Brain disorders

People who have experienced “visual snow” know what it means. Their vision tends to be distorted by white spots that resemble what you see on the television when there is no signal.

At the latest meeting of the International Headache Society, the topic of visual snow was addressed in four presentations. The first presentation by British and Swiss researchers attempted to give a definition, so that this phenomenon can be studied scientifically. They collected data on 636 subjects by using an online survey of patients. 636 is a surprisingly high number because this is thought to be a relatively uncommon symptom. I certainly do not see more than a handful of patients each year. They found this phenomenon to be present with equal frequency in men and women and 39% reported to have it all their lives. The majority (56%) saw black and white static, 44% saw colored spots, while 45% experienced flashing, and 52% described it as transparent. The most common non-visual symptom was tinnitus, or ringing in the ears, which was present in 74%. Only 226 patients gave information on headaches and 83% of them suffered at least one attack of migraine. They concluded that visual snow is an unrecognized symptom, which can be very disabling and which deserves further research.

The second presentation reported on 90 patients of the original 636 who agreed to keep a diary of their symptoms for 30 days. The results showed that the visual snow was least noticeable outdoors, in bright sun. It was most pronounced at night. The amount of distraction that was caused by visual snow was correlated to the size and density of the static.

The third study by German and Swiss doctors showed that visual snow is a phenomenon that is common in migraine sufferers, but it is distinct in its character. They came to this conclusion by testing the excitability of the visual cortex of the brain.

The fourth paper described the effectiveness of various treatments. The data was collected by reviewing questionnaires that were returned by 204 patients. The effect of 112 drugs was reported. Unfortunately, less than half (92) of the responders had any relief from medications. Antidepressants and anti-epilepsy drugs were most commonly used. Only 29% improved from benzodiazepine drugs (Valium or diazepam, Klonopin or clonazepam, and other). Recreational drug use was reported 117 times and in 32% produced worsening and in 61% there was no change.

We clearly do not know how to treat this condition, but if you have it, have your doctor check your RBC magnesium level since magnesium deficiency increases the excitability of the nervous system. I would also check vitamin B12, D, and CoQ10 levels, thyroid function, and routine blood tests, looking for an underlying medical condition (for example, anemia) which can worsen many symptoms. Regular and sufficient amounts of sleep, exercise and meditation can also reduce the excitability of nervous system.

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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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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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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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It is an established fact that migraine, and especially migraine with aura increases the risk of strokes. The increase in the risk is small, but according to a new study published in the British Medical Journal, it is higher during and after surgery.

The researchers examined records of 124,558 surgical patients at the Massachusetts General and two other hospitals. Among these, 8.2% or 10,179 patients had a history of migraines with 1,278 or 12.6% having migraine with aura. The risk of stroke during or within 30 days after surgery was 1-2 in 1,000 among patients without migraine history, 4 in 1,000 in those who had migraines and 6 in 1,000 in patients who had migraine with aura. So, the absolute risk of a stroke is still very small, but the relative risk is statistically much higher. They also discovered that strokes were more common in patients who during surgery needed medications to increase their blood pressure. Most of the strokes occurred within the first two days after surgery.

We do not know why migraine carries an increased risk for strokes, so the only recommendation the authors offer is for migraine diagnosis to be included in the preoperative risk assessment of patients. I would add that according to another study, taking high doses of magnesium and potassium supplements could possibly reduce this risk. Magnesium alone was shown to reduce the risk of strokes in another review of studies involving 6,477 patients. Our own research and that of others have shown the beneficial effect of magnesium on the prevention of migraines as well. Here is one of a dozen posts on magnesium on this blog that provides dosing recommendations.

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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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Stroke is slightly more common in migraine sufferers. There are two main types of stroke: hemorrhagic, which results from a burst blood vessel in the brain and ischemic, which is due to a blood clot closing off blood supply to a part of the brain. Closure of a blood vessel by a clot can be due to a blood clotting disorder, cholesterol plaque, or dissection of a blood vessel. Dissection is a lengthwise tear in the blood vessel wall.

A study just published by Italian researchers in JAMA Neurology included 2,485 patients aged 18 to 45 years with first-ever acute ischemic stroke. Of these patients 334 or 13% had a dissection and 2151 or 87% had a stroke not caused by dissection. Migraine was more common in the dissection group 31% vs 24% in non-dissection group. These differences are relatively small, but the importance of the study is that it should make doctors consider the possibility of a dissection when a patient with migraines develops a different type of headache or has a new onset of neck pain. If a dissection is suspected, a CT angiogram or an MRA should be done. Luckily, many dissections do not cause strokes and heal on their own. However, we do recommend blood-thinning medications (anticoagulants) for several months after the dissection even in the absence of a stroke.

My previous post described a scientific review on this topic, that showed a two-fold increase in the risk of dissection in migraine sufferers. Another practical aspect of these studies, which is mentioned in that previous post, is that if you suffer from migraines, avoid neck manipulation by chiropractors. If you do see a chiropractor, ask them not to do high velocity manipulations (sudden jerky movements), as I did when I visited a chiropractor.

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Restless leg syndrome (RLS) has been reported to be more common in patients with migraines. I wrote about this association in a previous post about 4 years ago. Another study, just published in The Journal of Headache and Pain confirms this association.

RLS is a common condition that often goes undiagnosed. This is in part due to the fact that RLS begins in childhood and it often runs in the family, so it is not perceived as an illness.

The new study involved 505 participants receiving outpatient headache treatment. The researchers collected information on experiences of migraine, RLS, sleep quality, anxiety, depression, and demographics. Participants were divided into low-frequency (1–8/month), high-frequency (9–14/month), and chronic (>15/month) headache groups.

Analysis revealed that with an increase in migraine frequency the occurrence of RLS also increased, particularly in those who had migraines with auras. Anxiety and sleep disturbance was also associated with RLS.

Sometimes the diagnosis of RLS is very easy to make – a person who constantly shakes his or her foot, usually has it. However, in some people the excessive leg or body movements occur only in sleep, so the diagnosis is less obvious to the doctor, but not to the bed partner who is constantly kicked and woken up by these movements. One of my patients could not sleep in the same bed with his wife, because he would move and kick her all night long. After he started taking ropinirole, one of the medications for RLS, he reported that he was able to sleep in the same bed with his wife for the first time in 20 years. If the diagnosis is in doubt, an overnight sleep study can confirm the diagnosis.

Unfortunately the person with RLS suffers much more than the bed partner. Moving all night means not getting good quality sleep and being tired all day. Treating RLS leads not only to improved sleep, but also to an overall improvement in the quality of life.

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Tremor of the hands is usually a benign condition. It is even called, benign essential tremor or, if it runs in the family, benign familial tremor. Patients with tremor are twice as likely to have migraines, so this is why I am writing about it. Tremor is also a symptom of Parkinson’s disease, but these two types of tremor can be easily differentiated. Parkinsonian tremor is a resting tremor, which means that hands shake at rest, while essential tremor occurs in action, like when trying to drink from a cup.

Even though it is benign, essential tremor can be incapacitating and socially embarrassing. Fortunately, in most people it responds to treatment. We usually start with propranolol (Inderal), a drug that belongs to the beta-blocker family, which is used for the treatment of high blood pressure and migraines. If propranolol or another beta-blocker is ineffective or causes side effects (due to low blood pressure or slow pulse), tremor can be treated with epilepsy drugs such as primidone (Mysoline), gabapentin (Neurontin), zonisamide (Zonegran), or an alpha-2 agonist such as clonidine (Catapres), which is a different type of blood pressure medicine.

In rare cases, tremor affects not hands but the voice. I recently treated such a patient. He tried some medications, but when they did not help, he was given Botox injections into the vocal cords. This reduced the tremulousness of his voice, but only partially. Botox can also help with hand tremor, but because there are so many small muscles involved, the results are not very good. Taking careful history revealed that this patient tried only 10 mg of propranolol and when it did not help, he stopped it. I decided to give it another try and built up the dose to 30 mg, which provided complete relief without any side effects. For migraines, we usually go up to 60 to 120 mg of propranolol, but some patients need and tolerate even higher doses.

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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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Fibromyalgia is a condition comorbid with migraine, which means that migraine sufferers are more likely to have fibromyalgia and those with fibromyalgia are more likely to have migraines (such relationships are not always bidirectional). One common finding in these two conditions is low magnesium level and both condition often improve with magnesium supplementation or magnesium infusions.

A new study by Dr. T. Romano of 60 patients with fibromyalgia showed that those who have low red blood cell (RBC) magnesium levels are likely to have low levels of growth hormone (IGF-1, or insulin-like growth factor 1). RBC magnesium level is a more accurate test than the routine serum magnesium level, which is highly unreliable as most of the body’s magnesium sits inside the cells.

Dr. Romano recommends magnesium supplementation and a referral to an endocrinologist. It is possible that treatment with growth hormone will help those who are deficient, although it is also possible that magnesium supplementation alone (oral or intravenous, if oral is ineffective) could increase the production of growth hormone.

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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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Pituitary gland which is located inside the skull and underneath the brain is responsible for secreting various hormones. Pituitary adenoma is a benign tumor of this gland and it often causes increased release of either prolactin, growth hormone, or cortisol. Very often the tumor does not release any hormones. These tumors are extremely common – a microscopic tumor is found in one out of five adults, but they cause symptoms only in a very small proportion of such people. The symptoms are related to the type of hormone that is being released or are caused by the pressure of a growing tumor on the surrounding brain structures, or both. A very small tumor can be treated with medications, while large ones often require surgery. Small tumors have traditionally not been thought to cause headaches.

A recent study showed that in a minority of patients small tumors do cause severe headaches and if these headaches do not respond to medications, surgery can provide relief. The study was done by a group of Japanese neurosurgeons who reviewed the records of 180 patients who underwent surgery for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. They found nine patients with intractable headaches as the main complaint, associated with a small, but not microscopic pituitary adenoma (average diameter of 15 mm, or 3/5 of an inch). In eight patients the tumor did not secrete any hormones and in one it secreted prolactin.

All nine patients had complete or significant relief of their headache after surgery. The surgeons measured pressure inside the enclosed space called sella, which contains the pituitary gland and discovered that the pressure was significantly higher in patients with headaches than in those without.

In conclusion, while most patients with small tumors do not need surgery, those who have severe headaches that do not respond to medications, Botox injections, and other medical treatments, could find relief from surgery.

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Headache is usually the main presenting symptom of temporal arteritis (also known as giant cell arteritis, or GCA), which is caused by inflammation of blood vessels. This condition happens almost exclusively in the elderly. It presents with a severe headache, which is often one-sided. Some, but not all patients have swelling and tenderness of their temporal artery at the temple. This is a serious condition because it damages blood vessels and can cause strokes, loss of vision, and other complications. The diagnosis is made by blood tests (C-reactive protein, or CRP and erythrocyte sedimentation rate, or ESR) and temporal artery biopsy. However, even the biopsy sometimes does not show the inflammation. The treatment consists of steroid medications, such as prednisone. Prednisone is usually very effective. Unfortunately, prednisone needs to be taken for years if not for the rest of the person’s life and when it is used for long periods, it has many potentially dangerous side effects.

A recent study published in JAMA Neurology showed that many patients with biopsy-proven giant cell arteritis have an infection with varicella-zoster virus. This virus is also responsible for shingles and chickenpox

The researchers reviewed samples of temporal arteries for the presence of varicella-zoster virus. It was found in 68 of 93 (73%) of temporal arteries of patients with the disease, compared with 11 of 49 (22%) normals.

The authors concluded that in patients with clinically suspected GCA, prevalence of the virus in their temporal arteries is similar independent of whether biopsy results are negative or positive. They also felt that “Antiviral treatment may confer additional benefit to patients with biopsy-negative GCA treated with corticosteroids, although the optimal antiviral regimen remains to be determined”, and that “Considering that antiviral medications such as Acyclovir are very safe, it is reasonable to give them to all patients with temporal arteritis.”

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The little white spots seen on brain MRI scans have long been thought to be benign. A nagging concern has always persisted since their meaning has remained unclear. A recent study by researchers at several medical centers across the US established that even very small brain lesions seen on MRI scans are associated with an increased risk of stroke and death.

This is a very credible study since it involved 1,900 people, who were followed for 15 years. Previous studies of these white matter lesions (WML), which are also called white matter hyperintensities (WMH) involved fewer people and lasted shorter periods of time (these are my previous 4 posts on this topic).

Migraine sufferers, especially those who have migraines with aura are more likely to have WMLs. One Chinese study showed that female migraine sufferers who were frequently taking (“overusing”) NSAIDs, such as aspirin and ibuprofen actually had fewer WMLs than women who did not overuse these medications. Even though most neurologists and headache specialists believe that NSAIDs worsen headaches and cause medication overuse headaches, this is not supported by rigorous scientific evidence (the same applies to triptan family of drugs, such as sumatriptan). Another interesting and worrying finding is that the brain lesions were often very small, less than 3 mm in diameter, which are often dismissed both by radiologists who may not report them and neurologists, even if they personally review the MRI images.

The risk of stroke and dying from a stroke in people with small lesions was three times greater compared with people with no lesions. People with both very small and larger lesions had seven to eight times higher risk of these poor outcomes.

This discovery may help warn people about the increased risk of stroke and death as early as middle age, long before they show any signs of underlying blood vessel disease. The most important question is what can be done to prevent future strokes.

An older discovery pointing to a potential way to prevent strokes is that people who have migraines with aura are more likely to have a mutation of the MTHFR gene, which leads to an elevated level of homocysteine. High levels of this amino acid is thought to damage the lining of blood vessels. This abnormality can be easily corrected with vitamin B12, folic acid and other B vitamins.

More than 800,000 strokes occur each year in the United States, according to the National Institute of Neurological Disorders and Strokes. Strokes are a leading cause of death in the country and cause more serious long-term disabilities than any other disease. Routine MRI scans should not be performed, even in migraine sufferers, but if an MRI is done and it shows these WMLs, it is important to warn the patient to take preventive measures.

There are several known ways to prevent or reduce the risk of strokes. These include controlling weight, hypertension, cholesterol, diabetes, reducing excessive alcohol intake, stopping smoking, and engaging in regular aerobic exercise.

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Migraine with aura is believed to increase the risk of strokes and possibly heart attacks, although the risk estimates vary from study to study.

A recent study demonstrated no increase in the risk of strokes in people who suffered from migraine with and without aura, unless they were active smokers. The findings were published last month in the journal Neurology. Among the 1292 participants with an average age of 68 years there were 262 with migraine. There was no relationship between migraine (with or without aura) and stroke or heart attacks during the 11 year follow up period. However, among the 198 current smokers, there was a 3-fold increased risk for stroke.

The lack of relationship between migraine with aura and stroke seen in previous studies is probably due to a relatively small sample size.

I personally have seen two young women with migraine with aura who suffered a stroke. Both of them were smokers and were taking oral contraceptives. Estrogen contraceptives (even newer ones with lower estrogen content) further increase the risk of strokes in women who have migraine with aura. Progesterone-only pill does not increase the risk of strokes. Some women with severe endometriosis, heavy menstrual blood loss, and severe PMS sometimes have to accept a slight increase in the risk of strokes and take an estrogen-based contraceptive. However, if they smoke, they must stop smoking and also try to reduce other risk factors for strokes, if they are present. These include keeping hypertension and diabetes under control, lower high cholesterol, maintain normal weight and exercise regularly.

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Chronic fatigue syndrome sufferers have endured years of neglect and sometimes ridicule. The condition has even been called “yuppie flu”. Informal surveys indicate that half of the doctors do not believe that this is a true physical disease. This is despite the fact that 1 to 2 million Americans have been diagnosed with this condition. In a previous post I mentioned that patients with chronic fatigue are much more likely to suffer from migraines – they occur in 84% of patients. Tension-type headaches were found in 81% and only 4% had no headaches at all.

There is an overwhelming amount of evidence that chronic fatigue syndrome is a physical condition and one of the names that has been used by doctors is Myalgic Encephalomyelitis. The Institute of Medicine recently issued a report, Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness, which proposes a new name – Systemic Exertion Intolerance Disease, or SEID. The name indicates that the main characteristic of the disease is the fact that exertion of any kind – physical, cognitive, or emotional – can affect many different body organs and impair normal functioning and reduce quality of life. The report also states that to make this diagnosis, the symptoms have to be chronic, frequent and moderate or severe in intensity. The experts suggest that patients could be diagnosed with both SEID and Lyme disease, fibromyalgia, or another disease that causes fatigue. Currently, if a patient suffers from Lyme disease or another fatiguing condition, chronic fatigue is not added as a separate disease. The report also noted that the prognosis is not very good – many people continue to suffer from SEID for many years.

Fibromyalgia, another condition which was thought to be purely psychological, now has three medications approved to treat it (Lyrica, Cymbalta, and Savella), which has led more doctors treat it as a real disease. Unfortunately, there are no drugs approved for chronic fatigue or SEID.

Here are the specific diagnostic criteria for SEID established by the Institute of Medicine:
– Reduction or impairment in the ability to carry out normal daily activities, accompanied by profound fatigue
– Post-exertional malaise
– Unrefreshing sleep
In addition, diagnosis requires one of the following symptoms:
– Cognitive impairment
– Orthostatic intolerance (difficulty standing up and being in an upright position).

I would add that to make this diagnosis, other known potential causes of fatigue should be ruled out. These include thyroid disease, anemia, chronic infections (Lyme and other), vitamin B12 and other deficiencies. As mentioned in a previous post, the test for vitamin B12 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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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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A report by Taiwanese doctors just published in the journal Neurology suggests that having migraine headaches may double the risk of Bell’s palsy.

Several medical conditions, such as asthma, anxiety, depression, irritable bowel syndrome, epilepsy, and other occur with higher frequency in migraineurs, but until now, no one suspected an association between migraines and Bell’s palsy.

The researchers compared two groups of 136,704 people aged 18 years and older – one group with migraine and the other without. They followed these two groups for an average of 3 years.

During that time, 671 people in the migraine group and 365 of the non-migraine group developed Bell’s palsy.

This association persisted even after other factors such as sex, high blood pressure, and diabetes were taken into account.

The authors speculated that the inflammation and the blood vessel problems seen in both conditions may explain this association.

This study appears to be of purely academic interest since we do not know how to prevent Bell’s palsy. However, I decided to write about it because a couple of my colleagues (one in our office and at least one other on a doctors’ discussion board) reported seeing Bell’s palsy soon after administering Botox injections for chronic migraines. This report by Taiwanese doctors suggests that Bell’s palsy might have been not due to Botox, but rather a coincidence since Bell’s palsy is more common in migraine sufferers.

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Migraine aura precedes the headache in about 20% of patients. The most common type of aura is visual. It consists of flashing lights, sparkles, partial loss of vision, and other visual distortions, which can move across the visual field. Typical duration of the aura is 20 to 60 minutes and it can occur without a headache. Many people get frightened when experiencing an aura for the first time. Thoughts of a brain tumor spring to their minds. Although auras rarely indicate a serious problem, an MRI scan is usually indicated when an aura occurs for the first time.

MRI scans are considered to be safe in pregnancy, but the current guidelines of the FDA require labeling of the MRI devices to indicate that the safety of MRI with respect to the fetus “has not been established”. Not surprisingly, most expecting mothers instinctively try to avoid any testing. So, what to do if a pregnant woman develops an aura? A study by headache specialists at the Montefiore Headache Center in the Bronx suggests that this is not an uncommon occurrence. Of 121 pregnant women presenting with an acute headache, 76 had migraines and a third of these had an aura for the first time in their lives. Two thirds of auras occurred in the third trimester. This report should be reassuring and may help avoid unnecessary MRI scans. However, MRI may still be needed if there are other signs of a more serious neurological problem on examination or by history.

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“Visual snow” is a continuous TV-static-like visual disturbance experienced by some people who suffer from migraines and by some without migraines. A group of British doctors examined 120 patients with persistent “visual snow” and found that 70 of them also suffered from migraines. Of these 70, 37 had migraine with aura and 33 had migraine without aura. Many of these patient had other visual complaints: some had a trailing after-image when shifting their gaze, saw sparkles, were always sensitive to light, and had poor night vision. Fifty two of them also complained of noise in their ears (tinnitus).

Seventeen of these patients underwent PET scans of their brain, which were compared to PET scans of 17 normal control subjects. Those with “visual snow” had increase brain activity in two parts of the brain, indicating that this is not a psychological or an eye problem, but a brain disorder.

Unfortunately, the authors did not provide any ideas as to how to treat these patients. However, the fact that some areas of the brain were overactive, suggests that using epilepsy drugs, which suppress excessive brain cell activation and are proven to help migraines, may help. These drugs include gabapentin (Neurontin), topiramate (Topamax), and divalproate (Depakote). Before using drugs though, I would suggest trying magnesium orally or intravenously because magnesium also reduces excitability of the nervous system and because half of migraine sufferers have low magnesium levels. See an article on magnesium and migraines here.

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Idiopathic intracranial hypertension is also called pseudotumor cerebri because just like with a brain tumor, the
pressure is increased inside the skull. This condition usually presents with a headache and sometimes with visual symptoms. Increased intracranial pressure is not only a very painful condition, but also, if left untreated, can cause loss of vision and strokes.

An observational study just published in JAMA Neurology reports on 165 patients with pseudotumor seen by a group of neurologists and ophthalmologists across the country. The mean age of these patients was 29 and only 4 were men. The vast majority of them were obese with an average body mass index of 40, while normal is below 25. Headache was present in 84% of patients and 68% reported transient loss of vision. Half of them had back pains and pulse-like noise in the ears (pulsatile tinnitus) was reported by 52%. Visual loss was found in 32% and it was usually loss of the peripheral vision with an enlarged blind spot in the middle.

The authors concluded that pseudotumor cerebri mostly occurs in young obese women. The importance of this report is in reminding physicians to consider this diagnosis in young obese women with headaches. The diagnosis is confirmed by performing a lumbar puncture (spinal tap), which is the only way to measure intracranial pressure. An MRI scan is also always done (before the spinal tap), to make sure that it is not a real tumor that is causing increased pressure and to visualize ventricles (fluid-filled spaces) inside the brain. These ventricles are usually small in patients with pseudotumor. Performing the lumbar puncture involves draining of the cerebrospinal fluid, which can immediately relieve the headache and also improve vision. Some patients require regular spinal taps or placement of a draining shunt (usually from one of the brain’s ventricle or spinal canal to the abdominal cavity).

However, many patients respond to medications, such as acetazolamide (Diamox) or topiramate (Topamax). Weight loss is the most effective, albeit difficult treatment. The same group of physicians reported that acetazolamide combined with weight loss was somewhat more effective than weight loss alone. Only rarely, when vision is acutely threatened, a surgical procedure to relieve pressure inside the optic nerve is performed by an ophthalmologist (the procedure is called optic nerve sheath fenestration).

In summary, increased intracranial pressure is often mistaken for chronic migraine and should be considered in every young female obese headache sufferer.

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Tylenol (acetaminophen, or in Europe it is called paracetamol) is the go-to drug for pain, headaches, and fever during pregnancy. A new study just published in the journal JAMA Pediatrics indicates that this drug may not be as safe as previously thought.

Animal research has long suggested that acetaminophen is a so called hormone disruptor, a substance that changes the normal balance of hormones. It is a well-established fact that an abnormal hormonal exposures in pregnancy may influence fetal brain development.

Danish researchers decided to evaluate whether prenatal exposure to acetaminophen increases the risk for developing attention-deficit/hyperactivity disorder (ADHD) in children. They studied 64,322 live-born children and mothers enrolled in the Danish National Birth Cohort during 1996-2002.

The doctors used parental reports of behavioral problems in children 7 years of age using a specific questionnaire, retrieved diagnoses from the Danish National Hospital Registry or the Danish Psychiatric Central Registry, and identified ADHD prescriptions (mainly Ritalin) for children from the Danish Prescription Registry.

More than half of all mothers reported acetaminophen use while pregnant. Children whose mothers used acetaminophen during pregnancy were at about 1.3 times higher risk for receiving a hospital diagnosis of ADHD, use of ADHD medications, or having ADHD-like behaviors at age 7 years. Stronger associations were observed with use in more than 1 trimester during pregnancy and with higher frequency of intake of acetaminophen.

The researchers concluded that maternal acetaminophen use during pregnancy is associated with a higher risk for ADHD-like behaviors in children.

This presents a difficult problem in treating headaches and pain in pregnant women. Aspirin and other non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen can cause other problems in pregnancy and are particularly dangerous in the third trimester. In women with migraines, acetaminophen tends to be ineffective anyway, so these women should be given migraine-specific drugs, such as triptans (Imitrex or sumatriptan, Maxalt or rizatriptan, and other). They are much more effective than acetaminophen and the woman may need to take much less of these drugs than of acetaminophen. Triptans are also in category C in pregnancy, which means that we do not know how safe they are. Imitrex was introduced more than 20 years ago and we do not that it does not have any major risks for the fetus, but that does not mean that more subtle problems, such as ADHD are also not more common. Another headache drug that should be avoided in pregnancy is Fioricet. It is popular with some obstetricians because it has been on the market for 40 years. However, it contains not only acetaminophen, but also caffeine, which can make headaches worse, as well as a barbiturate drug butalbital, which can also have deleterious effect on the fetal brain.

Fortunately, two out of three women stop having migraines during pregnancy, especially in the second and third trimester. If they continue having headaches, treatment is directed at prevention. Regular aerobic exercise, getting enough sleep, regular meals, good hydration, avoiding caffeine, learning biofeedback, meditation or another form of relaxation, magnesium supplementation, are all safe and can be very effective. Acute treatments that do not involve drugs are often not very practical for a busy person. However, if the headache prevents normal functioning anyway, taking a hot bath with an ice pack on the head at the same time can help some women. Taking a nap, getting a massage, aromatherapy with peppermint and lavender essential oils are good options. For nausea, ginger and Sea Bands are sometimes very effective.

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Many people who experience severe headaches are often concerned about having a brain aneurysm. What prompted this post is a patient I just saw who was found to have a small (3 mm) aneurysm on a routine MRI scan as well as a new article just published in The Lancet Neurology.

Considering that over 36 million Americans suffer from migraine headaches, this is by far the most common cause of severe headaches. However, aneurysms are not rare – more than 7 million Americans have them. The vast majority of these people do not know that they have an aneurysm and in 50 to 80 percent they never cause headaches or any other problems. Every year, more than 30,000 people do suffer a rupture of the aneurysm. The rupture of an aneurysm is what causes a very severe headache and about one in seven people with a rupture die before reaching the hospital. In addition to a severe headache, the hemorrhage from a ruptured aneurysm can cause a stiff neck, drowsiness, weakness or numbness on one side, difficulty speaking and other symptoms of a stroke.

Dutch researchers analyzed the available data, trying to find predictors of aneurysm rupture. They discovered that the risk goes up with age, high blood pressure (hypertension), history of a previous brain hemorrhage, aneurysm size, its location and the geographic region. There is nothing one can do about age and other factors, but blood pressure is one factor that can be controlled.

If the aneurysm is less than 5 mm, as in my recent patient, the risk of a rupture is very low. However, if the aneurysm is larger, surgical treatment is usually indicated, especially if other risk factors are present.

It is not clear why, but people living in Finland and Japan are about 3 times more likely to have an aneurysm rupture than those in the rest of Europe and North America.

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