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Headaches

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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We often get requests for a telephone consultation from patients who live too far to come in for a visit. Unfortunately, insurance companies do not cover telephone or video-link consultations. An additional obstacle in the US is that doctors cannot treat patients outside the state where they are licensed because each state licenses their own doctors. If patients can afford to pay, we do offer follow-up telephone consultations to patients who live out of state or abroad and who were first seen in our office.

A group of Norwegian researchers examined how safe and effective it is to treat patients without seeing them in person by using a video link. The results of their study was published in a recent issue of the journal Neurology. They compared 3 and 12 month outcomes after a single consultation in 200 patients using telemedicine with 202 patients seen in the office. All patients were referred by their primary care doctor. They included only patients with non-acute headaches, that is those whose headaches started gradually more than 4 weeks prior to the visit and showed no clinical or MRI abnormalities. Doctors ordered about the same number of MRI scans in both group (58 and 62). Over the subsequent year a serious underlying cause was found in one patient in each group. Treatment outcomes after 1 year were the same in both group, although in both groups the improvement in headache severity and its impact on the daily life was modest. There was a high level of satisfaction with the consultation in both groups.

The main shortcoming of the study is that every patient completed a variety of questionnaires and had a much more detailed evaluation than you’d expect in a non-study setting. The study suggests that a single consultation may not be sufficient to provide an optimal outcome. Also, while over 40% of patients had chronic migraines, obviously none could be treated with Botox, which is the only FDA-approved treatment for chronic migraines.

In conclusion, consultation via telemedicine is a viable option for patients in areas without headache specialists.

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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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Temporal arteritis occurs in one out of 5,000 people over 50. Women are 3-4 times more likely to be affected. It is not common below the age of 60 and becomes more prevalent with the advancing age. Temporal arteritis is also known as giant cell arteritis because it causes inflammation of arteries with giant cells seen under the microscope.

Headache is often the first symptom and it is typically localized to one temple, but it can involve other parts of the head and occur on both sides. If left undiagnosed and untreated temporal arteritis can cause a stroke and blindness, which can affect both eyes.

Besides headaches, temporal arteritis can cause neck and jaw pain, weakness, muscle aches, and a mild fever. The preliminary diagnosis is made by blood tests (ESR and CRP) and it is confirmed by a biopsy of the temporal artery. Polymyalgia rheumatica is a related rheumatological condition, which can occur alone or with temporal arteritis and it causes severe muscle pains.

Temporal arteritis (and polymyalgia rheumatica) are treated with steroid medications, such as prednisone. Although the initial dose is high, relatively small doses are usually effective for maintenance. Since the condition can last for years and long-term intake of prednisone can cause many potentially serious side effects it is very important to perform a temporal artery biopsy in most cases, rather than rely just on blood tests and clinical diagnosis.

Subcutaneous injection of Actemra (tocilizumab) was just approved by the FDA for the treatment of temporal arteritis. This drug has been available since 2010 for the treatment of rheumatoid and other forms of arthritis. Actemra was injected every two weeks for a year along with prednisone, but more patients were able to get off prednisone if they received Actemra rather than a placebo injection. Unfortunately Actemra also has potentially dangerous side effects, such as serious infections and it requires regular blood tests.

Because headache is one of the main symptoms of giant cell arteritis, the condition is often diagnosed by a neurologist or a primary care doctor. The treatment though is typically handled by a rheumatologist and they are already familiar with tocilizumab.

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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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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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With 13 million participants, soccer is the third most popular sport in the US after basketball and baseball. Worldwide, 250 million people play soccer. Unfortunately, a number of studies have linked playing soccer with neurological symptoms. The latest study from the Albert Einstein College of Medicine published in Neurology evaluated 222 amateur soccer players aged 18 and older (mostly in their 20s and 30s) over a two-week period.

The study suggests that playing soccer even without heading the ball is associated with symptoms of a concussion. Those who did not report heading the ball often had unintentional head impacts (head to head, elbow or knee to head, head kicked, etc) and were much more likely to have concussion-related symptoms which were rated as moderate or severe. These symptoms included headache, dizziness, feeling dazed, and other. Unintentional head impacts were experienced by 37% of men and 43% of women, while heading-related symptoms were reported by 20%.

Not all symptoms necessarily represent a concussion and some pain and dizziness could be neck-related, so additional large studies are needed. Some studies have detected brain changes in soccer players who frequently head the ball, but these findings are considered to be preliminary and not conclusive.

According to the US Soccer Federation children under the age of 10 should not be allowed to head the ball in practice or in games. Children aged 11 to 13 are allowed to head the ball only during practice. However, this new study suggests that soccer players of any age may be risking brain injury, mostly from heading and unintentional head injuries.

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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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Hypothyroidism, or under-active thyroid is known to cause headaches or worsen pre-existent migraines. Correcting this deficiency with medications such as Synthroid or Armour Thyroid often improves headaches.

Researchers at the University of Cincinnati College of Medicine tried to determine if having headaches made one more prone to developing hypothyroidism. They examined 8,412 healthy people and checked their thyroid function every 3 years over a 20 year period. They excluded from the group people with past thyroid disease or abnormal thyroid function tests at the first office visit. The diagnosis of a headache disorder was established based on person’s report of “frequent headaches,” by the use of any headache-specific medication, or a physician’s diagnosis of a headache disorder. They also recorded age, sex, body mass index, income, smoking, narcotic use, and medicines that could cause thyroid dysfunction.

Headache disorders were present in about 26% of the population and new onset hypothyroidism developed in 7%. Those who had a headache disorder had a slightly higher risk (1.2 times) of developing hypothyroidism. The researchers concluded that headache disorders may be associated with increased risk for the development of new onset hypothyroidism. These results were published in Headache.

One of my colleagues tells an embarrassing story of his wife’s headaches. She developed them after giving birth to their child, so he attributed them to stress and lack of sleep. When headaches persisted she went to her primary care doctor who discovered that she had an underactive thyroid. The headaches promptly went away with thyroid medicine.

Besides headaches, low thyroid function can cause weight gain, fatigue, constipation, muscle cramps, intolerance of cold, dryness of the skin, memory and concentration difficulties. Many of these symptoms also occur with magnesium deficiency, so both RBC magnesium and thyroid function tests (along with vitamin B12, vitamin D, and routine tests) need to be checked when headaches worsen or new ones develop.

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One of the most common problems with Botox injections given for chronic migraines is that doctors use the standard protocol without adjusting the dose. One of my patients is an 83 year old woman with chronic migraines who has done exceptionally well with Botox injections with no side effects for the past 16 years. She recently started living in Florida during the winter and had Botox injections given by a local doctor. I provided her with a copy of the injection sites and the total dose, which was 65 units given into 20 sites in the forehead and temples. Her Florida neurologist insisted on giving her the standard 31 injections with 155 units all around the head, neck and shoulders. The result was that she developed drooping of her eyelids and pain and weakness of her neck. It defies common sense to inject a small woman who weighs 90 lbs with the same amount of Botox as a 200-lbs man.

Sticking strictly to the protocol prevents many doctors from addressing clenching and grinding of the teeth (TMJ syndrome), which often worsens migraines. Injecting Botox into the masseter muscles (chewing muscles at the corner of the lower jaw) can have a dramatic effect on TMJ pain and migraines. Other patients may need additional injections into the scalp or upper back, depending on where the pain is felt. Since Botox comes only in 100 and 200 unit vials, if the insurance company approves Botox, it sends us 200 units. Instead of discarding the remaining 45 units, we usually give additional injections into the areas of pain that may not be included in the standard protocol.

Giving injections every 3 months or even every 12 weeks works well for many patients. However, about a quarter of my migraine patients find that the effect of Botox lasts only 10 weeks and in a small number , even less than 10 weeks. Fortunately, some insurance companies allow Botox to be administered every 10 weeks, but many do not. Some even limit injections to every 3 months, and not a day earlier, even though the clinical trials that led to the FDA approval involved giving injections every 12 weeks. Having a week or two of worsening migraines can eliminate the cumulative effect we see with repeated treatments. That is, each subsequent Botox treatment provides better relief than the previous one. This may not the case if headaches worsen before the next treatment is given.

Cosmetic concerns are not trivial since Botox injections can make you look strange – as if you are always surprised or look sinister with the ends of your eyebrows always lifted. This can be easily avoided by injecting a very small amount of Botox into the appropriate muscles above the ends of the eyebrows or a little beyond them. In some patients this can be predicted before the first treatment by looking at the lines seen with lifting of the eyebrows. In others, it becomes apparent only after the first treatment. If the appearance is very unappealing, we ask the patient to return to get two small additional injections for which we do not charge.

To minimize bruising and pain we use very thin needles. A 30-gauge needle is used most often, however an even thinner, 33-gauge needle is also available, but is rarely used (higher number indicates a thinner needle). We recommend using a 33-gauge needles, at least for the forehead, where injections tend to be more painful and where bruising, if it happens, is very visible.

Many dermatologists and plastic surgeons tell their patients not to bend down or do anything strenuous to avoid movement of Botox which may lead to drooping of the eyelids. There is no theoretical or practical evidence for this restriction. Once injected, Botox does not move around freely but stays in the injected area. In my 22 years of injecting Botox, I’ve treated thousands of headache sufferers and fewer than 1% of patients developed drooping eyelids and none were related to bending or any other activities. Drooping is more common in older patients, is always reversible within days or weeks, and sometimes can be relieved by eye drops (aproclonidine).

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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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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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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, Amazon.com, and Migralex.com.

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New onset of headaches is always worrisome, but even more so in a pregnant woman. Neurologists at the Montefiore Headache clinic in the Bronx conducted a 5-year retrospective study of pregnant women who presented with an acute headache, were hospitalized, and received a neurologic consultation. The study was published in Neurology.

The researchers identified 140 women with a mean age of 29 years. About 56% of these women presented in the third trimester. Primary headaches was present in 65% and secondary (due to an underlying disease) was found in 35% of women. The most common primary headache disorder was migraine and it was found in 91%, while the most common secondary headache disorder present in 51% was high blood pressure.

Primary headaches included migraine without aura, seen in 37%, migraine with aura, in 24%, chronic migraine, in 6%, episodic tension-type headache, in 3%, chronic tension-type headache, in 1%, and primary stabbing headache, in 2% (this adds up to more than 65% because some had more than one type of headaches). Besides hypertensive disorders such as preeclampsia and eclampsia (18%), secondary headache diagnoses included pituitary adenoma or apoplexy in 4%, infections in 2%, stroke in 3%. Pregnant women with secondary headaches were less likely to have had headaches in the past (37% in secondary vs 13% in primary) and were more likely to have seizures (12% vs 0%), elevated blood pressure (55% vs 9%), fever (8% vs 0%), and an abnormal neurologic examination (35% vs 17%). Psychiatric comorbidity (presence of depression, anxiety, bipolar, etc) and phonophobia (sensitivity to light) were less likely with secondary headache.

The authors concluded that among pregnant women receiving inpatient neurologic consultation, more than one-third have secondary headache. Doctors should be particularly vigilant in the absence of a headache history and if seizures, hypertension, or fever are present. On the other hand, specific headache features such as location of the pain, throbbing character, sensitivity to light and noise are less helpful in distinguish primary vs secondary headaches. The neurologists who conducted this review recommend low thresholds for neuroimaging (CT or MRI scan) and monitoring for preeclampsia and eclampsia. Preeclampsia and eclampsia are complications of pregnancy with elevated blood pressure, sometimes seizures, and kidney problems, which can be life-threatening and which are treated with intravenous infusions of magnesium.

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Ehlers-Danlos syndrome is a group of inherited disorders that are notable for excessive joint mobility with some people also having lax or stretchy skin, at times heart problems, and other symptoms. Headaches appear to be also very common.

We see Ehlers-Danlos syndrome in many of our migraine patients and most of our headache specialist colleagues also notice this association. However, there are very few studies that confirm this observation. One such study was recently presented at the annual scientific meeting of the American Headache Society in Washington, DC. The research was performed at a cardiology clinic in Texas. They looked at the records of 139 patients who were referred to this clinic in a period of one year. Of these 139 patients with Ehlers-Danlos syndrome, 90% were women and the average age was 32. Out of 139 patients, 70% suffered from headaches – 32% had tension-type, 26% had migraines, 9% had chronic migraines and 2% had sinus headaches. These numbers are much higher than what is seen in the general population, confirming clinical observations by headache specialists.

One form of Ehlers-Danlos syndrome affects not only joints and ligaments, but also the heart. So, when see a migraine patients who also appears to have Ehlers-Danlos syndrome, we also ask about symptoms related to the heart and if they are present refer such patients to a cardiologist.

Another presentation at the same meeting described a 23-year-old woman with Ehlers-Danlos syndrome who suddenly developed headaches that would worsen on standing up and improve on lying down. This is typical of headaches due to low cerebrospinal fluid (CSF) pressure, which was confirmed by a spinal tap. The most common causes of low CSF pressure are a leak caused by a spinal tap done to diagnose a neurological disease or caused by a complication of epidural anesthesia. Spontaneous unprovoked leaks have also been reported. In this patient with Ehlers-Danlos syndrome the leak probably occurred because of the lax ligaments that surround the spinal canal and contain the CSF. The report describes the most accurate test to document such leaks, which is an MRI myelogram.

The treatment of CSF leaks begins with a blood patch procedure, but if it is ineffective, surgery is sometimes done to repair the leak. A recent report suggested that Botox could be effective for low spinal fluid pressure headaches.

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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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Narcotics are not only ineffective for the treatment of headaches, but they can also make headaches worse and transform an episodic migraine into chronic. A study mentioned in a previous post showed that more than half of migraine sufferers who went to an ER were given a narcotic.

A new study recently published in the journal of the International Headache Society, Cephalalgia showed that if patients presenting with a headache to an ER are treated with an injection of opiates (narcotics) they will stay in the hospital longer than if no narcotics are given. This treatment also leads to an increased risk of return visits to the emergency department within seven days.

The study was conducted by two neurologists, Dr. McCarthy at Puget Sound VA Healthcare System in Seattle and Dr. Cowan at Stanford University in California. They examined charts of 574 people and discovered that 23% received a narcotic when they were seen at an emergency department. Only 53% were given an injection of a drug recommended by a published consensus of headache experts. These include sumatriptan (Imitrex, the only injectable triptan), prochlorperazine (Compazine), metoclopramide (Reglan), chlorpromazine (Thorazine), ketorolac (Toradol), aspirin, acetaminophen, and dihydroergotamine. The remaining 24% were given an injection of another non-narcotic drug.

Patients who were given opiates were 4 times more likely to have a long stay, compared with patients given first-line recommended medications. 69 participants had at least one readmission for headache, of whom 20 returned to the emergency department within seven days. Interestingly, patients who had a CAT or an MRI scan of the brain had a significantly higher rate of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended drugs.

Dr. McCarthy was quoted saying that “Opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications”. He added that regardless of whether the acute headache was diagnosed as a migraine or a tension-type headache, it is likely to respond to most non-narcotic injectable treatments.

An editorial accompanying this article concluded that “The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department”.

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Stabbing headaches can be a sign of acute multiple sclerosis, according to a report by German doctors in the journal Headache. Stabbing headache is a rare type of headache, although patients with migraines often report having occasional “ice pick” headaches. Some call these headaches “jabs and jolts”. In some people, stabbing headaches can be quite disabling. The pain lasts only a couple of seconds but can occur up to 100 times a day. Treatment usually involves indomethacin or another non-steroidal anti-inflammatory medication in the aspirin family (including our own Migralex). However, in this case where stabbing headaches were associated with MS, treating MS relieved headaches as well.

In a prior report in Clinical Neurology and Neurosurgery Italian physicians also found that of 26 patients with stabbing headaches they had seen over 10 years, more than half had autoimmune disorders, including multiple sclerosis, Sjögren’s disease, lupus, Behçet’s disease, autoimmune vasculitis, and antiphospholipid antibody syndrome. The authors speculated that stabbing headache may develop as a result of inflammation in the brain with loss of myelin around the nerve fibers, which is seen with MS and other auto-immune disorders.

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A report from the Cleveland Clinic and Case Western Reserve describes 22 patients with new daily persistent headaches (NDPH) who were treated with Botox injections.

NDPH is a condition in which the headache begins suddenly without an obvious trigger and persists continuously without a break. Because NDPH is relatively uncommon, there have been no large studies of this condition. Patients with NDPH usually do not exhibit symptoms of migraine, such as throbbing pain, nausea, sensitivity to light, noise or physical activity. Because of its sudden onset, we suspect that these headaches may be the result of a viral or another type of infection. There are no treatments that consistently relieve these headaches, but we usually try all of the drugs and approaches we use in migraines.

A group of doctors from Cleveland, Ohio discovered that while Botox seems to help, only 32% of patients with NDPH showed improvement, confirming the refractory nature of this type of headaches. Twenty one of the 22 patients underwent more than one treatment with Botox and most were given a standard migraine treatment protocol with 155 units injected into 31 sites. The improvement was modest but it did result in headache-free days, which were not observed prior to this treatment. The disability improved slightly and when the improvement did occur, it lasted about 8 weeks. Some of our chronic migraine patients also require Botox injections every 8 to 10 weeks, instead of the usual 12. Considering that we do not have any better treatments, Botox should be offered to patients with NDPH.

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Botox is FDA-approved only for chronic migraine headaches, however, it is being used “off-label” for other types of headaches as well. We find that frequent episodic migraines, cluster headaches, numular, and cervicogenic (neck-related) headaches improve with Botox. In our practice, post-traumatic headaches also seem to respond to Botox.

A report by neurologists from Stony Brook University describes five patients suffering from post-traumatic headaches, who responded to Botox. These patients sustained a traumatic brain injury and had suffered from post-traumatic headaches for years, despite trials of various prophylactic medications. After treatment with Botox, all of their five patients had greater than 50% improvement of their disability as measured by the MIDAS (MIgraine Disability Assessment Scale) questionnaire.

This is not a surprising observation because in many patients with a traumatic brain injury headaches have migraine features, suggesting similar underlying mechanisms. People with a family history of migraines who sustain a head injury seem to be more likely to develop post-traumatic headaches than those without such family history, which also suggests a link with migraines. Some patients with post-traumatic headaches and especially those with overt whiplash injury (almost all head injuries, to a varying degree, involve a whiplash neck injury) may respond to Botox because Botox relaxes tight muscles. We no longer think that this is the reason Botox helps migraines because there is evidence that in migraines Botox works by blocking sensory nerve endings rather than by relaxing muscles.

Because of the cost, insurance companies are often unwilling to pay for Botox to treat anything but chronic migraines. However, headaches that begin after a head injury and are accompanied by some migraine features can be correctly classified as post-traumatic chronic migraines, thus avoiding difficulties with the insurance companies.

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Triptans, such as Imitrex or sumatriptan and similar drugs are “designer” drugs which were developed to specifically treat migraine headaches. They are highly effective and, after more than 20 years on the market, proven safe. Four out of the seven drugs in this category (Imitrex, Maxalt, Zomig, Amerge) are available in a generic form, which significantly lowers their cost, which was one of the obstacles for their widespread use. So, it would appear that now there is no reason for doctors not to prescribe triptans to migraine sufferers.

In 1998, emergency department doctors gave more than half of the patients suffering from migraine headaches opioids (narcotics) to relieve pain and, according to a new study, 12 years later, this hasn’t changed.

Despite the fact that triptans are widely considered to be the best drugs for acute migraine, the use of these drugs in the emergency department has remained at 10%, according to a study led by Benjamin Friedman, an emergency medicine doctor at the Montefiore Medical Center in the Bronx.

In 1998, about 51% of patients presenting with migraine at the emergency department were treated with an injection of a narcotic and in 2010, narcotics were given to 53% of the patients.

Other than narcotics (opioids) emergency department doctors often give injections of an NSAID (non-steroidal anti-inflammatory drug) Toradol (ketorolac) or a nausea drug, such as Reglan (metoclopramide). These two drugs are more effective (especially if given together) and have fewer potential side effects than narcotics. They also do not cause addiction and rebound (medication overuse) headaches, which narcotics do.

Dr. Friedman and his colleagues looked at the national data for 2010 and found that there were 1.2 million visits to the emergency departments for the treatment of migraine. Migraine was the 5th most common reason people come to the emergency room.

They also discovered that people who were given a triptan in the emergency department had an average length of stay in the ER of 90 minutes, while those given Dilaudid (hydromorphone) – the most popular narcotic, stayed in the ER for an average of 178 minutes.

Opioids should be used only occasionally – when triptans, ketorolac, and metoclopramide are ineffective or are contraindicated. This should be the case in maybe 5% of these patients, according to Dr. Friedman

One possible reason why ER doctors do not follow recommended treatments and use narcotics instead, is that they do not recognize a severe headache as migraine and misdiagnose it as sinus, tension-type or just as a “severe headache”. Many doctors still believe that migraine has to be a one-sided headache, or a visual aura must precede a migraine, or that the pain has to be throbbing. It is well established that none of these features are required for the diagnosis of migraine.

Another possible reason for the widespread use of opioid drugs in the ER is that doctors are very accustomed to using them, while triptans may be unfamiliar and require thinking about potential contraindications, what dose to give, what side effects to expect, etc.

In summary, if you or someone you know has to go to an ER with a severe migraine, ask for injectable sumatriptan (which you should have at home to avoid such visits to the ER) or ketorolac.

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A severe migraine attack can sometimes land you in an emergency room. With its bright lights, noise, and long waits, it is the last place you want to be in. To add insult to the injury, some doctors will think that you are looking for narcotic drugs and treat you with suspicion, while others will offer ibuprofen tablets. It is hard to think clearly when you are in the throes of a migraine, so you need to be prepared and have a list of treatments you may want to ask for, just in case the ER doctor is not good at treating migraines.

If you are vomiting, first ask for intravenous hydration and insist on having at least 1 gram of magnesium added to the intravenous fluids. Everyone with severe migraines should have sumatriptan (Imitrex) injection at home since it often eliminates the need to go to an ER in the first place. If you haven’t taken a shot at home, ask for one in the ER. The next best drug is a non-narcotic pain medicine, ketorolac (Toradol) and if you are nauseous, metoclopramide (Reglan). Do not let the doctor start your treatment with divalproex sodium (Depakene, drug similar to an oral drug for migraine prophylaxis, Depakote) or opioid (narcotic drugs) such as demerol, morphine, hydromorphone and other.

This post was prompted by an article just published in the journal Neurology by emergency room doctors at the Montefiore Hospital in the Bronx. It was a double-blind trial which compared intravenous infusion of 1,000 mg of sodium valproate with 10 mg metoclopramide, and with 30 mg ketorolac. They looked at relief of headache by 1 hour, measured on a verbal 0 to 10 scale. They also recorded how many patients needed another rescue medication and how many had sustained headache freedom.

Three hundred thirty patients were enrolled in the study. Those on divalproex improved by a mean of 2.8 points, those receiving IV metoclopramide improved by 4.7 points, and those receiving IV ketorolac improved by 3.9 points. 69% of those given valproate required rescue medication, compared with 33% of metoclopramide patients and 52% of those assigned to ketorolac. Sustained headache freedom was achieved in 4% of those randomized to valproate, 11% of metoclopramide patients, and 16% receiving ketorolac. In the metoclopramide arm, 6% of patients reported feeling “very restless”, which can be a very unpleasant side effect of this drug.

The authors concluded that the valproate was less efficacious than either metoclopramide or ketorolac. Metoclopramide was somewhat better than ketorolac but it also had more side effects.

To summarize, ask the doctor to start with hydration and magnesium, then sumatriptan injection, followed by metoclopramide and ketorolac, if needed. If the above treatments do not help, we also give dexamethasone (Decadron, a steroid medication) and DHE-45 (dihydroergotamine). All these medications can be administered in the office and we always tell our patients not to go to an ER and to come into the office if the attack occurs during our office hours.

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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 Amazon.com, 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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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.


Photo credit: JulieMauskop.com

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Many medical specialty groups of doctors have been coming out with “Choosing Wisely” campaign where they recommend avoiding five things in their field. Headache specialists just came out with their own list of items that offer low-value and can be even harmful. The American Headache Society surveyed its members to develop a candidate list of items of low-value care in headache medicine. Then, a committee reviewed the literature and the available scientific evidence about the candidate items on the list and by consensus came up with a final list of five items. The five recommendations are: (1) don’t perform a brain scan (MRI or CAT) in patients with stable headaches that are typical migraines; (2) don’t perform CAT scan for headache when MRI scan is available, except in emergency settings (MRI is much more informative and does not subject the patient to radiation); (3) don’t recommend surgical procedures for migraine, unless it is a part of a clinical trial (several types of surgery are being promoted with little scientific evidence that they are safe and effective); (4) don’t prescribe opioids (narcotic drugs, such as codeine, Vicodin, Percocet) or butalbital-containing medications (Fioricet, Fiorinal, Esgic) as a first-line treatment for recurrent headache disorders because these drugs are often ineffective, can worsen headaches and can cause addiction; and (5) don’t recommend prolonged or frequent use of over-the-counter pain medications for headache. I would stress that the last item is particularly important in regard to caffeine-containing drugs, such as Excedrin and Anacin, while ibuprofen, naproxen, and acetaminophen are much less likely to cause medication overuse (rebound) headaches. Aspirin sometimes can actually prevent headaches from becoming more frequent or chronic (I admit that as a developer of Migralex I am biased in favor of aspirin, but scientific data supports this).

Art credit: JulieMauskop.com

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Cleveland Clinic doctors established that migraine patients who are educated about sumatriptan (Imitrex) and other triptans tend to do better. It is not a surprising discovery, but it highlights the importance of patient education. The study involved 207 patients at the Cleveland CLinic, Mayo Clinic, Brigham and Women’s Hospital. Here are some important facts that migraine sufferers need to know.

One such fact, taking medicine early, seems obvious, but many patients often wait to take a triptan for a variety of reasons. They often think that it may not be a migraine, but rather a tension headache that will not require a triptan. Others are reluctant to take medication because it might be dangerous, although the most common reason is that patients often don’t get enough medicine from their insurer. These are expensive drugs, even in a generic form. However, it is more expensive to lose a day of work and if the medicine is taken early one tablet may be sufficient, but if taken late, the patient may need 2 or 3 tablets to abort an attack.

Another fact is that you do not need to take an aspirin (or Migralex) or ibuprofen before resorting to a triptan if the headache is very severe. Many people often keep trying an over-the-counter drug first, even if they always end up taking a triptan. It is OK to combine aspirin or ibuprofen with a triptan if a triptan alone is insufficient.

Migraine sufferers should also know that triptans are contraindicated in people with coronary artery disease. If you had a heart attack, suffer from angina or have multiple risk factors (hypertension, diabetes, high cholesterol, smoking, etc).


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Increased intracranial pressure is an under-diagnosed cause of difficult to treat headaches. Persistent chronic headaches that do not respond to treatment may be due to increased pressure inside the head. These headaches may resemble chronic migraine headaches and many doctors will try treating these patients with preventive medications, such as Neurontin (gabapentin), Topamax (topiramate), amitriptyline (Elavil), or Botox injections. If these approaches do not provide relief, measurement of intracranial pressure should be considered. Most patients who suffer from increased intracranial pressure have swelling of the optic nerves (papilledema), which can be detected by examining the back of the eye, a standard part of a neurological and ophthalmological examination. However, some people with increased pressure do not have papilledema and they are the ones who present a diagnostic challenge. This condition is also called pseudotumor cerebri because tumors also raise intracranial pressure. To measure the pressure a spinal tap (lumbar puncture) is performed. The cerebrospinal fluid circulates around the brain, within its ventricles and around the spinal cord. Putting a needle into the spinal fluid at the lumbar spine level is much safer than anywhere else and gives the reading of the pressure everywhere within this enclosed space, including the brain.

Factors that predispose to increased intracranial pressure include delayed effects of a head trauma, certain medications, excessive amounts of vitamin A, obesity, and other. One of the more recent theories suggests that narrowing of the veins that drain blood from the brain is responsible for this condition. This diagnosis is made by performing an angiogram or a magnetic resonance venogram (MRV, a test done by an MRI machine), tests that show blood vessels.

In addition to headaches, increased pressure can cause nausea, dizziness, pulsating noise in the ears, and blurred vision. If left untreated, the increased pressure can lead to loss of vision.

If no obvious causes are found the condition is called idiopathic intracranial hypertension. Its treatment begins with the attempts to lose weight if the person is overweight. Pregnant women who are more prone to develop this condition often obtain relief after the delivery. Medications that can help include acetazolamide (Diamox) and topiramate (Topamax). If medications are ineffective a neurosurgeon can place a shunt that drains cerebrospinal fluid into the abdomen. This is a relatively simple procedure, but it does carry a risk of infections and other complications. Shunting is reserved for patients who have uncontrollable headaches or are threatened with loss of vision.


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Pituitary adenoma is a benign tumor of an endocrine gland that is situated underneath the brain. Pituitary gland is connected to the brain and it produces several hormones. The most common type of pituitary tumor is one that secretes prolactin, hormone responsible for breast milk production. Women with this tumor usually have irregular periods and breast discharge. Pituitary adenoma usually does not cause headaches, unless it becomes large and compresses the brain. Most of the tumors are small and are called microadenomas and only rarely become large macroadenomas. A group of German researchers just published a study in Cephalalgia that looked at possible causes of headaches induced by pituitary adenoma. Fifty-eight patients with pituitary adenoma were analyzed. Twenty-four patients (41%) had tumor-attributed headache with seven having migraine-like headaches, 11 tension-type headaches, and three having both. Cluster headache-like headache was found once, and two headaches remained unclassified. Tumor-attributed headache was associated with a positive prior history of headaches, nicotine abuse, and a faster tumor growth. Whenever a woman with headaches has irregular periods or a milky discharge from her breast an MRI scan of her brain and a blood test for prolactin level must be obtained. If the tumor is allowed to grow large it can cause impairment and even loss of vision because of the compression of optic nerves. The treatment is usually with medication that shrinks the tumor and only rarely surgery is needed. This surgery can often be performed transnasally – through the nose with faster recovery than when it has to be done by opening the skull.Pituitary adenoma

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Spinal tap, or lumbar puncture headache occurs in one out of four people undergoing this procedure. Spinal tap is usually done to examine spinal fluid for infections, bleeding, multiple sclerosis, and other conditions. A small percentage of people undergoing epidural anesthesia, which involves placement of the same kind of needle into the same space between vertebrae, also develop a spinal tap headache. This happens because the needle is accidentally placed too far and it causes a leak of spinal fluid. Spinal tap headache is very easy to diagnose – it stops as soon as the person lies down and begins within minutes of sitting up. Normally, the brain floats in cerebrospinal fluid, but if this fluid is drained away by a spinal tap, the brain sags, pulls on the brain coverings, called meninges, and causes a severe headache. The majority of people do not develop this headache after a spinal tap because as soon as the needle is withdrawn, the hole in the dural sac that covers the spinal cord and the brain closes. In some people, especially if it takes a few sticks to get the fluid flowing and with a larger needle, the hole may not close right away and the fluid keeps leaking inside the spine. In most people the headache stops on its own within a day or two. If it doesn’t, the problem can be fixed by a “blood patch” procedure. It involves taking the patient’s own blood from the vein and injecting it into the same space between vertebrae where the spinal tap was done. Patient’s blood clots and seals the persistent leak of the cerebrospinal fluid, which stops the headache, often within minutes.
A similar headache can rarely occur without a spinal tap or even a trauma to the spine. It is called spontaneous low cerebrospinal fluid headache and it is also very positional, meaning that it gets better when the person is lying down. This headache is more difficult to diagnose, but an MRI scan of the brain sometimes shows inflamed meninges around the brain, which suggests this diagnosis. Finding a leak is more difficult and requires looking at the flow of the spinal fluid and searching for a leak. When a single leak is found, a blood patch procedure can help, but with multiple leaks the treatment becomes more complicated. A single case of using Botox to helps this type of headaches was described here last year.

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Many patients visiting the New York Headache Center with persistent post-traumatic headaches report having had a relatively mild head injury. The perception by neurologists has always been that milder injuries without loss of consciousness are more likely to cause headaches that severe ones. A research study just presented at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles confirms this old observation. Dr. Sylvia Lucas and her colleagues at the University of Washington in Seattle evaluated 220 patients with a mild traumatic brain injury (TBI) and a group of 378 individuals with moderate or severe brain injury. Both groups were evaluated within a week of the head injury and then again, by phone, 3, 6 and 12 months later. Both groups had similar demographics (age, sex, etc) and similar causes of injury (motor vehicle accidents was the most common cause). In the mild TBI group headaches were present in 63% after 3 months, 69% after 6, and 58% after 12 months. In the moderate and severe TBI group these numbers were 37%, 33%, and 34%. In both groups about 17% also had headaches prior to the injury. As far as the kind of headaches these individuals experienced, migraine was the most common type in both groups. It remains unclear why a milder injury should cause so many more headaches than a severe one. Treatment of post-traumatic headaches includes the usual approaches to the treatment of migraines – aerobic exercise, biofeedback and relaxation training, magnesium, butterbur, CoQ10, and other supplements, abortive medications, such as Migralex and triptans, prevention with Botox and other medications.

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A throbbing headache in the left temple with sensitivity to light and noise, occurring daily and present for almost a year seemed to indicate a typical chronic migraine headache in a man I saw last week. His headache did not respond to pain medications, short courses of steroids and sinus surgery. The MRI scan of the brain and neurological examination was normal. The only unusual part was that this was a 66-year-old man who never had any headaches before and who had no family history of headaches. Migraines can begin as early as infancy and as late as 50’s, but it is extremely unusual to start having migraines for the first time in the 60s. Headaches that occur in later years are more likely to be due to conditions such as brain tumors (primary – glioma or meningioma, or secondary due to metastases from breast, lung and other tumors), subdural hematoma, or inflammation of blood vessels, which was the case in this 66-year-old man. He suffered from temporal arteritis, also called giant cell arteritis. The diagnosis is confirmed by blood tests (elevated ESR and CRP) and biopsy of the artery. Treatment is usually very effective and typically consists of a steroid medication such as prednisone. Unfortunately, many patients with temporal arteritis need to stay on at least a small amount of this medicine for many years if not the rest of their lives and this drug has many potential serious side effects. However, if left untreated temporal arteritis can cause strokes and blindness, so it is very important to diagnose and treat it as soon as possible.

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