miscarriages in couples where either partner, male or female consumed more than 2 caffeinated beverages prior to conception. Caffeine has been long suspected but not definitively proven to increase the risk of miscarriages in women who drink large amounts of caffeine during pregnancy, but what is surprising is that consumption of caffeine by the male partner also increases the risk.

At the same time, recent studies widely publicized in the press have shown beneficial effects of consuming large amounts of caffeine. Caffeine supposedly lowers the risk of certain cancers, strokes, diabetes, and other conditions. However, if you suffer from headaches, heart burn due to reflux, or are trying to conceive, caffeine should be avoided.

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Ketamine is a sedating agent used to induce anesthesia. It is also a drug of abuse with street names such as “Special K” or “Ket”.

Ketamine has many advantages, which makes it a very popular choice in anesthesia. It works fast, blocks pain, opens the lungs, it is easy on the heart, and has anti-inflammatory properties. It may also have anti-cancer properties. Ketamine is being extensively tested for the treatment of depression that does not respond to medications.

Because ketamine works on a receptor involved in transmitting pain messages in the brain (NMDA receptor), it has been studied in various painful conditions. The amounts being tested for pain are much smaller than those used to induce anesthesia or even those used recreationally.

Even though it is a drug of abuse, it appears to be less addictive than heroine and prescription narcotics.

There are only few small studies and reports about the use of ketamine for migraine headaches. One such report published in the leading neurological journal Neurology describes 18 patients with prolonged migraine auras who were treated with intranasal ketamine spray. The duration of their auras was not shortened by ketamine, but the severity was reduced.

Another study showed that severe disabling aura was relieved in 5 out of 11 patients with hemiplegic migraine.

Several anecdotal reports have touted the benefits of ketamine in chronic migraines, cluster headaches, and chronic paroxysmal hemicrania (a rare type of headache that often responds to indomethacin and at times to Botox). While such anecdotal reports are useful, we need to have controlled trials to make sure that placebo effect is not playing a major role. There is nothing wrong with utilizing the placebo effect, but only if the treatment is completely benign. Unfortunately, ketamine like any other drug can have potentially serious side effects. This is why before treating pain with ketamine intravenously patients must be screened for possible heart disease or psychiatric disorders such as schizophrenia. While intranasal ketamine can be given in an office setting, intravenous administration must be done under close monitoring. Another issue is the cost since insurance companies do not cover this treatment because it is considered experimental.

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A patient of mine just emailed me about a recent segment of the TV show, The Doctors, which featured a woman whose severe chronic migraines were cured by nasal surgery. The segment was shot a few weeks after the surgery, so it is not clear how long the relief will last in her case. The surgery involved removing a contact point, which occurs in people with a deviated septum. The septum, which consists of a cartilage in the front and bone in the back, divides the left and the right sides of the nose. If the bony septum is very deviated, which often happens from an injury, it sometimes touches the side of the nose, creating a contact point between the septum and the bony side wall of the nose.
contact point headache
Several small reports by ENT surgeons have described dramatic relief of migraine headaches with the removal of the contact point. If headaches are constant, then the constant pressure of the contact point would explain the pain. However, many of the successfully treated migraine sufferers had intermittent attacks. The theory of how a contact point could cause intermittent migraines is that if something causes swelling of the mucosa (lining) of the nasal cavity, then this swelling increases the pressure at the contact point and triggers a headache. This swelling can be caused by nasal congestion due to allergies, red wine, exercise, and possibly other typical migraine triggers.

This is a good theory, but it is only a theory and the dramatic relief seen after surgery could be all due to the placebo effect. The only way to prove that contact point headaches exist and can be relieved by surgery is by conducting a double-blind study, where half of the patients undergoes surgery and the other half does not. Giving both groups sedation and bringing them to the operating room will blind the patient while the neurologist who evaluates them will also not know who was operated on and who was not, making this a double-blind study. This design is also good only in theory because those who had surgery will have bloody nasal discharge and nasal packing, thus breaking the blind.

However, despite the fact that we will not see any double-blind studies in the near future, there is one way to predict who may respond to contact point surgery. An ENT surgeon can spray a local anesthetic, such as lidocaine, around the contact point during a migraine attack and if pain goes away, then surgery is more likely to help. I would not recommend anyone having surgery without such a test.

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Marijuana has been tried for a variety of medical conditions, including migraines, and in one of my previous post I mentioned dangers of smoking it. Medical marijuana does not have the same dangers since it is not smoked.

A study just published in the journal Pharmacotherapy involved 121 adults with migraine headaches who were treated with medical marijuana. The number of migraine headaches per month decreased from 10.4 to 4.6 with the use of medical marijuana. Most patients used more than one form of marijuana and used it daily for prevention of migraine headache. Positive results were reported by 48 patients (40%), with the most common effects being prevention of migraine headache and the second most common effect, aborted migraine attacks. Inhaled forms of marijuana were commonly used for acute migraine treatment and were reported to abort migraine headache. Side effects were reported in 14 patients (12%); the most common side effects were somnolence (2 patients) and difficulty controlling the effects of marijuana related to timing and intensity of the dose (2 patients), which were experienced only in patients using edible marijuana. Edible marijuana was also reported to cause more side effects compared with other forms. The authors concluded that the frequency of migraine headaches was decreased with medical marijuana use.

New York state just approved medical marijuana for ingestion by mouth or breathing in vapors. Medical marijuana is approved in NY for several medical conditions, including neuropathic pain, but not migraines. However, many migraine sufferers also have severe neuropathic pain over the scalp and neck. This pain is caused by irritation of the trigeminal and/or occipital nerves and manifests itself as burning or sharp and shooting sensation. To be able to prescribe medical marijuana doctors have to take a 4-hour online course. After taking this course, as I’ve discovered, it is not that simple to issue a prescription. It is done through a New York State website and requires a lot of detailed information. The patient also has to register with the State in order to be able to buy medical marijuana from the approved dispensaries. The dispensaries offer ingestible and vaporized forms of marijuana with a certain ratio of cannabidiol (CBD) and tetrahydrocannabinol (THC).

Pure cannabidiol was just shown to reduced seizures by one-third in patients with intractable epilepsy, that is epilepsy that does not respond to usual epilepsy medications. This was the largest trial of its kind conducted by a group of neurologists led by Dr. Orrin Devinsky of NYU School of Medicine. The true efficacy and safety of the drug is now being evaluated in a double-blind trial, currently under way. THC is responsible for the psychoactive effects of the drug, while CBD does not cause such effects. Pure CBD (Epidiolex) is available only for the treatment of two rare conditions of childhood. The same company also makes Sativex, which is a 50-50 mixture of THC and CBD, and is approved in Europe and Canada for treatment of spasms in multiple sclerosis.

It is possible that pure cannabidiol will also be effective for pain and migraines without causing psychotropic side effects which are caused by THC.

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There has been some backlash against meditation with newspapers publishing articles claiming that meditation is overrated. Fortunately, serious scientists continue to publish solid objective data proving that meditation not only relieves pain and headaches and makes you feel better, but in fact changes the structure of your brain. In my recent post I wrote about one such a study published in the Journal of Neuroscience.

A new rigorous scientific study was just published in Biological Psychiatry. It looked at the benefits of mindfulness meditation and how it changes people’s brains and potentially improves the overall health.

The study was conducted at the Health and Human Performance Laboratory at Carnegie Mellon University.

The researchers recruited 35 unemployed men and women who were looking for work and were under significant stress. Half of the people were taught mindfulness meditation at a residential retreat center, while the other half were provided sham mindfulness meditation, which involved relaxation and distraction from worries and stress.

All participants did stretching exercises, but the mindfulness group was asked to pay attention to bodily sensations, including unpleasant ones. The relaxation group was encouraged to talk to each other and ignore their bodily sensations.

After three days, all participants felt refreshed and better able to deal with the stress of unemployment. However, follow-up brain scans showed changes only in those who underwent mindfulness meditation. The scans showed more activity among the portions of their brains that process stress-related reactions and other areas related to focus and calm. By four months after the retreat most people stopped meditating, however the blood of those in mindfulness meditation group had much lower levels of interleukin-6, a marker of harmful inflammation, than blood of those in the relaxation group.

These changes occurred after only 3 days of meditation. It is likely that an ongoing meditation practice will produce stronger positive effects. Personally, I try to meditate 30 minutes on at least 5 days a week and this is what I recommend to my patients. Even 10 or 20 minutes can have an impact on migraine headaches and general well being.

There are several excellent resources for learning meditation. Free podcasts by a psychologist Tara Brach is an excellent resource. My favorite book to learn meditation is Mindfulness in Plain English by B. Gunaratana. And of course, there is an app for that – and

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Prilosec (omeprazole), Nexium, Prevacid, and other similar drugs in the family of proton pump inhibitors (PPIs) can cause headaches directly, but more often by reducing the absorption of vitamins such as B12 and D, and minerals such as magnesium, over a longer period of time. My previous post described a 26,000 patient study that convincingly showed that PPIs cause vitamin B12 deficiency. We also know that older women on PPIs have a higher risk of bone fractures.

A report just published in JAMA Neurology adds another dangerous association. This was also a very large study that involved over 73,000 older people, of whom almost 3,000 were taking PPIs. Those on PPIs had a significantly higher risk of developing dementia. This is possibly due to a direct toxic effect of these drugs, but more likely it is because these drugs cause vitamin and mineral deficiencies.

Three month earlier, the same journal published a study that showed that low vitamin D levels are associated with a significantly higher risk of developing dementia. A very important finding of this study was that even those who had what is considered a normal vitamin D level of between 30 and 50 had an increased risk of dementia, compared with those whose level was above 50. This is not surprising because a study of multiple sclerosis (MS) showed that those with low normal levels had many more attacks of MS than those who had high normal levels. Vitamin D seems to protect from many other diseases and to prolong life.

Many doctors will often tell you that your vitamin D level is normal if it is above 30, but you should ask what your actual level is and try to get it up to at least into 40s or 50s. The upper limit of normal is 100 (level higher than 125 can be harmful). This may require you taking 5,000 or more a day. Our government’s recommended daily requirement of 600 units is insufficient for most people. The same applies to vitamin B12 – many labs will consider a level between 200 to 1,100 to be normal, but in fact it should be at least 400.

If you take PPIs, try to get off them, which is not an easy task. Stopping such drug causes “rebound” increase in acid secretion, which makes symptoms worse than they were before PPI was started. The way to do it is to switch ot Zantac or Pepcid with antacids taken as needed. Then, you try to stop Zantac and keep taking antacids. After a while, with proper diet, you may be able to stop antacids as well.

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Treatment of medical conditions with electricity was first used by the ancient Romans who used electric eels to treat headaches, gout and in obstetrics.

Electric shock therapy for depression was one of the earliest widespread uses of electricity in medicine and it continues to be used successfully, although with some modifications to reduce side effects. Transcutaneous electric nerve stimulation (TENS) has been shown to relieve pain of neuromuscular disorders (back, muscle and joint pains) as well as headaches (see my blog post on Cefaly). While TENS uses alternating current, direct current has also been widely utilized in treating various conditions, including migraines.

Despite billions of dollars spent on research, there has been very little progress in developing more effective therapies for glioblastomas, the most common and the deadliest form of malignant brain tumor. The standard therapy for glioblastoma has consisted of surgery, radiation, and chemotherapy.
In October of last year, the FDA approved the use of the Novocure Tumor Treating Fields system for the treatment of patients with newly diagnosed glioblastoma. This device delivers alternating electric fields through scalp electrodes to the tumor, interrupting cell division. The addition of the electrical stimulation to chemotherapy increased progression-free survival to 7.1 months, compared to 4.2 months in the group who received chemotherapy alone. There was also an increase in overall survival from 16.6 to 19.4 months. Living three months longer does not seem like a lot, but chemotherapy and radiation, which cause severe side effects, are not much more effective. There is hope on the horizon, however. Several companies are developing vaccines to treat glioblastoma. In one small trial half of the patients survived for 5 years. Northwestern Therapeutics is another company with a similar promising approach in using vaccines derived from patients’ own tumor cells to treat their tumor.

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Asthma is more common in migraine sufferers and migraine is more common in those who suffer from asthma (the medical term is co-morbid conditions). A new study published in Headache examines a possible connection between asthma and chronic migraine. Migraine is considered chronic if headache occurs on 15 or more days each month.

This co-morbidity between migraine and asthma is thought to be due to the fact that both conditions involve inflammation, disturbance of the autonomic nervous system, and possibly shared genetic and environmental factors. What is not mentioned in the report is the fact that intravenous magnesium can relieve both an acute migraine (in up to 50% of migraine sufferers who are deficient in magnesium) and a severe asthma attack. This suggests another possible explanation for the co-morbidity. Magnesium deficiency may also explain, at least in part, co-morbidity between migraine and fibromyalgia and vascular disorders.

The Headache report was one of many based on the outcomes of the large and long-term American Migraine Prevalence and Prevention study (AMPP). Study participants had to meet criteria for episodic migraine in 2008, complete an asthma questionnaire in 2008, and provide follow-up information in 2009. The researchers counted the number of these patients who developed chronic migraine a year later. The sample for this study included 4446 individuals with episodic migraine in 2008 of whom 17% had asthma. The mean age was 50 and 81% were female. In 2009, of the patients who had episodic migraines and asthma, 5.4% developed chronic migraine, compared to only 2.5% of those without asthma. So, having asthma doubles the risk of episodic migraine becoming chronic within a year. There was also a correlation between the severity of asthma and the risk of developing chronic migraine.

What we don’t know is whether aggressive treatment of asthma and migraines will reduce the risk of chronification of migraines. It is also possible that simple magnesium supplementation may have a protective effect.

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Magnesium deficiency is a regular topic on this blog. Up to half of migraine sufferers are deficient in magnesium, but magnesium levels are rarely checked by doctors. Even when magnesium level is checked, it is usually the serum level, which is totally unreliable. The more accurate test is RBC magnesium or red blood cell magnesium because 98% of body’s magnesium resides inside cells or in bones. At the New York Headache Center we often don’t bother checking even the RBC magnesium level, especially if other signs of magnesium deficiency besides migraines are present. These include coldness of hands and feet or just always feeling cold, leg muscle cramps, palpitations, anxiety, brain fog, and in women, premenstrual syndrome or PMS (bloating, breast tenderness, irritability). For these patients we recommend daily magnesium supplementation and sometimes monthly magnesium infusions.

About 20 to 30 million women suffer from moderate or severe PMS, and a recent study published in the American Journal of Epidemiology indicates that having PMS increases the risk for hypertension (high blood pressure) later in life.

This study was done at the University of Massachusetts, Amherst and it involved 1,260 women who suffered from moderate or severe PMS as well as more than 2,400 women with mild or no PMS. Women with moderate or severe PMS were 40 percent more likely to develop high blood pressure than those with mild or no PMS symptoms. The researchers adjusted the risk for other risk for hypertension, such as being overweight, smoking, drinking, inactivity, use of birth control pills, postmenopausal hormone use, and family history of high blood pressure.

The association between moderate or severe PMS and high blood pressure was most pronounced among women younger than 40, who were three times more likely to develop hypertension.

Interestingly, the risk of high blood pressure was not increased in women with moderate or severe PMS who were taking thiamine (vitamin B1) and riboflavin (vitamin B2). Other researchers found that women who consumed high levels of those vitamins were 25 to 35 percent less likely to develop PMS.

Unfortunately, the researchers did not look at magnesium levels or magnesium consumption in these women. A strong association exists between magnesium deficiency and high blood pressure. There is also an association between an increased magnesium (and potassium) intake and reduced risk of strokes. Supplementation with magnesium during pregnancy decreases the risk of hypertension during pregnancy. There is also a strong association between magnesium and depression.

There are literally hundreds of scientific articles on beneficial effects of magnesium, but unfortunately magnesium remains ignored by mainstream physicians. However, consumers are ahead of most doctors and many do take magnesium supplements. This is helped by many print and online articles and many books. Some of these books include Magnificent Magnesium, Magnesium Miracle, Magnesium – The Miraculous Mineral of Calm, and my two books – The Headache Alternative: A Neurologist’s Guide to Drug-Free Relief and What Your Doctor May Not Tell You About Migraines.

Migralex is a product I patented and developed for the treatment of headaches. It contains an extra-strength dose of aspirin and magnesium. Magnesium in Migralex acts as a buffering agent and reduces the risk of stomach irritation by aspirin. Migralex is available at CVS stores,, and

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Meditation is growing in popularity and deservedly so. Several of my previous posts mentioned the benefit of meditation in migraine headaches. Scientists are conducting rigorous studies that repeatedly show the profound effect meditation has on the brain. The most recent study was done at the Wake Forest Baptist Medical Center and it compared the effect of meditation and placebo on pain.

The study was published in the recent issue of the Journal of Neuroscience. It showed that mindfulness meditation not only provided greater pain relief than placebo, but the brain scans could differentiate patterns of brain activity during meditation from that induced by placebo.

The study involved seventy five healthy, pain-free volunteers who were randomly assigned to one of four groups: mindfulness meditation, placebo meditation (“sham” meditation), placebo analgesic cream or control.

Pain was induced by heat applied to the skin. The mindfulness meditation group reported that pain intensity was reduced by 27 percent and the emotional aspect of pain (how unpleasant it was) by 44 percent. In contrast, the placebo cream reduced the sensation of pain by 11 percent and emotional aspect of pain by 13 percent.

Mindfulness meditation reduced pain by activating brain regions associated with the self-control of pain while the placebo cream lowered pain by reducing brain activity in pain-processing areas.

Another brain region, the thalamus, was deactivated during mindfulness meditation, but was activated during all other conditions. This brain region serves as a gateway that determines if sensory information is allowed to reach higher brain centers. By deactivating this area, mindfulness meditation may have caused signals about pain to simply fade away, said Dr. Zeidan, one of the researchers.

Mindfulness meditation also was significantly better at reducing pain intensity and pain unpleasantness than the placebo meditation. The placebo-meditation group had relatively small decreases in pain intensity (9 percent) and pain unpleasantness (24 percent). The study findings suggest that placebo meditation may have reduced pain through a relaxation effect that was associated with slower breathing.

This study is the first to show that mindfulness meditation does not relieve pain the way placebo does. This study confirms previous observations that as little as four 20-minute daily sessions of mindfulness meditation could enhance pain treatment. Another study has shown that an 8-week course of mindfulness meditation not only relieved pain but also made certain parts of the brain cortex measurably thicker.

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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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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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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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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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Ayurvedic medicine has many healthy aspects. However, a recent story on NPR described the risks involved with the traditional Ayurvedic medicines from India. A very high percentage of Ayurvedic supplements in the category called bhasmas sold in the US contains large amounts of lead and other toxic elements. There is a lot more to Ayurvedic medicine than these supplements, so it is important to separate dangerous parts from things like healthy diet, yoga, and other.

Unfortunately, the US government does not regulate supplements, so there is always a question of safety of these products, especially those made outside the US. The one exception is products made in Germany, where supplements are as strictly regulated as drugs (please note that Petadolex, a butterbur product is made in Germany, but is not allowed for sale there). Many patients ask me about not only Indian but also Chinese herbal medicines, which are often combined with acupuncture and other treatment methods. As a rule, I recommend avoiding products made in China or India, where quality controls are very poor. Instead, you should buy products made by major US manufacturers, although they do not make many traditional Chinese and Indian products. However, you cannot always count on products sold in major US store chains either – recently, herbal products sold at Walgreens, WalMart, Target and GNC were found to have no active ingredients. Thankfully, there were no toxic ingredients in those products.

The largest mass poisoning with a Chinese herbal dietary weight loss product occurred in Europe where 18 patients developed kidney failure and urinary cancer.

In summary, no matter how promising a Chinese or an Indian herbal product may sound, it is not worth the risk.

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Several presentations at the annual meeting of the American Headache Society held in Washington DC last weekend discussed the treatment of post-concussion symptoms in children (everything below also applies to adults). Among many topics, the speakers addressed the question of aerobic exercise after the concussion. Most experts agree that starting physical exercise too early can worsen the symptoms and delay recovery. At the same time, because aerobic exercise has so many benefits for the brain, it is prudent to begin aerobic exercise 2 to 4 weeks after the concussion. The child should begin exercising for short periods of time and at low intensity. Exercise should be stopped as soon as symptoms, such as headache or dizziness worsen. Brisk walking could be the first activity to be tried. The ideal duration is about 30 minutes and when this goal is achieved, the intensity of exercise can be gradually increased.

As far as the very common cognitive problems after a concussion, the experts also agreed that complete cognitive rest is not helpful. Just like with physical exercise, it is best to begin mild activities, such as reading for pleasure, and then slowly increase the load, as tolerated.

Several scientific presentations reported that the most common type of headaches that occurs after a concussion is migraine. When these post-concussion migraines last for more than 3 months and occur on more than 15 days each month, they are considered to be chronic migraines.

The treatment of post-concussion chronic migraines is the same as the treatment of chronic migraines that occur without a concussion. These treatments may include cognitive behavioral therapy, biofeedback, magnesium and other supplements (magnesium deficiency is found in up to 50% of migraine sufferers and magnesium is depleted by trauma), various preventive medications, and Botox injections.

Although the FDA has not yet approved Botox injections for the treatment of chronic migraines in children, Botox is safer than most drugs. We know about the safety of Botox in children because it has been widely used even in very young children who suffer from cerebral palsy and are unable to walk unless their stiff leg muscles are relaxed by Botox. Botox was approved by the FDA 26 years ago and some kids have been getting injections for over 20 years and so far there have been no long-term side effects observed.

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Transcranial magnetic stimulation (TMS) was approved by the FDA at the end of 2013 (see my earlier post) but it has not yet become available. This approval was for the treatment of acute migraine.

A new study just presented at the International Headache Congress suggests that TMS could be effective for the preventive treatment of migraines with medication overuse headache.

The study included only 28 patients and it was not a blinded study. However, these patients were severely affected and failed several other treatments. They were instructed to use the TMS device twice a day every day with an additional treatment at the time of a headache. Treatment lasted for at least 3 months, with an option to continue for another 3 months.

Of the 28 patients, 24 (86%) reported a reduction in their days of acute medication use per month, while 2 patients reported an increase in acute medication use. Nineteen patients (68%) experienced fewer migraine days per month, and 7 of the 19 had a 50% or greater reduction in migraine days. The number of patients with pain severity rated as excruciating or severe dropped from 19 at baseline to 3 at 3 months (84% reduction). Headache attack duration decreased in 15 patients, remained unchanged in 9, and increased in 4. The disability score (HIT-6) was severe at the beginning of the study in 26 of 28 participants. After 3 months, only 18 had severe disability.

The benefit was seen in patients who had migraines with and without aura.

After 3 months, five patients stopped using TMS because it was ineffective or inconvenient. Four were lost to follow-up. Of the remaining 19, 16 reported reduced days of acute medication use at 6 months, compared with baseline. Disability scores in the 19 patients who used TMS for 6 months were comparable to their scores at 3 months, suggesting that there was no additional benefit from longer-term use, but the benefit was maintained.

No side effects were reported, confirming the safety of TMS. Now we just have to wait for the company (eNeura) to release this product on the market.

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Another supplement to consider for the preventive treatment of migraine headaches is diamine oxidase (DAO). It is an enzyme that breaks down histamine.

Histamine is released during an allergic reaction and is present in many foods. It is one of the neurotransmitters that is involved in the process of migraine. A quarter of the population has insufficient amounts of DAO, which leads to inefficient metabolism of histamine. The largest amounts of DAO in the body are found in the intestines and the kidneys.

A group of Spanish neurologists published a study that showed that of 137 patients with migraines, 119 (87%) showed impaired activity of the enzyme.

The normal enzyme activity is a score of at least 80 histamine-degrading units [HDU]/mL. In a survey which was conducted in 2006 and again in 2012, migraine symptom scores correlated with enzyme activity. Symptom scores rose progressively as enzyme activity dropped below 80 HDU/mL, with scores almost twice as high in the 30-40 HDU/mL range compared with enzyme activity >80 HDU/mL.

Dr. Izquierdo and his colleagues in Barcelona conducted a double-blind, placebo-controlled trial of DAO oral supplementation, for the prevention of migraines in patients with DAO activity less than 80 HDU/mL.

Participants were men or women age 18 to 60 years old with an attack within the previous 6 months. Most of the patients were women, with only 8 men in each group.

The supplement contained 4.2 mg of DAO which participants took with a glass of water before breakfast, lunch, and dinner. The supplement was associated with a similar reduction in the mean number of attacks per month in the placebo and DAO groups, but the group that took DAO used significantly fewer triptan drugs (such as sumatriptan, Imitrex). These results are not overwhelming, but they possibly hide the fact that some of these patients had a very good response while others had none, which averaged out to a modest benefit. Considering that this a very benign supplement with no potential for serious side effects (unlike prescription drugs), it may be worth trying.

Histamine intolerance is defined by an imbalance of histamine and the histamine degrading enzyme diamine oxidase (DAO), which is mainly produced in the small intestine. Excessive amounts of histamine in the body can cause not only migraine and other types of headaches, but also diarrhea, nasal congestion, asthma, rashes, and other symptoms. People who are prone to severe allergic reactions with anaphylactic shock often have lower DAO activity. Diamine oxidase activity can be measured in blood, but the test is expensive and not very reliable. Instead of doing this test, try a low histamine diet or taking a DAO supplement. This is particularly worthwhile for people who in addition to migraines suffer from colitis (such as Crohn’s), allergic conditions, asthma, and celiac disease.

Here is an informative post on this topic on The Daily Headache blog.

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Tension headaches can be prevented, or at least made milder by strength training, according to a new Danish study just published in the journal of the International Headache Society, Cephalalgia.

Tension-type headache is the most common type of headaches and it is usually accompanied by increased muscle tenderness.

The researchers compared muscle strength in neck and shoulder muscles in 60 patients with tension-type headaches and 30 healthy controls, using rigorous strength measurement techniques. Patients were included if they had tension-type headaches on more than 8 days per month and had no more than 3 migraines a month. Compared to controls headache patients had significantly weaker muscle strength in neck extension, which helps keep the head straight. Headache patients also showed a tendency toward significantly lower muscle strength in shoulder muscles. Among the 60 headache patients, 25 had frequent headaches and 35 had chronic tension-type headaches (defined as occurring on 15 or more days each month).

The use of computers, laptops, tablets, and smart phones has increased in recent years and this may increase the time people are sitting with a forward leaning head posture, which contributes to neck muscle weakness.

Neck pain and tenderness is a common symptom in both tension-type and migraine headache sufferers.

This is not the first study to show that muscle strength and weakness were associated with tension-type headaches, but it is still not clear whether the muscle weakness is the cause or the effect of headaches. Neck and shoulder strengthening exercises have been shown to reduce neck pain in previous studies and in my experience strengthening neck muscles will often relieve not only tension-type headaches, but also migraines. So it is most likely that there is not a clear cause-and-effect relationship, but a vicious cycle of neck pain causing headaches and headaches causing worsening of neck pain and neck muscle weakness.

Physical therapy can help, but the mainstay of treatment is strengthening neck exercises. Here is a YouTube video showing how to do them. The exercise takes less than a minute, but needs to be repeated many times throughout the day (10 or more). Many people have difficulty remembering to do them, so using your cell phone alarm can help. Other treatment measures include being aware of your posture when sitting in front of a computer or when using your smart phone, wearing a head set if you spend long periods of time on the phone, doing yoga or other upper body exercises, in addition to the isometrics.

Sometimes pain medications or muscle relaxants are necessary, while for very severe pain, nerve blocks and trigger point injections can help. Persistent neck pain can respond to Botox injections. When treating chronic migraines with Botox, the standard protocol includes injections of neck and shoulder/upper back muscles. Here is a video of a typical Botox treatment procedure for chronic migraines.

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A topical cream seems to be effective in treating migraine headaches. Achelios Therapeutics announced results from a Phase IIa placebo-controlled clinical trial in moderate and severe migraine sufferers treated with Topofen, the company’s proprietary topical anti-migraine therapy. This is a well-known non-steroidal anti-inflammatory drug (NSAID) ketoprofen, which is applied to the face and seems to provide relief for patients suffering from acute migraine.

The results of the clinical trial were presented at the American Academy of Neurology annual meeting in Washington, D.C. Surprisingly, this study showed that it may be possible to relieve severe migraine with a topical application to facial nerve endings. Topical application avoids potentially serious side effects of NSAIDs, such as stomach bleeding and ulcers. The randomized, crossover, double-blind, placebo-controlled study involved only 48 adults with a history of episodic migraine with and without aura. Of the severe migraine patients, 77 percent experienced relief of pain and migraine-associated symptoms and 45 percent had sustained pain relief from two to 24 hours compared to 15 percent on placebo. Also, 50 percent of patients who treated their severe pain with Topofen were pain free at 24 hours compared to 25 percent of placebo-treated patients. Some patients experienced application-site irritation, which was mild or moderate in severity. That was the only reported side effect, which resolved quickly.

Such a small study does not prove that this treatment is in fact effective. A typical drug trial required for an FDA approval usually involves hundreds of patients. However, you do not need to wait for this cream to appear on the market because there are creams containing an NSAID already available by prescription (Voltaren Gel) and over-the-counter (Aspercreme). It is possible that the cream tested in the study may be better because it is a different NSAID, but Voltaren Gel is already approved and you can ask your doctor for a prescription. It is possible that insurance companies will not pay for it since it is not approved for migraines. A tube of Voltaren Gel will cost you about $55 (go to to get the lowest price).

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Low vitamin D level predicts larger stroke size and poor outcome, according to a new study by University of Massachusetts researchers. They examined data on 96 consecutive patients with stroke and found a strong inverse correlation between the level of vitamin D and the size of the stroke. This is not surprising since vitamin D seems to be very important for the normal functioning of the nervous system. In a previous post I mentioned a study that showed an inverse correlation between vitamin D level and relapses of multiple sclerosis. Such correlation has been also found with migraine headaches and other major diseases.

Yes, all these studies are correlational and do not prove that taking vitamin D will prevent any of these conditions. But there is no evidence at all that taking vitamin D to maintain your blood level in the normal range has any side effects.

The stroke study was done only in caucasian patients and we know that blacks may need lower levels of vitamin D than caucasians, at least as measured by the standard blood test. This test is not very reliable since it measures the total level of vitamin D, while only the free portion of it is biologically active. To be safe, try to aim to have vitamin D level at least in the middle of normal range, which is from 30 to 100. Many people take the recommended 400 unit dose of vitamin D, but still have low levels in their blood. It is important to check your vitamin D level even if you are taking a supplement. Some patients require 2,000 and even 5,000 units daily to get their blood level to the middle of normal range.

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Chronic migraine sufferers appear to be more likely to have dryness of their eyes, according to a study by ophthalmologists at the University of Utah, which was published in the journal Headache. The researchers used sophisticated techniques to measure tear production, corneal sensitivity, dry eye questionnaire, and other tests. The results of these tests were compared in migraine sufferers and healthy control subjects.

A total of 19 chronic migraine patients and 30 control participants completed the study. The nerve fiber density was significantly lower in the corneas of migraine patients compared with controls. All migraine sufferers had symptoms consistent with a diagnosis of dry eye syndrome. The researchers plan to continue studying the interrelationships between migraine, corneal nerve architecture, and dry eye.

Similar findings in patients with episodic migraine were published by a group of Turkish doctors in the journal Cornea in 2012.

Migraine sufferers and their doctors should be aware of this correlation since irritation caused by dry eyes could potentially trigger a migraine. It is possible that some migraines can be prevented by using over-the-counter and prescription eye drops or, in severe cases, eye inserts (Lacrisert). High doses of omega-3 fatty acids have been reported to help dry eyes and omega-3 fatty acids have also been reported to relieve migraines.

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The existence of gluten sensitivity has been long denied by the mainstream medical establishment. A study described in a previous post over two years ago documented higher incidence of migraine headaches in people with gluten sensitivity than in those with celiac disease (56% vs 30%). Celiac disease, which is a severe autoimmune disease caused by wheat allergy, affects about 3 million Americans, but the estimates of gluten sensitivity run as high as 18 million. Billions of dollars of gluten-free products are sold in the US and they can be found in almost every grocery store.

A recent study by the National Institutes of Health led by Dr. Sabatino examined 59 patients who did not have celiac disease, but believed gluten-containing food was causing them intestinal and other symptoms. Every day for one week these people were randomly given capsules containing 5 grams of gluten or a placebo of rice starch. After only one week, those who were taking the gluten pills reported a significant difference in symptoms compared to those who took non-gluten placebo pills. In addition to intestinal pains, they felt abdominal bloating, a foggy mind, depression, and canker sores. Clearly, they didn’t know if they were taking the gluten pill or the placebo, but their symptoms were very revealing and proved the existence of gluten sensitivity.

The bottom line is, if you have stomach pains, bloating, foggy mind, depression, headaches, malaise, and other symptoms, it may be worth going on a gluten-free diet for a couple of weeks to see if your symptoms improve. Unfortunately, we do not have any tests to document this condition, so this is the only way to find out if you have gluten sensitivity.

We do have tests for celiac disease – this condition can be detected by a blood test and an intestinal biopsy done through an endoscopy. However, despite the availability of these tests, even this severe form of gluten sensitivity is diagnosed in only one out of six Americans who suffer from it. And the number of cases of celiac, just like with non-celiac gluten sensitivity, are going up. The incidence of celiac is now five times higher than 50 years ago.

Stomach pains and bloating are the most common symptoms of celiac, but a recent review in JAMA Pediatrics, lists other symptoms, including persistent or intermittent constipation, vomiting, poor appetite, weight loss or growth delay in children, fatigue, anemia, dental problems, canker sores, arthritis and joint pains, bone loss and fractures, short stature, delayed puberty, unexplained infertility and miscarriage, recurring headaches, loss of feeling in hands and feet, poor coordination and unsteadiness, epileptic seizures, depression, hallucinations, anxiety and panic attacks. Many of these symptoms are the result of poor absorption of vitamins and minerals, including magnesium, vitamin D, vitamin B12, and other because of the damaged intestinal lining.

Those with celiac disease are more sensitive to even minute amounts of gluten than people with non-celiac gluten sensitivity.

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The new dietary guidelines issued by a government advisory committee have many positive changes from the old guidelines. These include a focus on food rather than nutrients. For example, there is no proposed limit on the intake of cholesterol and eating eggs is encouraged. There is an emphasis on eating less meat and more fruits and vegetables and on limiting sugar intake. All these recommendations apply to headache sufferers as well.

However, the guidelines are advising people to increase their consumption of coffee. They suggest that 3 to 5 cups a day can be part of a healthy diet because there is evidence that coffee may reduce risk of type 2 diabetes and heart disease (and possibly Parkinson’s disease). This is because coffee contains flavonoid compounds that have health benefits. However, coffee and caffeine in general are proven to cause worsening of headaches. As little as 2-3 cups a day can worsen headaches by causing caffeine withdrawal. Flavonoids are present in many fruits and vegetables, so it is not necessary to drink coffee to benefit from these compounds. If you are prone to having headaches it is better to limit your caffeine intake to one cup of coffee a day.

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The Journal of Nutrition just published a study that suggests life-extending benefits of taking vitamin and mineral supplements. Multivitamin with minerals products are the most commonly used supplements in the United States, followed by multivitamin products without minerals. While prior studies did not show an effect of such supplements in preventing deaths from cardiovascular disease, however, no previous trial looked for potential benefits just in women.

This new study examined the effect of a multivitamin with or without minerals on 8678 men and women. An adjustment was made for many potential confounders, that is factors that could have influenced the results, including age, race, education, weight (body mass index), alcohol, aspirin use, serum lipids (cholesterol, etc), blood pressure, and blood glucose.

The researchers observed no significant association between mortality due to cardiovascular disease in users of supplements compared with nonusers. However, when users were classified by the reported length of time products were used, a significant association was found with the use of multivitamins with minerals if they were taken for more than three years, compared with nonusers. This finding applied only to women and only to multivitamin products that also included minerals.

Magnesium is one of the minerals which is always included in combination vitamin products. Many studies have shown a beneficial effect of magnesium on cardiovascular and other causes of death in both women and men. And, of course, taking magnesium prevents migraine headaches since magnesium deficiency is found in up to 50% of migraine sufferers.

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Eating more salt leads to more headaches, according to a study published in BMJ Open last December. In a multicentre feeding study with three 30-day periods, 390 participants were randomised to the DASH (a healthy diet that was expected to lower blood pressure) or control (regular, not very healthy) diet. On their assigned diet (DASH and regular), participants ate food with high sodium during one period, intermediate sodium during another period and low sodium during another period, in random order. The occurrence and severity of headache were recorded at the end of each feeding period. The researchers did not attempt to determine which type of headaches people were suffering from, but it is safe to assume that the majority suffered from tension-type and migraine headaches. The average age was 48 and 57% were women.

The occurrence of headaches was similar in DASH versus control, at high, intermediate and low sodium levels. By contrast, there was a lower risk of headache on the low, compared with high sodium level, both on the control and DASH diets. Obviously, there are many reasons to eat a healthy diet, but prevention of headaches is not one of them.

Interestingly, there was no correlation between elevated blood pressure and headaches.

The authors concluded that reduced sodium intake was associated with a significantly lower risk of headache, while dietary patterns had no effect on the risk of headaches in adults. This study showed that reducing dietary sodium intake offers a new approach to preventing headaches.

P.S. DASH stands for Dietary Approaches to Stop Hypertension, diet rich in fruits, vegetables and low-fat dairy products with reduced saturated and total fat.

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Epilepsy drugs Depakote and Topamax are two of only four drugs approved by the FDA for the prevention of episodic migraines (the other two are blood pressure medications in the beta blocker family, propranolol and timolol, while Botox is the only drug approved for the preventive treatment of chronic migraines). However, these two drugs are contraindicated in pregnancy. Considering that the majority of migraine sufferers are young women, this is a topic that needs to be revisited regularly, especially when additional data appears.

A new study just published in the journal Neurology followed children in the British National Health Service whose mothers suffered from epilepsy and who were taking Depakote (valproate) or Tegretol (Carbamazepine) or Lamictal (lamotrigine). Only Depakote caused a significant drop in IQ in children whose mother was taking more than 800 mg of Depakote a day. Children whose mother took less than 800 mg (the usual dose for migraines is 500 mg, but sometimes 1,000 mg is needed) did not have a lower IQ, but had impaired verbal abilities and a 6-fold increase in needing educational intervention.

Unfortunately, Tegretol and Lamictal are not effective for the prevention of migraine headaches, while Topamax which is effective, can cause birth defects. Neurontin (gabapentin) is a relatively benign medication, which is safe in pregnancy and it is somewhat effective in the prevention of migraines, including chronic migraines.

Ideally, all drugs should be avoided in pregnancy. We usually advise non-drug approaches, including regular sleep, healthy diet, exercise, biofeedback or meditation, and magnesium supplementation. If this is insufficient, we usually recommend Botox if migraines remain frequent (they often improve in pregnancy). Botox is not approved for use in pregnant women, but considering that it acts locally on nerve endings with very little of it getting into the blood stream, it is most likely safer than any drug that is ingested.

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I recommend several supplements to my headache patients. However, the supplement industry is not regulated by the FDA and a few days ago another scandal has erupted. The attorney general of New York ordered Walgreens, WalMart, Target and GNC to stop selling their store brand herbal supplements. His investigation revealed that most of the supplements contained no active ingredients. In case of WalMart, only 4% of their herbal products contained an active ingredient. The tests involved Gingko biloba, St. John’s Wort, Ginseng, Garlic, Echinacea, Saw Palmetto, and Valerian root.

Of the herbal supplements for headaches, I recommend Boswellia and Feverfew made by a high quality manufacturer, Nature’s Way. I do not recommend butterbur, even though I participated in a large study that showed its efficacy in preventing migraine headaches. Butterbur contains several toxic chemicals, which can cause liver damage and other serious problems. Petadolex brand of butterbur claims to be free of these toxic ingredients, but the product is not allowed to be sold in Germany where it is manufactured. Here is my previous post on Petadolex.

Non-herbal supplements such as CoQ10 could also present a problem. For years, I have been recommending WalMart’s brand because it was much less expensive than any other brand and because I assumed that such a large company will have strict quality controls. Now I am thinking that it is possible that the price is so low because there is not much CoQ10 in it. CoQ10 by Nature’s Way costs more than twice as much as WalMart’s ($75 vs $30 for a month supply of 300 mg a day), but it may be worth it.

My most recommended supplement for migraines is magnesium and it is much less likely to present a problem because it is very inexpensive. Most of the cost is in manufacturing, bottling, shipping, etc. and not in the active ingredient.

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An email I just received, which is attached at the end of this post, prompted me to write again about magnesium. In my opinion, every migraine sufferer should try taking magnesium. It’s been 20 years since we published our first study of magnesium, in which we showed that during an attack, half of migraine sufferers have a magnesium deficiency. In that study, patients who were deficient had dramatic relief of their acute migraine with an intravenous infusion of magnesium. Subsequent studies by other researchers have shown that oral magnesium supplementation can also help. The results of those studies were not as dramatic because many people do not absorb magnesium taken by mouth. One large double-blind study used a salt of magnesium that was caused diarrhea in almost half of the patients. The magnesium salts that are better absorbed include magnesium glycinate, gluconate, aspartate (these are so called chelated forms), but some people do well with magnesium oxide, citrate, or chloride. The recommended daily dose of magnesium for a healthy adult is 400 mg a day, but some people need a higher dose. However, higher doses can cause diarrhea, while in others, even a high dose does not get absorbed. In these cases, monthly intravenous injections can be very effective. To establish who is deficient, a special blood test can help. The regular blood test is called serum magnesium level, but it is highly unreliable. A better test is RBC magnesium, but even with this test, if the value is normal, but is at the bottom of normal range, a deficiency is likely to be present. In many people there is no need for a test because they have multiple symptoms of magnesium deficiency. These symptoms include coldness of extremities, leg or foot cramps, PMS in women, “brain fog”, difficulty breathing, insomnia, and palpitations.

Here is the email I just received:

Dr. Mauskop,

I am a 76 year old male; serious headaches began at 8 years of age.
Full migraines started at 18 years of age, with aura, intense pain on one side, violent vomiting.
Sought treatment at UCLA, Thomas Jefferson University, London, Singapore. Had brain scans, biofeedback, full allergy testing, beta blockers. Started on Imigran/Imitrex in 1993 in Singapore, worked well, but did not stop pain completely. Still took a day to recover.
Nothing stopped the 2 to 4 episodes per week.
Two months ago, I read about magnesium deficiency. (Not recommended by any doctor before.)
Took 600 mg capsule per day for three days. No migraine.
Had a bit of diarrhea – checked on internet, saw it was the dose of magnesium.
Dropped intake to 340 mg per day.
Miracle: No migraine in two months.
Thank you for your research and service.
I had an annual physical in December, and mentioned to my doctor – an internist – what I had recently read about magnesium. He had not heard about it; checked on the internet while I was there; and said “interesting”. So, the word is certainly not out.


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A study by Australian doctors led by Dr. Lyn Griffiths confirmed a previous observation that higher dietary intake of
folic acid leads to lower frequency of migraine headaches. A 2009 study by Spanish doctors showed that patients with migraine with aura are more likely to have high homocysteine levels in their blood, a condition that can be corrected by taking folic acid and other B vitamins.

The authors of this new study have shown before that folic acid, vitamin B6, and B12 supplementation reduces migraine symptoms in patients with a certain genetic mutation (MTHFR gene), which leads to high homocysteine levels. However, the influence of dietary folate intake on migraine has been unclear. The aim of their current study was to analyze the association of dietary folate intake with migraine frequency, severity, and disability.

They studied 141 adult caucasian women with migraine with aura who had the MTHFR gene C677T variant. Dietary folate information was collected from all participants. Folate consumption was compared with migraine frequency, severity, and disability.

A significant correlation was observed between dietary folate consumption and migraine frequency. The conclusion of this study was that folate intake may influence migraine frequency in female sufferers with migraine with aura.

Good dietary sources of folic acid include spinach, lettuce, avocado, and other vegetables. If you suffer from migraine with aura you may want to ask your doctor to check your homocysteine level, as well as levels of folic acid and vitamin B12. Vitamin B12 level is not a reliable test because it can be normal even when a person is deficient and that is why it is important to check homocysteine level as well.

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Vitamin D deficiency has received wide attention and many doctors now check for this deficiency during routine check-ups. I’ve posted about the importance of vitamin D in migraine headaches and for general health. Vitamin D deficiency seems to increase the risk of cancer, other serious diseases and death.

However, just like with vitamin B12 and magnesium, the regular blood test for vitamin D can be misleading. It appears that while blacks have lower levels of vitamin D than whites, they have healthier bones. A study by R. Thadhani of Massachusetts General Hospital explained this paradox. It appears that some of vitamin D circulates in the blood in a free form, while the rest is bound to protein. Only the free form is active, but the blood test measures only the total amount of vitamin D. Blacks appear to have much less of the protein-bound vitamin D, so the amount of the active form can be higher in blacks even if the overall amount of vitamin D is lower. These researchers are developing a more sensitive test for vitamin D levels.

To be on the safe side, most people should aim to have their vitamin D level at least in the middle of normal range. The normal range is 30 to 100 and some studies (for example, in multiple sclerosis) suggest that the higher the level (within the normal range), the better. So, I would recommend getting your level up into the 40s and 50s. Many multivitamins, calcium with vitamin D products, and plain vitamin D supplements have only 200 or 400 units of vitamin D (it is usually listed as vitamin D3). I have seen many patients who need to take 2,000 or even 5,000 units daily to have a good level in the blood. In severe deficiency that does not respond to even these amounts, I prescribe 50,000 units of vitamin D weekly, which is available only by prescription. Unfortunately, unlike with magnesium or vitamin B12, vitamin D is not available in an injection.

The bottom line is that if you are taking a supplement, it does not necessarily mean you have enough of vitamin D in your blood and you should have the test repeated.

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While being overweight doese not cause migraines, in those who do suffer with migraines there is an inverse relationship between person’s weight and the frequency and severity of migraine headaches. Weight loss, including that due to weight loss (bariatric) surgery, has been reported to reduce the frequency of migraine headaches and migraine-related disability. Obesity is also associated with headaches due to increased intracranial pressure (also called pseudotumor cerebri) and losing weight improves such headaches as well.

However, while bariatric surgery may improve migraines, in a small number of people it can cause a different type of headaches. This rare type of headache is caused by a spontaneous leak of cerebro-spinal fluid (CSF), the fluid which surrounds the brain and the spinal cord. Such leaks are common after a spinal tap or can be a complication of epidural anesthesia. Loss of CSF can cause severe headaches, which are strictly positional. They are severe in the upright position, sitting or standing, but quickly improve upon lying down.

A study of 338 patients who underwent bariatric surgery at the Cedars-Sinai Medical Center in Los Angeles detected 11 patients who developed a spontaneous CSF leak with severe headaches. Headaches started anywhere within three months and 20 years after surgery. Clearly, headaches starting 20 years later are not likely to be related to surgery, which suggests that this link between bariatric surgery and headaches is far from proven. Of these 11 patients, 9 improved with treatment. The typical treatment for a CSF leak is a “blood patch” procedure, which involves taking blood from the patient’s vein and injecting it into the area of the leak. When blood clots, it usually seals the leak and the headache improves within hours.

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Vertigo and dizziness are more common in migraine sufferers than in people without migraines. A patient I am treating for migraines emailed me a few days ago complaining of vertigo. Dizziness is a term which can mean unsteadiness, lightheadedness, or vertigo. Vertigo is a sensation of spinning, which is most often caused by a disturbance of the inner ear. One type of vertigo is called benign positional vertigo (BPV). BPV usually causes very severe vertigo. One patients told me that while lying on the floor he felt as if he was falling off the floor. BPV is caused by a loose crystal in the inner ear. As the name implies, this type of vertigo occurs only when turning to one side, but not the other. If turning in bed to the right causes vertigo, then the problem is in the right inner ear. A simple (Epley) maneuver can quickly cure this problem by stopping this loose crystal from rolling around and causing havoc. I emailed my patient a link to a YouTube video showing how to do the Epley maneuver and half an hour later she emailed back saying that the vertigo was gone. Sometimes this maneuver needs to be repeated a few times before vertigo completely disappears. Here is the link to the Epley maneuver

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Considering that meditation can literally change your brain, it is not at all surprising that it can also prevent migraine headaches. A study by doctors at Wake Forest School of Medicine and Harvard Medical School published in the journal Headache confirmed that meditation can prevent migraine headaches.

I’ve written before about studies showing that meditation reduces negative perception of pain and that even three daily 20-minute meditation sessions reduce pain.

Stress is one of the most common triggers for migraine headaches. Many studies of various mind/body interventions have been shown to be helpful for migraine. The researchers in the latest study used a standardized 8-week mindfulness-based stress reduction program that teaches mindfulness meditation and yoga. This approach has been shown to be effective for chronic pain syndromes, but this was the first time it was tested for migraines.

The study included 9 adults who received their usual care and 10 who were enrolled in the meditation program. The program consisted of 8 weekly 2-hour sessions, plus one mindfulness retreat day (6 hours) led by a trained instructor.

All 10 patients completed the program. The program participants had on average 1.4 fewer migraines per month. The reduction ranged from 3.5 to 1.0 migraines, while in the control group the improvement ranged from 1.2 to 0 migraines per month. Headaches were less severe and shorter in those who meditated compared to those who did not. Disability also improved (measured by Migraine Disability Assessment and Headache Impact Test-6) in the active group, compared to controls.

The authors concluded that mindfulness-based stress reduction is safe and feasible for adults with migraines. Although the study included a small number of patients this intervention had a beneficial effect on headache duration, disability, self-efficacy, and mindfulness. The authors feel that there is a clear need for studies with larger numbers of patients. I, on the other hand, feel that every patient with migraines should try meditation even before larger studies are completed. If meditation can increase the thickness of your brain and prevent age-related brain atrophy, it is very likely to have many other health benefits, including prevention of migraine headaches.

How do you start meditating? Meditation classes are widely available and you can start by reading a book or taking an on-line course. I can recommend a book by BH Gunaratana, Mindfulness in Plain English and a website,, but there are many other good resources available.

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Fish oil, or rather omega-3 fatty acids, seem to reduce the risk of Lou Gehrig disease or ALS (amyotrophic lateral sclerosis). An article in JAMA Neurology by Dr. Fitzgerald and her colleagues analyzed 1,002,082 participants in 5 different large-scale studies. A total of 995 ALS cases were documented. A greater omega-3 intake was associated with a reduced risk for ALS. Consumption of both linolenic acid and marine (fish oil-derived) omega-3s contributed to this inverse association. The researchers concluded that consumption of foods high in omega-3s may help prevent or delay the onset of ALS.

Omega-3s may also relieve migraine headaches, help cope better with stress, prevent damage to nerve endings by chemotherapy, prevent mental decline, and provide other benefits.

I usually recommend (and take it myself) Omax3 brand, which is very pure and concentrated.

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The first time I heard of the potential benefit of stem cells for migraine headaches was last year from one of my patients. This 55-year-old woman had been having some improvement from intravenous magnesium and nerve blocks, while Botox was ineffective. However, she reported a dramatic improvement in her headaches after receiving an intravenous infusion of stem cells in Panama. The stem cells were obtained from a donated umbilical cord.

Stem cell research has been controversial because most of the early research used stem cells obtained from an aborted fetus. Since then, stem cells have been obtained from the bone marrow, umbilical cord, placenta, and artificial fertilization. Another rich source of stem cells is body’s fat tissue. Most of the stem cell procedures are not yet approved in the US. The main concern is that when you obtain stem cells from another person’s umbilical cord or placenta, there is a risk of transmitting an infection. There are relatively few stem cells in the bone marrow, placenta or the umbilical cord, which means that after isolating them, they need to be grown in a petri dish. This process involves adding various chemicals, which may not be safe, according to the FDA.

A group of doctors in Australia recently reported relief of migraines using stem cells from patients’ own fat. These doctors did not grow these cells, but infused them intravenously right after separating them from fat. The infused cells were not only stem cells, but so called stromal vascular fraction, which also includes cells that surround blood vessels. These four patients were given stem cell treatment for osteoarthritis and not migraines, but they noticed that their migraines and tension-type headaches improved.

Four women with long histories of chronic migraine or chronic tension-type headaches were given an infusion of cells isolated from fat, which was obtained by liposuction. Two of the four patients, aged 40 and 36 years, stopped having migraines after 1 month, for a period of 12 to 18 months. The third patient, aged 43 years, had a significant decrease in the frequency and severity of migraines with only seven migraines over 18 months. The fourth patient, aged 44 years, obtained a temporary decrease for a period of a month and was retreated 18 months later and was still free of migraines at the time the report was submitted one month later.

This case series is the first published evidence of the possible efficacy of stromal vascular fraction in the treatment of migraine and tension-type headaches.

It is not very surprising that stem cells can improve migraine headaches because stem cells are tested as a treatment for a variety of inflammatory diseases, such as multiple sclerosis, arthritis, and colitis. Inflammation is proven to be present during a migraine attack and this inflammation may attract stem cells. Many experts believe that stem cells may work for MS or other neurological disorders not by becoming brain cells, but by stimulating body’s own repair mechanisms.

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Peripheral nerve blocks can be very effective in stopping a severe migraine attack. We utilize them when a patient does not respond to oral or injected medications or when medications are contraindicated because of a coexisting disease or pregnancy.

Dr. Jessica Ailani and her colleagues at the Georgetown University in Washington, D.C. presented their experience with nerve blocks at the last annual meeting of the American Headache Society in Los Angeles. The study included 164 patients. Most patients received occipital and trigeminal nerve blocks using lidocaine or a similar local anesthetic.

Most patients were satisfied with the results, which lasted from several days up to 2 weeks. Only a small number of participants experienced side effects such as soreness at the site of injections, nausea and vomiting, and head and neck pain.

Dr. Ailani noted that more than 71% of patients rated their pain as 4 to 8 out of 10 before treatment with a nerve block. After a nerve block, nearly half (47.2%) said the pain had reduced to 1 out of 10.

“This is a very well-tolerated procedure and patients are very satisfied with the procedure,” said Dr. Ailani.

Nerve blocks can help keeps headache sufferers out of the emergency room and provide an alternative to systemic drugs, that is drugs that are injected or ingested. Systemic drugs affect the entire body while nerve blocks exert only local effects (unless one is allergic to local anesthetics).

Dr. Robert Kaniecki, a headache specialist in Pittsburgh uses nerve blocks for the prevention of chronic migraine headaches. He administers them into the same areas where Botox is injected. He finds that for some of his patients nerve blocks given every 12 weeks can be as effective as Botox. It is possible that such patients have milder migraines since the effect of nerve blocks lasts a very short time (lidocaine leaves the body after 4 hours or so) compared with the effect of Botox which lasts 3 months. Unlike Botox injections, nerve blocks have not been subjected to a rigorous scientific study comparing them to placebo (saline) injections.

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Severe persistent migraines can affect emotional, interpersonal, social, and work-related functioning. It is difficult to learn how to cope with pain and improve your functioning on your own. Cognitive-behavioral therapy (CBT) has been proven to improve lives of people with pain, including migraine headaches and not only in adults, but also in children. One major problem with CBT is that it is not readily available in many areas and when available, it is expensive.

I’ve written about two online programs for CBT, which offer help to patients with anxiety and depression. Another online service offers free resources that have been shown to improve coping with pain, to decrease anxiety and depression, and to provide other benefits. The site offers help to patients with migraine, as well as cancer pain, back and arthritis pain, and neuropathic pain. The migraine section has five modules: communication skills, emotional coping, self-management skills, knowledge base, and medication safety.

I do have a problem with their medication safety section in that it does not mention caffeine and caffeine-containing drugs when describing rebound, or medication overuse headaches. These drugs include Excedrin, Anacin, Fiorinal, Fioricet, Esgic, and other. At the same time, they list aspirin, which actually may prevent medication overuse headaches and triptans, which rarely cause such headaches (one of my most popular posts is devoted to daily intake of triptans, which is not something I encourage, but which is the only solution for some patients).

But overall, this is a very useful resource for headache sufferers. To take full advantage of this site you need to go through multiple modules, preferably on a regular basis, say twice a week. It is also useful to keep going back to the old material since it is not easy to change faulty thought processes. The site has enough material to keep you engaged for many sessions. And if you do visit the site regularly you will find that your headaches may become more manageable and that they may have less of an impact on your life.

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Skipping meals, for some people, is a sure way to get a migraine headache. Even those who do not suffer from migraines can get a headache from not eating breakfast and lunch. However, fasting has remained popular for the treatment of various conditions. Migraine sufferers who suspect that some foods may be triggering their headaches are sometime advised to try an elimination diet. This diet often begins with a fast and then one type of food is introduced at a time to see if it triggers a negative reaction. Anecdotal reports describe relief of migraine headaches with fasting for periods of up to five days. Some programs recommend five-day fasts twice a year, while others are advocating five days each month. A 5:2 diet involves eating a normal amount of calories for five days and the following two days eating 1/4 of that amount. The problem is that some people will have worsening of their headaches in the first day or two. However, most patient reports that after having headaches for a day or two the head becomes very clear.

It is not clear if fasting helps various medical conditions, if indeed it does, which remains an open question. One potential mechanism may involve stem cells. Recent studies suggest that fasting causes proliferation of stem cells. The study was published in the journal Cell Stem Cell. The research was done in mice and showed that prolonged fasting protects against immune system damage and induce immune system regeneration. The researchers speculated that fasting induces stem cells from a dormant state to a state of proliferation.

One of the authors of the study said that “We could not predict that prolonged fasting would have such a remarkable effect in promoting stem cell-based regeneration of the hematopoietic system. When you starve, the system tries to save energy, and one of the things it can do to save energy is to recycle a lot of the immune cells that are not needed, especially those that may be damaged. What we started noticing in both our human work and animal work is that the white blood cell count goes down with prolonged fasting. Then when you re-feed, the blood cells come back. ”

Fasting and induction of stem cells seems to reduce an enzyme which has been linked to aging, tumor progression and cancer. Fasting also protected against toxicity in a small human trial where patients fasted for 72 hours prior to chemotherapy.

“Chemotherapy causes significant collateral damage to the immune system. The results of this study suggest that fasting may mitigate some of the harmful effects of chemotherapy.”

So, how long do you need to fast to induce your stem cells and to get beneficial results? Some advocate suggest one or two days a week. Others promote twice yearly five-day fasts. The bottom line, we have no research on this topic.

Fasting may help protect against brain disease. Researchers at the National Institute on Aging have found evidence that fasting for one or two days a week can prevent the effects of Alzheimer and Parkinson’s disease. Research also found that cutting the daily intake to 500 calories a day for two days out of the seven can show clear beneficial effects for the brain. It is possible that fasting helps by inducing proliferation of stem cells in the brain.

Fasting cuts your risk of heart disease and diabetes:
Regularly going a day without food reduces your risk of heart disease and diabetes. Studies show that fasting releases a significant surge in human growth hormone, which is associated with speeding up metabolism and burning off fat. Shedding fat is known to cut the risk of heart disease and diabetes. Doctors are even starting to consider fasting as a treatment.

3. Fasting effectively treats cancer in human cells:
A study from the journal of aging found that cancer patients who included fasting into their therapy perceived fewer side effects from chemotherapy. All tests conducted so far show that fasting improves survival, slow tumor growth and limit the spread of tumors. The National Institute on Aging has also studied one type of breast cancer in detail to further understand the effects of fasting on cancer. As a result of fasting, the cancer cells tried to make new proteins and took other steps to keep growing and dividing. As a result of these steps, which in turn led to a number of other steps, damaging free radical molecules were created which broke down the cancer cells own DNA and caused their destruction! It’s cellular suicide, the cancer cell is trying to replace all of the stuff missing in the bloodstream that it needs to survive after a period of fasting, but can’t. In turn, it tries to create them and this leads to its own destruction.

This post contains direct quotes from

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Cluster headache patients have been coming to our office in increasing numbers in the past few weeks. We seem to be in a cluster season – many patients with cluster headaches come within the same month or two and then, for several months we see very few cluster patients. Many cluster headache sufferers ask about the efficacy of LSD, hallucinogenic mushrooms and seeds.

The use of hallucinogens for cluster headaches was first reported by a Scottish man in 1998. He started using LSD for recreation and for the first time in many years had a year without cluster headaches. The first report in scientific literature appeared in 2006 in the journal Neurology. Dr. Sewell and his colleagues surveyed 53 cluster headache sufferers, of whom 21 had chronic cluster headaches. Half of those who tried LSD reported complete relief.

Researchers are trying to study a version of LSD (brominated LSD) that does not cause hallucinations. This form of LSD was reported in the journal Cephalalgia to stop cluster attacks in all five patients it was given to. It is not clear if any additional studies are underway, but one American doctor, John Halpern is trying to bring this product to the market in the US.

Trying to obtain LSD or hallucinogenic mushrooms carries legal risks, including incarceration. According to Dr. McGeeney, who is an Assistant Professor at Boston University School of Medicine, it is legal to buy, cultivate, and sell seeds of certain hallucinogenic plants, such as Rivea Corymbosa, Hawaiian baby woodrose, and certain strains of morning glory seeds. However, it is not legal to ingest them.

The bottom line is that I urge my patients not to try hallucinogens because their safety has not been established. This is especially true for illicit products, which may contain additional toxic substances.

Fortunately, we do not need to resort to these agent because we have such a variety of safer and legal products. These include preventive medications, such as verapamil in high doses, topiramate, lithium, and for chronic cluster headaches, Botox injections. None of these drugs are approved by the FDA and are not likely to be approved because this is a relatively rare condition, which makes performing large studies very difficult. The only FDA-approved drug for cluster headaches is an abortive drug, injectable sumatriptan (Imitrex).

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Stress is considered to be one of the main migraine triggers. However, a study just published in the journal Neurology suggests that it is the period after stress when people are more likely to develop a migraine.

A group of doctors at the Montefiore Hospital in the Bronx led by Dr. Richard Lipton enrolled 22 participants, of whom 17 completed their diaries. These migraine sufferers made 2,011 diary entries including 110 migraine attacks eligible for statistical analysis. Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with an increased chance of migraine over the subsequent 6 to 18 hours. The authors concluded that the reduction in stress from one day to the next is associated with migraine onset the next day. They said that “The decline in stress may be a warning sign for an impending migraine attack and may create opportunities for preemptive drug or behavioral interventions.”

What they meant is that people could try meditation and other relaxation techniques or, if that is ineffective, they could take a medication ahead of time. Taking medication before headache starts is often more effective and requires milder and fewer drugs than if a migraine is already in full bloom.

Many migraine sufferers know that changes in sleep, meal intake, weather, and stress can trigger an attack. So, it is important to keep your life stable as much as possible. Biofeedback, meditation and other relaxation techniques, as well as regular aerobic exercise, magnesium and other supplements, all could improve the resistance against migraine attacks.

The accompanying editorial in Neurology mentioned that migraine is the single biggest source of neurologic disability in the world and any practical finding that helps people avoid migraines can have a major impact on lives of millions of people.

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Cefaly, a TENS unit specifically developed for the treatment of migraine headaches, was cleared for sale in the US. It was available last year for a short time on, but because it was not yet approved, it was taken off the market. I mentioned in my previous post that TENS units have been in use for muscle and nerve pain for decades. TENS has good proof of efficacy in musculo-skeletal pain, but studies in migraines have been relatively small. Even Cefaly was tested in only 67 migraine patients. So, while it is not definitely proven effective, TENS is safe and is worth a try if usual treatments do not help. Cefaly is easy to use but it is expected to cost around $300. The old-fashioned TENS units are not as convenient to use, but sell for as little as $50. Both Cefaly and regular TENS units require doctor’s prescription, although many websites sell TENS units without one. These devices are usually powered by a 9 volt battery and, unless you have a pacemaker or another electrical device in your body, the risk of side effects is low.

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Vitamin D has been reported to be low in patients with migraines as well as a host of other medical conditions. The big question is whether this is just a coincidence or a cause-and-effect relationship. In some conditions, such as multiple sclerosis, people with higher vitamin D levels have fewer relapses than those with lower levels, indicating a direct benefit of vitamin D. In other diseases, such as Alzheimer’s, strokes, and migraine this relationship is not clear.

A new study by Iranian doctors published in BioMed Research International shows that vitamin D deficiency is found in about half of 105 migraine patients they tested. However, when they looked at 110 matched controls without migraines, they found that half of them were also deficient. They also found that those with more severe migraines did not have lower levels than those with milder ones. This strongly suggests that vitamin D has no effect on migraine headaches.

So if you suffer from migraines, do not expect vitamin D to improve your headaches. However, if your blood test shows a deficiency, you should definitely take a vitamin D supplement to avoid some known and possibly some yet unknown problems. Taking the daily recommended dose of 600 units may not be sufficient and you may need to recheck your level to make sure that you are absorbing it. Some of my patients have needed as much as 5,000 units daily to get their vitamin D level to normal range.

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Many headache sufferers take over-the-counter medications which can cause upset stomach and heartburn due to reflux. Many will then resort to taking acid lowering drugs. These drugs reduce acidity which also impairs absorption of various vitamins and minerals, including vitamin B12, D, magnesium, and other. Magnesium deficiency is known to worsen migraine and cluster headaches.

The most popular drugs for indigestion, reflux, and stomach ulcers are so called proton-pump inhibitors, or PPIs (Prilosec, Protonix, Nexium, and other), and histamine 2 receptor antagonists (Zantac, Tagamet), and they are available by prescription and over the counter. Over 150 million prescriptions were written for PPIs alone last year.

A new study, published in The Journal of the American Medical Association by Dr. D. Corley and his colleagues shows that people who are taking these medications are more likely than the average person to be vitamin B12 deficient.

The study was performed at Kaiser Permanente. It involved 25,956 adults who were found to have vitamin B12 deficiency between 1997 and 2011, and who were compared with 184,199 patients without B12 deficiency during that period.

Patients who took acid lowering drugs for more than two years were 65 percent more likely to have a vitamin B12 deficiency. Higher doses of PPIs were more strongly associated with the vitamin deficiency, as well.

Twelve percent of patients deficient in vitamin B12 had used PPIs for two years or more, compared with 7.2 percent of control patients. The risk of deficiency was less pronounced among patients using drugs like Zantac and Tagamet long term: 4.2 percent, compared with 3.2 percent of nonusers.

The new study is the largest to date to demonstrate a link between taking acid suppressants and vitamin B12 deficiency across age groups. Earlier small studies focused primarily on the elderly.

The surprise was that the association was strongest in adults younger than age 30, since in the past only elderly were suspected to be at risk.

Vitamin B12 deficiency has been very common even in people not taking PPIs. This is in part due to healthier diets, which are often low in vitamin B12 which is found in high amounts in meat and liver. Vegetarians are particularly at risk.

Vitamin B12 deficiency is a serious condition, which in severe cases can be fatal. It can present with fatigue, memory impairment, tingling, weakness, dizziness, worsening headaches, anemia, and other symptoms.

Dr. Corley and his colleagues do not recommended stopping PPIs or similar drugs in people with clear need for these drugs. However, studies have found that the drugs are often overused or used for longer than necessary. One reason for this is that stopping PPIs often causes “rebound” increase in reflux making people think that they must continue taking these drugs. The way to get off PPIs is to first switch to Zantac and antacids, such as Tums or Mylanta. After a few weeks, stop taking Zantac and continue only antacids. Avoid eating foods that worsen reflux, such as chocolate, alcohol, and other, and you may need the antacids only occasionally.

Besides vitamin B12 deficiency, prolonged use of PPIs leads to other problems, including increased risk of bone fractures, pneumonia, and a serious gastro-ointestinal infection with C. difficile.

To see whether study patients were not just low in vitmain B12 but also had symptoms of deficiency, researchers reviewed the charts of 20 randomly selected PPI-using patients to determine why they had their vitamin B12 levels tested. Twenty five percent of that small sample had also been tested for anemia and 15 percent for memory loss. This indicates that many people with this deficiency have symptoms. However, because the symptoms are vague and not specific for this deficiency, doctors often ignore them and do not order any tests.

To complicate matters, when doctors do test for vitamin B12 deficiency, the test they use is not very accurate. Many laboratories list normal levels being between 200 and 1,000. However, many patients with levels below 400, and some even with levels above 400 still have a deficiency. If a deficiency is strongly suspected, additional tests are needed – homocysteine and methylmalonic acid levels.

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Another large scientific article on the benefits of cognitive behavioral therapy (CBT) was just published in the Journal of the American Medical Association. In this study by doctors at the Cincinnati Children’s Hospital led by Dr. Andrew Hershey, CBT was combined with amitriptyline (an antidepressant used for the treatment of pain and headaches) and compared to headache education plus amitriptyline.

They enrolled 135 children (79% girls) aged 10 to 17 years who were diagnosed with chronic migraine (15 days with headaches per month or more) and who had migraine-related disability. The study was conducted between October 2006 and September 2012. An unusually large number of kids completed the trial – 129 completed 20-week follow-up and 124 completed 12-month follow-up.

The treatment consisted of ten CBT or 10 headache education sessions involving equivalent time and therapists’ attention. Each group received the same dose of amitriptyline per pound of weight.

The main end point was days with headache and the secondary end point was the disability score determined at 20 weeks. Durability was examined over the 12-month follow-up period.

The results at the 20-week end point showed that days with headache were reduced by 11.5 for the CBT plus amitriptyline group vs 6.8 for the headache education plus amitriptyline group. The disability score decreased by 53 points for the CBT group vs 39 points for the headache education group. At 12-month follow-up, 86% of the CBT group had a 50% or greater reduction in headache days vs 69% of the headache education group;

The authors concluded that among young persons with chronic migraine, the use of CBT plus amitriptyline resulted in greater reductions in days with headache and migraine-related disability compared with use of headache education plus amitriptyline. These findings support the efficacy of CBT in the treatment of chronic migraine in children and adolescents.

The accompanying editorial strongly endorsed the results of the study, which is only the last one of many studies showing the benefits of CBT with or without biofeedback in treating headaches in children and adults. The editorial also pointed out several obstacles to the implementation of these findings. First, many doctors do not refer their patients for CBT because they are not aware of these studies or, more often lack the time and the training to explain the benefits of CBT without implying that the headache is a purely psychological problem, which obviously it is not. Secondly, even if they do refer for CBT, less than half of children and adults actually pursue this treatment.

Most doctors usually just prescribe amitriptyline or an epilepsy drug used for chronic migraines. In my experience with adolescents, Botox provides excellent relief for chronic migraines in children as well as it does in adults, although Botox is approved by the FDA only for adults. Botox has far fewer side effects than medications and I find that it is well accepted and tolerated by kids as young as 10. However, I always start with dietary changes, sleep hygiene, exercise, supplements such as magnesium and CoQ10 and CBT, biofeedback or meditation. These measures alone are often sufficient to provide significant relief and in many children there is no need for medications or Botox.

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Mindfulness appears to reduce the effect of pain on day-to-day functioning in adolescents, according to a new study published in The Journal of Pain by Canadian researchers. This was a scientifically rigorous study of 198 boys and girls aged 13 to 18 years. The researchers made an effort to recruit some children who meditated and some who did not. They were all subjected to the Child and Adolescent Mindfulness Measure questionnaire and to the Pain Catastrophizing Scale (questions such as “When I have pain I feel I can’t stand it anymore). They were asked about their daily pains, such as headache, stomachache, tooth pain, muscle pain, back pain. They were also subjected to experimental pain, which was produced by submerging their hand into ice cold water. The results showed that mindfulness had a direct effect on pain interference with daily activity and an indirect effect on the experimental pain intensity and tolerance by producing less catastrophizing.

The good news is that mindfulness is something that can be learned by meditation and can be taught as part of a course of cognitive-behavioral therapy. Kids with migraines, headaches, and other pains should be always advised to start with meditation, biofeedback, or cognitive-behavioral therapy.

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Research by Israeli pediatric neurologists confirms the clinical observation that chewing gum can make headaches worse. By chewing gum teenagers and younger children appear to be giving themselves headaches, according to a study published in the journal Pediatric Neurology.

Dr. Watemberg, the lead author said that “Out of our 30 patients, 26 reported significant improvement, and 19 had complete headache resolution. Twenty of the improved patients later agreed to go back to chewing gum, and all of them reported an immediate relapse of symptoms.”

Headaches occur in about 6% of children before puberty and become three times as frequent in girls after puberty. Typical triggers are stress, lack of sleep, dehydration, skipping meals, noise, and menstruation. Teenage girl patients are more likely to chew gum – a finding supported by previous dental studies.

Two previous studies linked gum chewing to headaches. One study suggested that gum chewing causes stress to the temporomandibular joint, or TMJ. The other study blamed aspartame, the artificial sweetener used in most popular chewing gums. Dr. Watemberg favors the TMJ explanation because gum does not contain much aspartame. I suspect that it is not the TMJ joint itself that is responsible for headaches, but tension in masticatory muscles – those we chew with. The main ones are temporalis muscles – the ones over the temples, and masseter – those at the corner of the jaw. I can sometimes tell that those muscles are at least in part responsible for headaches as soon as the patient enters the room because they have a square jaw due to enlarged masseter muscles.

Dr. Watemberg says “Every doctor knows that overuse of the TMJ will cause headaches. I believe this is what’s happening when children and teenagers chew gum excessively.” and that his findings can be put to use immediately. By advising teenagers with chronic headaches to simply stop chewing gum, doctors can provide many of them with prompt relief.

For people with hypertrophied (enlarged due to overuse) muscles stopping chewing gum sometimes is not sufficient or they never chew gum, but develop this condition because they clench and grind their teeth in sleep. These patients often respond well to injections of Botox, which shrinks those muscles and often eliminates headaches and relieves TMJ pain and dysfunction. However, Botox is only approved by the FDA for the treatment of chronic migraine and unless the patient also has this condition as well (which is common), the insurance may not reimburse for Botox injections. Biofeedback is another effective treatment for both TMJ disorder and chronic migraines.

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Transcranial magnetic stimulation (stimulation of the brain with a magnetic field) has been researched for over 30 years. It has been used to study the brain and to treat a variety of conditions, such as depression, Parkinson’s, strokes, pain, and other. The U.S. Food and Drug Administration has “allowed marketing of the Cerena Transcranial Magnetic Stimulator (TMS), the first device to relieve pain caused by migraine headaches that are preceded by an aura: a visual, sensory or motor disturbance immediately preceding the onset of a migraine attack.”

Here is an excerpt from the FDA News Release:

“The Cerena TMS is a prescription device used after the onset of pain associated with migraine headaches preceded by an aura. Using both hands to hold the device against the back of the head, the user presses a button to release a pulse of magnetic energy to stimulate the occipital cortex in the brain, which may stop or lessen the pain associated with migraine headaches preceded by an aura.

The FDA reviewed a randomized control clinical trial of 201 patients who had mostly moderate to strong migraine headaches and who had auras preceding at least 30 percent of their migraines. Of the study subjects, 113 recorded treating a migraine at least once when pain was present. Analysis of these 113 subjects was used to support marketing authorization of the Cerena TMS for the acute treatment of pain associated with migraine headache with aura.

The study showed that nearly 38 percent of subjects who used the Cerena TMS when they had migraine pain were pain-free two hours after using the device compared to about 17 percent of patients in the control group. After 24 hours, nearly 34 percent of the Cerena TMS users were pain-free compared to 10 percent in the control group.”

The study did not show that the Cerena TMS is effective in relieving the associated symptoms of migraine, such as sensitivity to light, sensitivity to sound, and nausea. The device is for use in people 18 years of age and older. The study did not evaluate the device’s performance when treating types of headaches other than migraine headaches preceded by an aura.

Adverse events reported during the study were rare for both the device and the control groups but included single reports of sinusitis, aphasia (inability to speak or understand language) and vertigo (sensation of spinning). Dizziness may be associated with the use of the device.

Patients must not use the Cerena TMS device if they have metals in the head, neck, or upper body that are attracted by a magnet, or if they have an active implanted medical device such as a pacemaker or deep brain stimulator. The Cerena TMS device should not be used in patients with suspected or diagnosed epilepsy or a personal or family history of seizures. The recommended daily usage of the device is not to exceed one treatment in 24 hours.”

After 30 years of research we know that the risks of TMS are minimal, although theoretically, TMS induces an electric current in the brain, similarly to what happens with electric shock therapy, but to a much milder degree. TMS treatment of migraines does not appear to cause memory or any other problems seen with electric shock therapy for depression.

The main problem with this device is that it is bulky and inconvenient to carry around. It will probably will be reserved for people who have severe migraines that do not respond to preventive and abortive medications and Botox injections and cause disability. Considering its inconvenience, cost, and the fact that only 15% to 20% of migraine sufferers have auras (most of whom can be treated with medications or Botox), this device is not likely to be used widely. But for those for whom it works, it could be life changing.

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The risk of dying from a variety of causes can be reduced by exercise, according to a new study published in the British Medical Journal. The effect of exercise was as strong as the effect of drugs for the prevention of diabetes, coronary heart disease, rehabilitation of stroke, and treatment of heart failure. The authors reviewed 305 previous trials that involved almost 340,000 people, making their findings very reliable.

Exercise has been also proven to prevent migraine headaches (see my previous post). This finding was based on a review of over 46,000 patient records, also a very large number that suggests a true effect. Most people don’t need these studies to convince them of the benefits – they know that exercise improves their headaches and makes them feel better. The most common problem is lack of time and motivation. However, headaches also cost time and reduce productivity, so exercising 30 minutes four days a week will save time.

Doctor recommendations often do influence their patients’ behavior and doctors need to remember to emphasize to their patients the importance of exercise, both for headaches and other conditions.

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Many migraine sufferers appear to have cold hands and nose, according to a new study by Finnish researchers described in the Wall Street Journal. The study compared 12 women with migraines with 29 healthy controls without migraines. Family history of migraine was present in 85% of those with migraines and 31% of controls. Five migraine sufferers had auras. The average temperature of the nose and hands was 3.6 degrees lower in migraine sufferers and two out of three had temperatures lower than 86 degrees, which is considered the lower end of normal. Only one out of three of those without migraines had temperatures below 85 degrees.

The authors speculate that the disturbance of the autonomic nervous system in migraine sufferers might be responsible for the constriction of blood vessels, which leads to lower temperatures. However, the authors do not mention a much more important cause of coldness of extremities, which is magnesium deficiency. Our research has shown that up to half of migraine patients are deficient in magnesium. One of the main symptoms of magnesium deficiency is coldness of hands and feet or just feeling colder in general than other people in the same environment. Other symptoms of magnesium deficiency are muscle cramps in legs and other places, mental fog, palpitations, PMS in women, difficulty breathing (intravenous magnesium is also given for asthma), and other. Blood test for magnesium is not reliable because the routine test measures so called serum level, while over 98% of magnesium sits inside the cells or bones. So, if someone has symptoms of magnesium deficiency we strongly recommend oral magnesium supplementation or give an intravenous infusion of magnesium. I’ve also seen many migraine sufferers without other symptoms of magnesium deficiency who are in fact deficient and respond to magnesium. This is why I wrote an article for doctors in a scientific journal entitled: Why all patients with severe headaches should be treated with magnesium. This is also why I included magnesium as a buffering agent in Migralex, an over-the-counter headache medicine.

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Vitamin D seems to prevent relapses of multiple sclerosis, according to a large study by Dr. Ascherio and his colleagues at the Harvard School of Public Health. My previous posts mentioned that a high proportion of migraine sufferers have low vitamin D levels and that low vitamin D levels have been associated with Alzheimer’s disease, other dementias, and strokes. This latest study of patients with MS indicates that those with higher levels of vitamin D did better than those with lower, even if the lower level was still within normal range. Studies of vitamin D in other conditions also reported similar findings of progressive benefits with increasing levels. Many laboratories consider a level between 30 and 100 to be normal. However, even in the absence of definitive proof of benefit, it is probably prudent to aim for a level of at least 50. Just taking vitamin D, even at doses of 2,000 to 5,000 units a day does not guarantee a good level because many people do not absorb it well. Ideally, you should have your vitamin D level rechecked after taking vitamin D for a few months.

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Three out of four migraine sufferers may have reactive hypoglycemia, which may be contributing to their headaches. Reactive hypoglycemia is the so called sugar crash – a drop in blood glucose level after eating or drinking a large amount of sugar. The body’s reaction to the consumption of sugar is to produce insulin, but in those with reactive hypoglycemia too much insulin is produced and the blood sugar level drops below normal.

A recent study published in Cancer Epidemiology, Biomarkers & Prevention and reported in the NY Times showed that high consumption of sugary drinks significantly raises the risk of endometrial cancer. The researchers at the National Institutes of Health who conducted this large study speculated that the wide fluctuations in sugar levels from very high to very low could play a role in the development of cancer.

Obviously, there are other reasons to avoid sugary drinks, such as to avoid weight gain which leads to more frequent migraine and other health problems, such as diabetes, heart disease, strokes, and other. For that matter it is not just sugary drinks, but sugar in any form. Many of my patients are often surprised that I would even advise against drinking orange juice, eating grapes, melons, or other very sweet fruit. These fruit have some redeeming properties, such as having vitamins and fiber, but they also contain too much sugar and can cause the same problems as refined sugar.

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A study of 13,573 people by a Harvard physician Catherine Beuttner examined the role of nutrition in patients with migraines and severe headaches. Among these participants of the National Health and Nutrition Examination Survey who were 20 years old or older, 22% or 2,880 suffered from migraines or severe headaches. A large variety of factors that could influence headaches were examined, including age, sex, race/ethnicity, education, smoking, alcohol intake, physical activity, health status, body mass index, diabetes, and number of prescription medications used. Sophisticated statistical analysis established that carbohydrate intake as a percentage of energy consumption and caffeine use were associated with higher prevalence of migraine and severe headaches. On the other hand, fiber intake appeared to reduce the prevalence of migraines and severe headaches. Dr. Beuttner also discovered that intake of foods rich in folate (folic acid, or vitamin B9), thiamine (vitamin B1), and vitamin C was also associated with lower prevalence of migraines and severe headaches.

This large study confirms some of the previous reports about the role of carbohydrates and caffeine in the development of headaches. According to one small study, three out of four migraine sufferers have reactive hypoglycemia. Reactive hypoglycemia is a condition that causes blood sugar to drop too low after eating a carbohydrate-rich meal. This drop of sugar seems to trigger headaches. Many migraine sufferers figure this out on their own and reduce their carbohydrate intake, but some fail to make this connection. So, if you suffer from severe headaches try eating small frequent meals that are low in carbs.

Caffeine is a well-known and proven trigger of migraine headaches. Caffeine can sometimes cause headaches directly, but more often headaches occur due to caffeine withdrawal. This is why many people wake up in the morning with a headache – they’ve gone all night without caffeine. Since caffeine is a short-acting drug withdrawal can occur throughout the day leading people to consume more and more caffeine. Eventually the headache become constant with some improvement after each dose of caffeine, whether it is from coffee, soda, strong tea or medications, such as Excedrin, Anacin, Fioricet, and Fiorinal. Getting off caffeine is the only way to stop these headaches. It can be done gradually or “cold turkey”. Your doctor can prescribe medications to make this process less painful because headaches will get worse before they get better. These medications may include triptans (Imitrex, Maxalt, and other), Migralex, or naproxen (Aleve). Botox injections can also help. Many of my patients argue that caffeine is not the cause of their headaches since headaches started long before they were consuming any caffeine. It is true that caffeine does not cause headaches, but if you suffer from migraines and other headaches, caffeine can make them worse. And getting off caffeine may not eliminate all headaches, but will make them much more amenable to treatment.

As far as folic acid and vitamin B1, there have been some studies proving that B vitamins (including B12) can prevent migrianes, but fiber and vitamin C have not been reported to help headaches in the past.

In summary, if you suffer from migraines or severe headaches try to keep your carbohydrate intake low, eliminate caffeine, increase your intake of foods rich in fiber, B vitamins, and vitamin C. You may also want to consider taking a supplement of these vitamins, along with B12, magnesium, CoQ10, and possibly some herbal products mentioned earlier in my blog or on our main site,

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Omega-3 and omega-6 fatty acids are needed for our body to produce pain-relieving and pain-enhancing substances. Researchers at the University of North Carolina at Chapel Hill conducted a randomized, single-blinded, parallel-group clinical trial, which was published in the journal Pain, to assess clinical and biochemical effects of changing the dietary intake of omega-3 and omega-6 fatty acids on chronic headaches.

After a 4-week baseline, patients with chronic daily headaches undergoing usual care were randomized to 1 of 2 intensive, food-based 12-week dietary interventions: a high omega-3 plus low omega-6 intervention, or a low omega-6 intervention. Clinical outcomes included the Headache Impact Test, which measures headache-related disability, headache days per month, and headache hours per day. They also measured omega-3 and omega-6 levels in red blood cells. Fifty-six of 67 patients completed the intervention.

The first intervention (increasing omega-3 and lowering omega-6) produced significantly greater improvement in the Headache Impact Test score and the number of headache days per month compared to the second group (lowering omega-6). The first intervention also produced significantly greater reductions in headache hours per day. The authors concluded that dietary intervention increasing omega-3 and reducing omega-6 fatty acids reduced headache pain and improved quality-of-life in chronic headache sufferers.

The omega-3 fatty acids are generally considered good and the omega-6 are considered bad, but it appears that what is more important is the balance between the two types. The known beneficial effects of fish oil include their effect on the heart, brain, peripheral nerves, mood, inflammation, as well as headaches. There is little downside to taking omega-3 supplements, as long as you buy fish oil from a reputable store chain or a well-know brand, which is purified of mercury.

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A variety of electrical devices have been tried for the treatment of headaches and have been mentioned in several of my previous blogs. One study showed that passing direct current through the head may help migraines and depression. Another study recently presented at the joint meeting of the International and American Headache Societies showed that passing alternating current, just like done by any TENS (transcutaneous electric nerve stimulation) machine, but using a proprietary device, Fisher Wallace Stimulator, did not provide relief. This study performed by Dr. Tietjen and her colleagues in Ohio was blinded and involved 50 patients. They applied the stimulator for 20 minutes every day for a month with one half receiving stimulation and the other half not. After a month both groups used real stimulation for another month. While this device did not cause any serious side effects, it also did not help. Hopefully, we will soon see results of large studies using direct current stimulation since this method appears to be more promising than alternating current used in TENS devices.

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Fish oil supplements may protect the heart in stressful situations, according to a study conducted in Michigan with 67 healthy volunteers. The researchers, led by Jason Carter, looked at the effect of fish oil on body’s stress response. The volunteers were given either nine grams of fish oil pills or nine grams of olive oil as a placebo, over a two-month period. The heart rate, blood pressure and other parameters were measured before and after the study.

After two months, both groups took a math test, which involved adding and subtracting numbers in their head. Their stress response was measured. Those who took fish oil supplements had a milder response to mental stress, including heart rate and sympathetic nervous system activity, which is part of the “fight or flight” response, compared to those who took olive oil instead.

The author concluded that “these results show that fish oil could have a protective effect on cardiovascular function during mental stress, a finding that adds a piece to the puzzle on why taking fish oil helps the heart stay healthy,”

This study supports the evidence that the omega-3 fatty acids have positive health benefits on the nervous and cardiovascular systems.

The author concluded that “In today’s fast-paced society, stress is as certain as death and taxes,” he added. “Moreover, our eating habits have deteriorated. This study reinforces that fish oils may be beneficial for cardiovascular health, particularly when we are exposed to stressful conditions.”

He also suggested “If you don’t do it already, consider taking fish oil supplementation, or better yet, eat natural foods high in omega-3 fatty acids.” Such foods include Alaska salmon, rainbow trout and sardines.

As far as the effect of omega-3 fatty acids on headaches, there is only one small but blinded study of 15 patients that suggests that they might help prevent migraines. Considering that in addition to counteracting the effect of stress, a major migraine trigger, omega-3 fatty acids reduce inflammation (which is one of the underlying processes during a migraine attack), it is very likely that omega-3 fatty acids may help some migraine sufferers.

Most people do not eat enough fish, so it makes sense to supplement your diet with omega-3 fatty acids. It is important to make sure that the brand you take does not contain mercury and other impurities. One of the brands I came across recently, Omax3 was developed by physicians from Yale university. It is pure and concentrated, meaning that you need to take only 2 capsules a day to get 1,500 mg of omega-3s. Most people who do take a supplement often don’t take enough of it. The study mentioned above used 9 grams of fish oil daily, while the headache study used 15 capsules with each containing 300 mg of omega-3s. To get the same amount from Omax3 you’d have to take 6 instead of 15 capsules.

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The manufacturer of Petadolex brand of butterbur sent me an email saying that the FDA conducted an inspection of their manufacturing plant in Germany. However, my concerns about butterbur, which I mentioned in a previous blog post, has not been addressed. Here is my email response to the manufacturer:
“Thank you for this additional information. It is good to see that the FDA conducted a “comprehensive inspection” of the manufacturing facility in Germany. However, my concerns about the safety of Petadolex are not due to possible deficiencies in manufacturing, but are related to the extraction process. As far as I know, this is why German and UK governments still do not allow the sale of Petadolex and this is why I do not recommend Petadolex to my patients. I am also concerned that because Petadolex is fairly expensive, many patients will decide to buy a cheaper brand of butterbur, which can be truly dangerous. Once Petadolex is cleared for sale in Germany I will be happy to resume recommending it to my migraine patients”.

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Nausea of migraines responds to an acupressure device, according to two German doctors who presented their findings last week at the International Headache Congress in Boston. I spoke to one of the authors, Dr. Zoltan Medgyessy about his study. The study included 41 patients, whose average age was 47 years. They had been suffering from migraines for on average 26 years and had experienced an average of 33 migraine
days over the previous three months. The average migraine pain intensity was 7 on a scale from 0 to 10; the average intensity of nausea was 6 on a 1-10 scale. Patients were instructed to use the device (Sea Band) instead of taking nausea medication during their next migraine attack and to complete and return a migraine attack diary. After using the acupressure band, 34 (83%) patients noticed a reduction of nausea and 18 (44%) reported a significant improvement in nausea. The average intensity of nausea after therapy was 3. The relief of nausea was reported after an average of 29 minutes. The average duration of the migraine attacks was 22 hours. The Sea Bands were worn on average for 18 hours. Forty patients (98%) reported that they would use Sea Band during migraine attacks again. The authors concluded that the use of an acupressure band can reduce migraine-related nausea. The advantage of this therapy is that it is drug-free and has no risks
or side-effects such as dizziness, fatigue, or restlessness seen with drugs. Its effect is rapid, and it is easy and it is inexpensive to use (in the US, $6 to $10). To prove that this method works beyond just placebo effect we need a blinded trial comparing anti-nausea medication with Sea Bands. I do recommend Sea Bands or a similar device, Psi Band for my migraine patients. A controlled trial in 60 women showed that Sea Bands relieve morning sickness of pregnancy (nausea and vomiting of pregnancy), which suggests that the relief we see in migraine patients is also real and not just due to placebo.

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Leeches are not pleasant to look at, but they have been used for medicinal purposes for hundreds of years. Growing up in the Ukraine in the 1960s I remember (this is hard to forget) seeing big jars with leeches in a corner pharmacy. Patients would bring in a prescription from the doctor for 4 leeches to be applied daily. The leeches would be placed into a small jar and taken home by the patient to treat swelling, high blood pressure and I don’t know what else. Leeches went out of fashion because of the advances in medicine and just because they are just disgusting. They are being used again in the US for removing extra blood around the scars after cosmetic surgery, arthritic pains, shingles, and other conditions.

British writer Emma Parker Bowles was recently in the news writing about how leeches cured her migraines. She decided on this unusual treatment because her headaches were so severe. She says, “the word headache doesn’t even begin to describe them”. She goes on with a vivid description, “Migraines are miserable with bells on – actually, the idea of listening to the sound of a bell with a migraine brings me out in a sweat. When I am suffering with one, I can’t even stand the sound of my sheets rustling. Apart from the intense throbbing, all-encompassing pain in my head, I also feel extremely nauseous and sensitive to light. I feel as if I am a vampire – a small sliver of daylight and POOF: I will spontaneously combust”.

Leeches do not hurt when they are applied because they first release a numbing substance, which along with a blood thinner and other chemicals released by the leech may be responsible for their beneficial effect. They do not have any known serious side effects. Leeches are used once and then destroyed to avoid transmitting diseases, although there is no reason why a person could not reuse them herself or himself. Several companies sell leeches to the public with instructions on how to use them. Although leeches have been used for the treatment of migraines for many years, there have been no good clinical trials or even reports of large series of cases, but someone should definitely undertake this research. Me? I am not sure I am ready.

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In my previous post I mentioned a TENS unit spcifically designed for the treatment of migraine headaches. It was available for a short time on, but no longer is. It is sold at COSTCO stores in Canada and in Europe. Howere, regular TENS units can be tried and they are less expensive.

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Food sensitivities have been always suspected to be a trigger for migraine headaches. A group of Turkish neurologists published a study in the journal Headache in which they gave an elimination diet to 21 migraine sufferers who also had irritable bowel syndrome (IBS). The study was double-blind, randomized, controlled, and cross-over, which is the most reliable type of study. Depending on the results of blood tests against 270 potential food triggers each patient was given a diet that eliminated foods they tested positive for. On average, patients were sensitive to 23 items. Compared with baseline levels, elimination diet was associated with significant reductions in migraine attack count, maximum attack duration, maximum attack severity, and number of attacks requiring medication. There was a significant reduction in pain-bloating severity, pain-bloating within the last 10 days, and was a significant improvement in quality of life by the elimination diet as compared with provocation diet.
The authors concluded that food elimination based on IgG antibodies in migraine patients who suffer from concomitant IBS may effectively reduce symptoms of both disorders with a positive impact on the quality of life of patients.
A similar, but much larger double-blind study published in 2011 compared true and sham diets in 167 migraine sufferers. 84 patients received a diet that eliminated trigger foods identified by IgG testing and the other 83 a sham diet and neither the doctor nor the patients knew who received a true elimination diet and who was given a sham diet. After 12 weeks on these diets there was no difference between the true and the sham group, suggesting that IgG testing is not useful.

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Many people report that sex relieve their migraine and tension-type headaches. We also know that sexual activity can trigger severe headaches. A group of German researchers conducted an observational study among patients of a headache clinic. They sent out a questionnaire to 800 unselected migraine patients and 200 unselected cluster headache patients. They asked about their experience with sexual activity during a headache attack and its impact on headache intensity. 38% of the migraine patients and 48% of the patients with cluster headaches responded. In migraine, 34% of the patients had experience with sexual activity during an attack; out of these patients, 60% reported an improvement of their migraine attack (70% of them reported moderate to complete relief) and 33% reported worsening. In those with cluster headaches, 31% of the patients had experience with sexual activity during an attack; out of these patients, 37% reported an improvement of their cluster headache attack (91% of them reported moderate to complete relief) and 50% reported worsening. Some patients, in particular male migraine patients, even used sexual activity to treat their headaches.
Obviously, the majority of patients with migraine or cluster headache do not have sexual activity during headache attacks. However, the doctors concluded that sexual activity can lead to partial or complete relief of headache in some migraine and a few cluster headache patients. Some of my patients report that masturbation is as good as having sex in relieving their migraine attacks.

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Celiac disease and gluten sensitivity is known to cause or at least increase the frequency of migraine headaches. The recently published study in journal Headache by doctors from Columbia University and Mt. Sinai School of Medicine in New York City examined records of 502 individuals in an attempt to find out the frequency of headaches in these conditions. They looked at records of 188 patients with celiac disease, 111 with inflammatory bowel disease (such as Crohn’s and ulcerative colitis, 25 with gluten sensitivity and compared these to 178 healthy controls. Chronic headaches were reported by 30% of celiac disease, 56% of gluten sensitivity, 23% of inflammatory bowel disease, and 14% of control subjects. Migraine headaches were more common in women and those with anxiety and depression. The severity of the impact of migraine headaches was worst in celiac patients – 72% reported it to be severe, while this number was 60% in those with gluten sensitivity and 30 % with inflammatory bowel disease.
This study confirms previous observations that celiac disease and gluten sensitivity are associated with increased frequency of migraine headaches. The difference between celiac disease and gluten sensitivity was well described in this WSJ aritcle.

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Marijuana seems to help some patients with migraine and cluster headaches. However a new study suggests that it has more negative effects than previously thought. We know that smoking pot causes lung problems and risks serious damage to various organs due to possible impurities. A recent report in the Proceedings of the National Academy of Sciences shows that regular cannabis use is harmful to health. Adolescents are beginning to use marijuana at younger ages, and more adolescents are using it on a daily basis. This study showed that persistent use of marijuana leads to neuropsychological decline. Researchers from Duke University, England and New Zealand examined records of 1,037 individuals who were followed from birth to age 38. Marijuana use was determined in interviews at ages 18, 21, 26, 32, and 38. Neuropsychological testing was conducted at age 13, before initiation of marijuana use, and again at age 38. Persistent use was associated with neuropsychological decline, including IQ, even after taking into account years of education. Persistent marijuana users reported noticing more cognitive problems. Impairment was strongest among those who started using marijuana in adolescence and the more persistent was the use the greater was the cognitive decline. Stopping marijuana use did not fully restore neuropsychological functioning and IQ among those who started its use in adolescence. This study suggests that cannabis has a toxic an persistent effect on the adolescent brain.

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Cognitive-behavioral therapy (CBT) has been convincingly proven to help pain and headache sufferers. Many people are very skeptical about the value of psychological treatments and tell me, just get rid of my migraines and I will be fine. Unfortunately, sometimes it takes time to relieve chronic headaches and pain. So, while we are trying to find relief, it helps to learn how to function better despite pain, how not to panic and become completely paralyzed by headaches, how to inform and interact better with family, friends, and employers. Research indicates, that people who take charge of their care, get involved in working with the doctor to find relief, learn relaxation techniques, rather than just sit back and wait for doctors to “fix” the problem, do much better. CBT, which usually involves relaxation training, is one way to improve your care and it usually involves 8 to 12 structured sessions. Here is an example of what might take place during these sessions:
1. Three-component CBT model (thoughts, feelings, behaviors), pain monitoring
2. Relaxation training (diaphragmatic breathing, progressive muscle relaxation, guided imagery)
3. Migraine trigger avoidance
4. Pain-fatigue cycle, activity pacing, and pleasant event scheduling
5. Identifying and challenging negative thoughts (Activity, Belief, Consequences, Dispute model)
6. Problem-solving skills training and assertive communication
7. Review and practice
8. Review and practice
9. Relapse prevention
Another form of CBT is Acceptance Commitment Therapy (ACT) and this is what a typical schedule of sessions of ACT looks like:
1. The limits of control (short and long-term costs and benefits; finger
traps), focus on experience (body scan)
2. Values (what you care about, how you want to live your
3. Cognitive defusion (observing thoughts without trying to evaluate or
change them)
4. Mindfulness (being in the moment, raisin exercise)
5. Committed action (“road map” connecting values, goals, actions,
obstacles, and strategies)
6. Review and continued action in support of values
7. Review and continued action in support of values
8. Moving forward
CBT usually is conducted by a a social worker or a psychologist and sometimes this treatment is covered by insurance. Group sessions have also been shown to be effective. However, sometimes insurance does nor cover this service or a therapist is not available. Online, web-based CBT seems to work too. Two Australian web sites offer free CBT for anxiety, depression and other problems, although they are not specifically tailored for people with headaches or pain. and are both excellent free resources for people who are looking for help, but cannot find or afford a therapist. The psychologists who developed and run these sites published results of their treatments in scientific journals, showing that self-taught CBT can be very effective. Here is a schedule of lessons for anxiety and depression on ThisWayUp website:
Lesson 1
About anxiety and depression
Learn about your own symptoms of anxiety and/or depression, and learn to tackle the physical symptoms of anxiety/depression.
Lesson 2
Identifying thoughts and tackling low activity
Learn to identify the thought symptoms of anxiety/depression, and learn to tackle the behaviours associated with anxiety/depression.
Lesson 3
Tackling thoughts
Learn to tackle the thought symptoms of anxiety/depression.
Lesson 4
Tackling avoidance
Learn to tackle avoidance behaviours associated with anxiety/depression by facing your fears.
Lesson 5
Mastering your skills
Learn to master your ability to face your fears using graded exposure, and learn to cope with the distressing emotions associated with anxiety/depression.
Lesson 6
Staying well
Learn how to avoid relapses and how to keep getting better!

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There is a long history of applying various ointments for the treatment of headaches. Widely available Tiger Balm, Head-On and other topical products can provide relief of milder headaches. There are no scientific studies proving that these treatments work beyond the placebo effect, although we do have some evidence established by Hartmut Gobel and his colleagues in Germany suggesting that the smell of peppermint can provide some pain relief. So it is possible, that the smell of herbs in Tiger Balm and possibly the cooling effect of these ointments combined with placebo effect is what accounts for the popularity of these products.
I have been using a prescription ointment for some of my patients with headaches and neck pain. This ointment has to be prepared by a compounding pharmacy and typically is not available from big chains, such as CVS or Walmart, although Walgreens does offer compounding services at some of its pharmacies. We do not have any information about the best combination of ingredients to use for the relief of headaches and pain. However, some studies indicate that topical skin application of some products does provide relief. Ketamine, which blocks the so called NMDA pain receptor can relieve pain of complex regional pain syndrome, a very serious and painful condition. Application of clonidine, a blood pressure medication has been shown to relieve pain of diabetic neuropathy – painful nerve damage due to diabetes. We also know that lidocaine is very effective when applied to the skin and it is the active ingredient in a prescription pain patch, Lidoderm. Anti-inflammatory drugs, such as aspirin or similar salicilate drugs (Aspercreme), diclofenac (Flector patch), piroxicam and other also help pain when applied to the skin. There are no studies of topical application of muscle relaxants, such as baclofen and tizanidine or an epilepsy drug gabapentin, but these drugs are often also included in compounded creams.
My usual prescription is to combine ketamine with lidocaine, piroxicam and baclofen. Unfortunately, we do not know what is the most effective combination and it would be very difficult to compare so many available ingredients in a scientific study. However, these creams are safer than oral drugs and for some patients can be as effective. Another drawback of the compounded products is that insurance often will not pay for it.

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Omega-3 fatty acids (most abundantly found in fish oil) may relieve migraine headaches but only one small study found this to be the case. However, there is mounting evidence for beneficial effects of omega-3 fatty acids for various conditions, such as strokes, heart disease, dementia, and other. A just published study in the journal BMC Cancer shows that omega-3 fatty acids prevent nerve damage caused by a chemotherapy drug used to treat breast cancer. Paclitaxel (Taxol) caused peripheral neuropathy in 60% of women who received placebo and in only 30% of those who were given omega-3 fatty acids (640 mg three times a day). Using this safe and natural supplement may allow many more women receive this life-saving chemotherapy without causing crippling side effects. Considering all of the positive studies of fish oil for a variety of neurological and other conditions and, considering its safety and low cost, it is reasonable to try this supplement for the prevention of migraine headaches despite the lack of definitive studies.

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Slow breathing can reduce pain, according to a recently published study in The Journal of Pain. Researchers at the University of Tulsa led by Satin Martin evaluated the effect on pain of slow breathing, normal and fast breathing in 30 healthy volunteers. Pain was induced by an electric shock to the leg. Slow breathing (50% of normal rate) significantly reduced pain perception when compared to normal or fast (at 125% of normal rate) breathing. Slow breathing has been long utilized for the reduction of pain and is usually included in biofeedback, meditation, and other relaxation methods. This study provides solid scientific support for this simple and ancient technique, which should be utilized more widely in the management of pain, including migraine and other headaches.

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Extraordinary benefits of meditation are described in the current issue of Neurology Now – The American Academy of Neurology’s Magazine for Patients & Caregivers”. Dr. Mauskop is extensively quoted in this article.

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Many patients ask about the best type of magnesium supplement to take for the prevention of migraines and other symptoms. Research studies have compared magnesium oxide with chelated magnesium and a slow release form of magnesium chloride and showed that all three types are absorbed equally well. I usually recommend starting with 400 mg of magnesium oxide but chelated magnesium is also very inexpensive and either one can be effective. However, if one type of magnesium causes upset stomach or diarrhea, another one should be tried. Chelated magnesium is a form of magnesium which is attached to an amino acid and depending on the amino acid it is called magnesium aspartate, glycinate, gluconate, orotate, malate, and other. Besides chelated and magnesium oxide, magnesium citrate or carbonate can be tried. When these magnesium salts are not tolerated or not absorbed, slow release forms should be considered, although they are much more expensive. There are two slow release forms, Mag Tab SR (containing magnesium lactate) and Slow Mag (magnesium chloride with calcium). Each tablet of these two products contains only a small amount of magnesium and the daily dose is at least 4 tables. Presence of calcium in Slow Mag may impair absorption of magnesium, making Mag Tab SR the preferred product. People who need to take calcium as well as magnesium should be taking these two separately because calcium interferes with the absorption of magnesium. The reason calcium and magnesium are often combined in one pill (Cal-Mag, Slow Mag, and other) is that magnesium helps improve the absorption of calcium, so it would not be too much to take Cal-Mag with one meal and magnesium alone with another. Patients with serious kidney problems should not be taking magnesium or any other supplements without consulting their nephrologist and having regular blood tests.

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Boswellia extract may relieve migraine, cluster and indomethacin-responsive headaches. Boswellia serrata (Indian frankincense) has been long reported to relieve migraines, although I could not find any scientific articles. A study recently published in journal Cephalalgia by Christian Lampl and his colleagues describes four patients with chronic cluster headaches whose headaches improved after taking Boswellia extract. The dose of Boswellia was 350 to 700 mg three times a day. All four patients failed at least three standard preventive medications for cluster headaches, such as verapamil (Calan), topiramate (Topamax), and lithium. It is very surprising that an herbal remedy helps what many consider to be the most painful type of headaches.
Dr. Eric Eross reported that Boswellia extract was also reported to help another very severe headache type – indomethacin responsive headache syndrome. Of the 27 patients with this type of headaches who were given Boswellia, 21 responded. The starting dose was 250 mg three times a day and then the dose was increased as needed, although it is not clear what the highest dose was. Indomethacin is a very strong non-steroidal anti-inflammatory medication, but it also tends to have strong gastro-intestinal side effects.
Finding a safe natural alternative is a very important discovery. Unlike butterbur, Boswellia has no toxic ingredients and is safe to consume in any form. The mechanism of action of Boswellia is not entirely clear, but it seems to have anti-inflammatory properties similar to aspirin. Obviously, it does more than that since aspirin is usually ineffective for cluster or indomethacin-responsive headaches.
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We no longer recommend butterbur to our patients. We participated in a large (245 patients) placebo-controlled trial of butterbur, which showed that 150 mg of butterbur is effective in the prevention of migraine headaches when compared to placebo. The results were published in the leading neurological journal – Neurology and the American Academy of Neurology recently endorsed the use of butterbur for the prevention of migraine headaches. Because butterbur is highly toxic to the liver and can cause cancer we were very happy to have a highly purified product manufactured in Germany (sold as Petadolex and other brands), where it had to pass strict safety studies. However, Germany is no longer allowing butterbur to be sold there because the manufacturer changed its purification process and did not repeat all of the required safety studies. Butterbur made in Germany and in the US is still sold in the US, but our FDA does not regulate herbal products and does not require the extensive safety tests that are required in Germany. This is why we no longer recommend butterbur for our patients.

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Behavioral therapies, such as biofeedback, progressive relaxation, cognitive therapy, and other alternative therapies are routinely recommended only by a quarter of headache specialists, according to research presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles by Robert Nichols of St. Louis. This despite the fact that these therapies are considered proven (so called, Grade A evidence) to relieve migraine and other headaches. Physicians are more likely to prescribe medications, even if they are less proven to work and carry a risk of serious side effects, which are absent with behavioral therapies. Cost of biofeedback and cognitive therapy can be one of the obstacle for some patients, but many techniques such as relaxation training or meditation are inexpensive and are easily learned without the help of a mental health professional. Other studies have shown that combining a behavioral technique with a preventive migraine medication results in better outcomes than with either therapy alone. So, if you take a medication it does not mean that you could not find additional relief from behavioral approaches, as well as aerobic exercise, magnesium, and other alternative therapies.

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Biofeedback is an excellent preventive headache treatment with its efficacy proven in many rigorous studies. What prompted me to write this blog post is seeing yet another child (I see kids with headaches aged 10 and older) who had seen his pediatrician and a pediatric neurologist and neither physician mentioned biofeedback. Instead, they just prescribed drugs. Biofeedback is very effective for adults as well, but seeing a 10-year-old child with headaches who is prescribed medications as the only option was somehow more upsetting than when I see and adult under the same circumstances. Children tend to learn biofeedback with greater ease than adults – sometimes they need only 4 – 5 sessions instead of the usual 10 or more. Biofeedback is a way to learn to relax and stay relaxed under pressure, at least relaxed as far as your body goes, if not the mind. The person learning biofeedback is usually connected to a computer by a probe which measures body’s temperature or muscle tension (or brain wave activity in case of neurofeedback). The computer displays this information on the screen, which helps you learn how to relax your body. Biofeedback is taught by a psychologist, a nurse or another trained professional. Some insurers will cover this treatment, but many do not. Fortunately, studies show that self-taught relaxation training can be as effective as biofeedback. There are many free sources and some that you can buy. Many people are skeptical about biofeedback, but there is a simple explanation why it works. You are supposed to stop for a minute or even less to take an inventory of neck, facial, and other muscles, to make sure you are not tensing them up, then take a few deep breath. This will bring your tension down just a little, but if you repeat this one minute exercise every hour, at the end of the day you will avoid having knots in your shoulders and your neck and may avoid a headache. Eventually, this exercise becomes subconscious as you automatically monitor your body and whenever you feel that you are frowning, holding shoulders up, or holding your breath, you stop doing that without having to pause.
In addition to biofeedback and obvious sleep, exercise, and food recommendations, I suggest that all children take a magnesium and CoQ10 supplements. Both have been shown to help children with migraines.

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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.

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Omega-3 fatty acids, found in fish oil, have been reported to relieve migraine headaches, although the only such study was relatively small. The dose of omega-3 fatty acids was 6 grams taken daily as a preventive treatment for migraines. A recent study published in Neurology shows another reason to take fish oil. Researchers at UCLA measured levels of omega-3 fatty acids, DHA and EPA in red blood cells of 1,575 healthy people with an average age of 67 +/- 9 years. They discovered a strong correlation between low levels of DHA and EPA and shrinking of the brain as well as impaired cognitive function even in people without any signs of dementia. High fish intake has been associated with reduced risk of death from heart disease and strokes and this study shows another highly beneficial effect of omega-3 fatty acids.

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Acupuncture has been widely used for the treatment of migraine headaches and it has been subjected to many clinical trials. A new study published in the Canadian Medical Association Journal confirms what previous research has shown – that acupuncture in fact is effective. This study was performed by Chinese researchers and it involved 480 patients. It was a well-designed and rigorously conducted study. The doctors divided patients into 4 groups with 3 groups receiving different types of real acupuncture and the fourth one receiving sham acupuncture. Sham acupuncture group had needles inserted, but they were not manipulated to elicit a specific “qi” sensation, which was done in the real groups. Patients in all three groups receiving real acupuncture did better than those in the sham group. The benefit persisted for at least three months after the treatment. The difference was statistically significant (meaning it did not occur by chance) but not very large, mostly because the sham group also improved. In summary, this study strongly supports the results of previous clinical trials in migraines, which showed positive effects of acupuncture. It also showed that the type of acupuncture is not important, but needles need to be inserted properly and probably need to have electrical stimulation (all groups in this study had electrical stimulation). One difficulty in following the treatment used in this study is the need for doing acupuncture five days a week for 4 weeks. Many people may have difficulty finding the time (and money) for such a regimen. However, many of the previous positive studies were conducted with acupuncture treatment being performed once a week.

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Swearing is a common response to pain. A study just published in The Journal of Pain examines whether swearing can actually help pain. Oxford English Dictionary defines swearing as the use of offensive or obscene language. Prior studies by the same researchers at the Keele University in the UK showed that for most people swearing produces a pain lessening effect. In this new study Richard Stephens and Claudia Umland looked at the effect of repeated daily swearing on experimental pain. They took 71 healthy undergraduate students (who else?) and subjected them to pain using a standard research procedure – submerging subjects’ hand into cold water. They again showed that swearing reduces pain and increases heart rate. The latter suggests that swearing reduces pain not only by distraction, but through physiologic effect on the body. They also found that people who tended to swear frequently throughout the day had less of a pain relieving effect from swearing when subjected to pain. So, listen to your mother and don’t swear all the time – save it for when it can do some good for you.

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Yet another study finds that exercise is as good for the prevention of migraines as drugs. The research report in journal Cephalalgia by Swedish doctors shows that 40 minutes of exercise three times a week was as effective as taking topiramate (Topamax) or doing relaxation exercises. Topiramate is one of the most popular drugs for the prevention of migraine headaches, but it can have many potential serious side effects, including kidney stones in 20% of patients, glaucoma, memory and other cognitive problems. The same group of researcher published a large study of over 46,648 Swedes which showed a strong inverse correlation between exercise and any type of headaches, including migraines. So, before resorting to drugs or even Botox injections it is worth trying a regimen of avoiding triggers such caffeine, adhering to a regular sleep schedule, taking magnesium and other supplements, and regular exercise.

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Migraine prevention is most effective when a preventive medication and behavioral management are combined together. A study by Dr. Holroyd and his colleagues published in the British Medical Journal showed that a beta blocker alone and behavioral management alone did not help patients with migraine headaches. However, combining these two resulted in a significant improvement. This was a very rigorous trial involving 232 patients who were divided into 4 groups: behavioral management alone (with a placebo pill), beta blocker alone, both interventions, and no intervention group (they did receive placebo pills). Patients and doctors did not know which patient received a beta blocker or placebo. Every patients was seen every month for four months and had 3 telephone calls in these four months. During each visit the behavioral management group received one hour of training. All patients were given optimal acute therapy with a triptan and if needed, ibuprofen and a nausea medication.
All patients were evaluated 10 and 16 months later and the combined group was improved compared to the other 3 groups both in the number of attacks, number of migraine days, and in the quality of life.
This confirms the validity of our usual practice of combining several approaches at once rather than trying one at a time. The list of our typical recommendations includes combination of several of these options: avoidance of caffeine, aerobic exercise, behavioral management, magnesium and other supplements, Botox injections, non-prescription medications, such as ibuprofen, naproxen, and Migralex, as well as triptans and prophylactic medications, such as beta blockers, epilepsy drugs, and antidepressants.

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Body–Mind, Self-Care Program:
Everything you do – eat, drink, sleep, move, sit, stand, think, feel, interact – adds up to how you feel and function. In a body-mind program, as with one for diet or exercise, by changing your daily practices, you will get a different result.
Headache Coach Jan Mundo will guide you to wellness and help you overcome your pain. Lessons, accompanied by handouts, individualized coaching, and assessments, include: tracking your triggers, headache-healthy diet, stress relief, and harnessing the power of your body and mind for healing.
The New York Headache Center, located at 30 East 76th Street, New York, NY generously offered its space for this program to be held weekly from March 8 until April 12, 2011, at 6 – 8:15 pm.
For more information see Jan Mundo’s site

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Headache coach, Jan Mundo will be conducting classes at the New York Headache Center (this is a second announcement).   The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27.  Jan’s course is “for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies.”  For details and registration go to  Facebook page:!/event.php?eid=102475893145453&index=1..

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Headache coach, Jan Mundo will be conducting classes at the New York Headache Center.   The course consists of 6 weekly sessions which will be held on Wednesdays from 6 to 8 PM from September 22 through October 27.  Jan’s course is “for headache or migraine sufferers who want natural solutions! Learn how to use your body and mind to relieve and prevent your cycles of pain. In a supportive environment: Find your best headache diet, use centering practices to de-stress, learn self-massage to ease pain, practice hands-on headache relief, enlist thoughts, moods, and emotions as allies.”  For details and registration go to

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Many migraine sufferers feel that food allergies cause their headaches.  There is little dispute that certain foods can trigger migraines.  Some of these foods include chocolate, wine, cheese, citrus fruit, onions, smoked, cured, and pickled foods.  However, migraine that results from eating these foods is not due to an allergic reaction, but rather is due to a chemical reaction.  An allergic reaction occurs when the body’s immune defense mechanisms try to isolate and attack an offending substance, called an allergen.  It is possible to evaluate this immune response by measuring blood levels of immune globuline (IgG) which is specific to to a particular food or substance.  Since there are so many different foods that we eat, literally hundreds of tests are required.  Doing such extensive testing has been controversial, in part because of its high cost.  This testing has been advocated for patients with irritable bowel syndrome.  People who are found to have high levels of of IgG to certain foods can improve their condition by eliminating those foods.  Another way to detect food allergies is by scratch test, where an extract of different foods is placed into skin scratches and then the skin reaction is measured.

A sophisticated study recently published in Cephalalgia by Dr. Ertas and his colleagues looked at food allergies in migraine patients.  They tested IgG levels to 266 foods in the blood of 30 migraine sufferers.  The number of foods these 30 patients were allergic to ranged from 13 to 35.  After testing, for six weeks each patient ate a diet which included or excluded foods they were allergic to. After that, they had two weeks of unrestricted diet, followed by another 6 weeks of the opposite diet (if they first had a diet free of allergen, then they were switched to a diet with allergens, and vice versa).  Neither the doctor, nor the patient knew what foods the patient was allergic to or which diet was given in each 6-week period.  The results of the study showed that significantly fewer migraines occurred when the diet excluded foods patients were allergic to.  This is the first rigorous study which suggests that food allergy testing may find a place in the management of patients with migraine headaches.

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74% of girls and 52% of boys have headaches at age 17, according to a Finnish study of 6,262 twins.  At age 11, 60% of girls and 59% of boys had headaches at least once a month.   The prevalence of weekly headaches increase d in girls from 16% to 25% between ages 11 and 14.  Headaches in kids is a major problem, but unfortunately it does not receive proper attention.  Sometimes parents do not believe that their child has a headache or if they do, they are reluctant to take the child to a doctor because they don’t want to resort to prescription medications.  Fortunately, many non-drug approaches are very effective in kids.  Regular sleep schedule (very hard to enforce in teenagers), regular meals, frequent aerobic exercise, biofeedback or meditation, and supplements can be very effective.  Several studies have shown that kids with headaches are often deficient in magnesium, riboflavin (vitamin B2), and Co-enzyme Q10 (CoQ10).  If a child still has headaches, a medications may also be appropriate.

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Vitamin D deficiency is often found in patients with headaches and neuralgia, which I’ve already mentioned in previous posts.  Chronic pain patients with low vitamin D levels were also found to have poor exercise tolerance, making their rehabilitation more difficult.  Now, there is strong evidence from two independent studies, which involved over one thousand people, that those with low vitamin D levels were twice as likely to develop Alzheimer’s disease, other types of dementia, and strokes.  The researchers and those commenting on this research called for more studies before any recommendations can be made.  This response of the medical establishment is typical in its lack of common sense.  Yes, there are dangers in taking too much vitamin D, but shouldn’t they call for doctors to test for this deficiency and correct it when it is present?  Even if we don’t know exactly if this supplementation will prevent strokes, Alzheimer’s or headaches, it makes sense to keep everyone’s level in the middle of the normal range.

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Acupuncture increases connections between different areas of the brain, according to Dhond and other Korean researchers who published their findings in the journal Pain.  They compared the effect of true and sham acupuncture in healthy volunteers using functional MRI of the brain.  They discovered that true acupuncture (insertion of one needle into the forearm) enhanced the “spacial extent of resting brain networks to include anti-nociceptive (pain-relieving), memory, and affective (responsible for emotions) brain regions”.   The researchers felt that this enhancement of connections between various parts of the brain is probably responsible for the pain relief induced by acupuncture.   After the recent German study of acupuncture for headaches which involved over 15,000 patients there is little doubt that acupuncture works for headaches (and many other pain conditions), but this study helps provide stronger scientific evidence that the relief is not due to placebo.

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I’ve written in a previous post that people exposed to pleasant music feel less pain than people listening to unpleasant music or to no music at all.  Some studies have suggested that happy music (typically music with faster tempo and major mode) is better at relieving pain than sad music.  A study by Chinese researchers published earlier this year in the journal Pain showed that both sad and happy melodies lower pain perception in healthy volunteers, as long as the melodies are pleasant.  This study adds to the growing evidence that music can indeed relieve pain and, not surprisingly, that the music has to be pleasant.

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Holiday headaches are quite avoidable, but to avoid them you have to have willpower.  I know myself that it is hard to resist all the chocolate that surrounds you during the holidays.  If you have a choice, pick milk chocolate over dark.  There is no scientific proof, but in my case I find that the higher the cocoa content the more likely I will get a headache.  Of course I, like many other chocoholics do not consider milk chocolate real chocolate and don’t bother eating it.  For the most part I stay away from chocolate altogether because it is addictive – once you start eating it, it is hard to stop.  My headaches do respond to medication and when I do eat chocolate I make sure to have it handy.  Another way to avoid headaches from chocolate, or for that matter any other trigger, is to avoid having more than one trigger at a time.  That is if you want to have some chocolate do not also drink wine or do not eat chocolate if you did not get enough sleep.

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Dr. Oz : “Like Alexander Mauskop, I believe that magnesium can help—it relaxes arteries and muscles in the body, both of which can help with headaches”.   This statement in the latest issue of O, The Oprah Magazine is not very surprising coming from a cardiac surgeon – magnesium is routinely used after open heart surgery.  Unfortunately, many neurologist and other physicians treating headaches still do not recommend magnesium for their headache patients.  And this is despite all the scientific evidence and despite the recommendation of the American Academy of Neurology.  I think this is in part due to their training that emphasizes the use of drugs rather than natural approaches.  This bias is reinforced by the strong influence of the pharmaceutical industry.

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Smoking marijuana and taking its legal medicinal derivative, dronabinol helped one patient with cluster headaches, according to a report from the Montefiore Headache Clinic.  Dronabinol is approved for the treatment of nausea and loss of appetite.  The effectiveness of smoking marijuana or taking dronabinol for the relief of pain has been reported by many patients, but never proven in large trials.  I generally discourage patients trying marijuana for the relief of any symptoms, unless they have tried and failed traditional medications and they have already tried marijuana and it did help.  Marijuana not only has many negative effects on the body, but can be also contaminated by other harmful substances.  Cluster headaches can be extremely intense and at times lead patients to thoughts of suicide.  In view of this report it seems reasonable to try dronabinol in patients who failed Imitrex injections, oxygen and preventive drugs, such as high dose of verapamil, lithium, and topiramate.

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Physical inactivity was strongly associated with headache disorders, according to a large study by Swedish researchers published in Headache.  They looked at 43,770 people with recurrent headaches and migraines and found that economic hardship and psychosocial factors (poor social support and experience of being belittled) seem to play a role in headache disorders.   Of lifestyle factors, physical inactivity was strongly associated with headache disorders, while smoking to a lesser extent.  Skipping breakfast, being overweight and underweight seemed to be connected to headaches.

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Red wine to relieve migraine?  Red wine is a well-known trigger of migraine headaches (although French tend to disagree).  A recent study published in journal Pain found that resveratrol, the active ingredient in red wine which is responsible for its health benefits, has pain relieving properties when given to rats.  There have been no reports in the literature or from my own patients that resveratrol causes headaches and judging from this study, it may in fact help.

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Migraines may be helped by omega-3 fatty acids, a supplement that has gained well deserved popularity.  Several recent studies suggesting benefits for the cardiovascular system prompted me to look at the headache literature.  An article in Cephalalgia in 2001 by Pradalier and his colleagues concluded that this supplement is ineffective, at least when they looked at the number of headaches in the last 4 weeks of treatment.   However, the active treatment with 6 grams of omega-3 fatty acids was significantly better than placebo when they looked at the total number of attacks during the entire 4 months of treatment.  Taking into account this finding and considering that omega-3 fatty acids have other benefits while being very safe, it is worth trying to take daily 6 grams of omega-3 fatty acids if you suffer from migraine headaches.

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Magnesium is effective in preventing migraine headaches according to a new study published in the last issue of journal Magnesium Research.  The researchers found that patients treated with magnesium, compared to those treated with placebo, had fewer migraine attacks and the attacks were milder.  In addition, magnesium treated patients had improved blood flow in their brains, while those on placebo did not.  This is just another confirmation of previous findings of the efficacy of magnesium in the treatment of migraine headaches.  Since magnesium is very inexpensive and extremely safe, every patient with migraine headache should be given a trial of magnesium supplementation.

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15,056 patients with migraine and tension-type headaches were treated with acupuncture in a largest acupuncture study, which was financed by the German government.  Results published in the latest issue of journal Cephalalgia by S. Jena and colleagues indicate that “acupuncture plus routine care in patients with headache was associated with marked clinical improvements compared with routine care alone”.  This study should dispel any remaining doubt about the efficacy of acupuncture in the treatment of headaches.

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Vitamin D deficiency has become a very popular topic in lay and professional literature, and deservedly so.  Vitamin D is important not only for bone health, but for normal functioning of many organs.  Its deficiency appears to be much more common than it was previously suspected.  Dr. Steve Wheeler has found vitamin D deficiency in 42% of 55 patients with chronic migraine headaches.  He presented these findings at the recent meeting of the American Headache Society.  We do not have evidence that taking vitamin D will help relieve headaches, however if a deficiency is present correcting it can certainly improve overall health of the patient.  One possible cause of what appears to be increasing incidence of vitamin D deficiency is widespread use of prescription and over-the-counter antacids.  Reducing stomach acidity helps relieve heartburn and other symptoms of reflux, but it may also interfere with absorption of vitamins and minerals.

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Two recent studies suggest that music can relieve migraine headache in children and relieve experimentally-induced pain.  In a study of 58 children with migraine headaches published in the European Journal of Pain music therapy was compared to a placebo pill and an herbal supplement, butterbur.  Both music therapy and butterbur provided significantly better relief than placebo.  In the second study published in journal Pain, healthy volunteers were subjected to pain by heating up a spot on their forearms.  The volunteers were divided into three groups: a silent control group, a group listening to pleasant music and another group listening to unpleasant music.   Those who listened to pleasant music felt less pain than the other two groups.  These two studes provide scientific support to the use of music therapy for painful conditions, including migraine headaches. 

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Bright light can trigger migraine headaches and many migraine sufferers have increased sensitivity to light during an attack.  A recent report has suggested that wearing amber colored lenses (Nike Maxsight) can relieve the light sensitivity.  For some of our patients wearing these lenses has allowed them to go outdoors on a sunny day without getting a migraine.  A new report in the journal Drug Development Research proposed a theory that each patient might best benefit from an individually selected tint (PSF, or precision spectral filters).  The article, Prevention of visual stress and migraine with precision spectral filters presents a convincing argument which should be relatively easy to test.  PSF appears to be more easily available in the UK where most of the research has been conducted.  

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German researchers showed that acupuncture relieves back pain significantly better than combination of medications, physical therapy and exercise.  They enrolled over one thousand patients with chronic back pain in a study that compared traditional Chinese acupuncture (where acupuncture sites selected based on pulse diagnosis and other traditional methods and needles are placed along specific meridians on the body) with sham acupuncture (needle are placed superficially and outside the traditional points) and conventional approach.  It turns out that 10-15 sessions of both traditional and sham acupuncture treatments were better than conventional treatment, providing relief in 47.6%, 44.2% and 27.4% of patients respectively.  This large study clearly proves the efficacy of acupuncture in back pain, regardless of the acupuncture technique. Similar results have been found in headache patients. 

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A recent study by Richard Harris presented at the American Pain Society’s meeting of 18 patients with fibromyalgia showed different brain mechanisms for true and sham acupuncture.  It appears that placebo response in sham acupuncture can be differntiated from the true acupuncture response by measuring binding properties of the mu opioid receptor in the brain.  This study further confirms the fact that one of the most important mechanisms of action of acupuncture is through the endogenous opioid system and that it is different from the mechanism of the placebo effect.

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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.

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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.

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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.

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Noise is a well-known trigger of migraines. Recent findings by WHO researchers indicate that excessive exposure to noise causes other health hazards as well. Noise from daytime traffic can result in chronic stress with an increase in the risk of heart attacks and strokes. Installing noise-insulating windows and using noise-cancelling ear phones can be helpful, albeit expensive. Listening to music to drown out the noise is another option, but can be hazardous when walking in the streets of a big city. Mayor Bloomberg’s recent focus on reducing noise pollution in New York City is a step in the right direction.

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A recent survey by Beatrice Golomb and her colleagues which was reported by Reuters Health discovered that when patients reported adverse reactions to drugs their doctors routinely denied that the drug was responsible for these side effects. To a great extent this is due to doctors’ lack of knowledge about potential side effects, but I suspect it is also because doctors have an unreasonable degree of reliance and faith in drugs. Pharmaceutical companies are doing a great job selling benefits of drugs to doctors, but the education about potential side effects is clearly lacking. Medical school training also makes doctors biased toward drugs and against alternative therapies. In treating migraine patients I often see people who were prescribed by their doctor 2-3 daily medications and who were never offered any alternatives. The efficacy of many of the supplements (magnesium, CoQ10, alpha-lipoic acid and others) is as good as that of many drugs doctors use for headaches. Eliminating caffeine, regular exercise, dietary changes, biofeedback and even Botox injections are some of the other excellent approaches that should be tried before drugs.

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According to a recent study by Magis and colleagues (Headache 2007;47:52-57) daily dose of 600 mg of alpha lipoic acid (also known as thioctic acid) was significantly better than placebo in reducing the frequency of migraine attacks, headache days and pain severity. This natural supplement is being investigated as a treatment for multiple sclerosis and HIV disease and it may be helpful for patients with Alzheimer’s and Parkinson’s as well as diabetes, strokes and heart attacks. Since the publication of this study we have been recommending alpha lipoic acid to many of our migraine patients.

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A study just published in the journal Pain looked at the effect of patient expectations on outcome of acupuncture treatment. Four large studies were analyzed and one of the four A study just published in the journal Pain looked at the effect of patient expectations on outcome of acupuncture treatment. Four large studies were analyzed and one of the four involved treatment of migraines and one of tension-type headaches. Patients who prior to the start of treatment thought that acupuncture was effective or highly effective did much better than those who were skeptical about it’s efficacy. The difference persisted 6 months following the treatment. These finding are not very surprising, but they do have an important practical application. If you do not believe acupuncture will work you are better off trying another treatment.

(Linde K, Witt, C, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain 128 (2007) 264-271)

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Intranasal use of capsaicin (on the side of the headache) has been reported to relieve cluster headaches. Capsaicin is an extract of hot peppers and can cause burning pain and irritation of the nasal mucosa. It must be used twice a day for several days before improvement is noticed. Intranasal use of capsaicin (on the side of the headache) has been reported to relieve cluster headaches. Capsaicin is an extract of hot peppers and can cause burning pain and irritation of the nasal mucosa. It must be used twice a day for several days before improvement is noticed.

A study published in Neurology, the journal of the American Academy of Neurology, indicates that oral zolmitriptan (Zomig) is effective in the treatment of cluster headaches. The study used a 10 mg dose, which exceeds the FDA-approved maximum dose of 5 mg for migraines. However, oxygen inhalation and injectable sumatriptan (Imitrex), when effective, usually provide faster relief.

Prophylactic treatment

Several reports suggest that in addition to such standard therapies as Depakote, verapamil, and lithium a nightly 10 mg dose of over-the-counter melatonin can prevent cluster headaches in some patients. Since a short course of melatonin is very safe, it is worth a try after consultation with your physician.

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