Functional MRI (fMRI) imaging has been a powerful tool for visualizing processing of information in the brain. This technique is based on the observation that the MRI signal changes with changes in the amount of blood flowing to a particular region of the brain, which correlates with the activity of that brain region. This is a very sophisticated technique that relies on complicated computer algorithms and this is where the problem lies.

A review of the three most popular software processing packages suggested that false-positive results are present in up to 70% of studies, which means up to 40,000 published trials may provide erroneous results. This review was published in the Proceedings of the National Academy of Sciences.

fMRI reports often provide tantalizing details about the effect of emotions, thoughts, drugs, etc on the brain. I searched through my posts and found three “Expect relief and you will get it“, “Botox helps headaches, makes you happier“, and “Science of acupuncture“.

This is not to say that all of this research is worthless. However, I would be skeptical of studies that involve a small number of subjects and from centers not known for rigorous scientific research.

Parkinson’s disease (PD), parkinsonian symptoms, and restless leg syndrome (RLS) are more common in people who in middle age suffered from migraines with aura. Those suffering from migraine without aura in their midlife had increased risk of having symptoms of Parkinson’s and RLS, but not PD. These are the findings of a large study of residents of Reykjavik, Iceland who were born between 1907 and 1935. These residents had been followed since 1967. Headaches were classified based on symptoms assessed in middle age. From 2002 to 2006, 5,764 participants were reexamined to assess symptoms of parkinsonism, diagnosis of PD, family history of PD, and RLS.

People who suffered from migraines, particularly migraine with aura, were in later life more likely than others to report parkinsonian symptoms and diagnosed to have PD. Women with migraine with aura were more likely than others to have a parent or sibling with PD. Late-life RLS was increased in those with headaches generally.

The authors concluded that there may be a common vulnerability to, or consequences of, migraine and multiple indicators of parkinsonism.

There are no proven ways to prevent PD, but eating more fruits and vegetables, high-fiber foods, fish, and omega-3 rich oils (or taking an omega-3 supplement, such as Omax3) and avoiding red meat and dairy may have some protective effect against PD.

Intensive research into the causes and treatment of Parkinson’s disease, supported by Michael J. Fox and Sergey Brin of Google among others, should lead to true breakthroughs in the next few years.

Sleep deprivation is a very common trigger of migraine and tension-type headaches. Scientists have always wondered about the purpose of sleep. We know that sleep helps strengthen our memories. New research suggests that sleep is also needed for other housekeeping chores, such as cleaning junk out of our brains. Literally, the brain rids itself of damaged proteins during sleep. It appears that poor sleep quality leads to accumulation of these proteins, which can lead to a higher risk of Alzheimer’s disease.

Another recent study showed that people with insomnia tended to have smaller brain volume in certain regions of the brain, particularly frontal lobes.

Other research showed that a variety of psychiatric illnesses also lead to a reduced brain volume. The frontal lobes are necessary for planning our actions, mood, and affect.

Veterans with post-traumatic stress disorder (PTSD) frequently complain about sleep difficulties and have documented high rates of sleep disorders

In the latest study, the researchers scanned the brains of 144 veterans using magnetic resonance imaging (MRI).

The participants with poor sleep quality had less frontal lobe gray matter than vets who reported sleeping well.

These veteran had other psychological disorders, in addition to the sleep disorder. Half of them abused alcohol, 40 percent had depression and 18 percent had PTSD.

The connection between sleep disorders and the brain volume was not affected by psychiatric medications.

The researchers speculated that these findings are not necessarily limited to veterans. However, they were careful to stress that their findings do not prove that there is a cause and effect relationship between sleep quality and brain volume. It is possible that something else is causing both sleep problems and shrinkage of the brain or that shrinking of the brain causes sleep disturbances and not the other way around.

What is indisputable is that we all need good night’s sleep to function normally, avoid headaches, accidents, and be happy. Most people need 7 hours of sleep, but there are some who need only 5 or 6 and others, 8 to 9 hours. A very small percentage of people function perfectly well with 3 or 4 hours of sleep. On the other hand, some people do not feel rested no matter how long they sleep. Those usually suffer from a sleep disorder, such as sleep apnea, restless leg syndrome, narcolepsy, and other. The diagnosis is made through a sleep study. Treating the underlying sleep disorder often leads to a dramatic improvement in the quality of life, including an improvement in migraine and tension-type headaches.

Imbalance of many hormones produced by our endocrine system can lead to headaches. Here is a brief summary of the hormones linked to headaches.

Dr. Andrew Charles and his associates at UCLA just published a fascinating report on migraine aura in the journal Brain. We still do not understand the brain mechanisms that lead to the phenomenon of migraine aura. The published report characterizes a large number of visual auras recorded by a single individual over nearly two decades. This person made detailed drawings of his visual aura in real time during more than 1000 attacks of migraine aura. His auras were never followed by a headache. The drawings showed the shape and location of the aura wavefront or blackout areas in the visual field with one minute intervals. These drawings were digitized by the researchers to make it easier to analyze them. Consistent patterns of aura initiation, propagation and termination were observed in both right and left visual fields. Most aura attacks started centrally, but some also started in the periphery, which in most people is more common. The auras that started centrally moved down and in first and then up and to the side. The speed of progression of the auras was always the same. The speed was about 2-3 millimeters per minute, which is what has been reported by most other people in the past. Some auras started and then quickly stopped without progressing. In some episodes the visual aura disappeared for several minutes before reappearing in a distant location, suggesting that the aura can be clinically ‘silent’. The authors concluded that these results indicate that there can be multiple distinct sites of aura initiation in a given individual, which has never been established before. They also stated that the visual perception of migraine aura changes depending on the region of the brain’s occipital cortex that is involved. This study is another small contribution to the unraveling of the puzzle that is migraine headache.

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Thirty-two percent of patients with multiple sclerosis experience both migraine and pain with neuropathic (related to nerve damage) characteristics, according to a report by French researchers led by Xavier Moisse. These two symptoms appear to be caused by different mechanisms.

The authors conducted a postal survey to assess the prevalence and characteristics of neuropathic pain and migraine in multiple sclerosis (MS) patients. Of the 1300 questionnaires sent, 673 were complete enough be used for statistical analysis. Among the respondents, the overall pain prevalence in the previous month was 79%, with 51% experiencing pain with neuropathic characteristics and 46% migraine. MS patients with both migraine and neuropathic pain (32% of the respondents) reported more severe pain and had lower health-related quality of life than MS patients with either migraine or just pain. Migraine was mostly episodic, but in 15% they were chronic, meaning that they occurred on 15 or more days per month. Neuropathic pain was most often located in the extremities, back and head, and was frequently described as tingling and pins-and-needles. The intensity of pain was low to moderate. Nonetheless, patients with pain were more disabled than patients with migraine. Migraine, but not pain, was more common with older age, disease duration, relapsing-remitting course, and interferon-beta treatment.

We do see patients without a history of headaches who develop headaches, including migraines, as a side effect of interferon treatment, both when it is given for MS as well as hepatitis C. These headaches can be managed just like any other migraine or chronic migraine with magnesium, medications, Botox injections, etc., although the response to treatment sometimes is not as good. If a patient with MS has both migraines and pain, we try using medications such as gabapentin or amitriptyline, which can help both conditions.

Migraine headaches can be triggered by exposure to a variety of chemicals, including fumes, MSG, artificial sweeteners and many other. Now, scientists at the university of Kansas Medical Center published a study suggesting that BPA, a ubiquitous toxic chemical found in plastics, canned food, and ATM receipts, may be also involved in triggering migraine attacks. The New York Times columnist, Nicholas Kristof has been publicizing the dangers of BPA (bisphenol A) in many of his articles. BPA was recently banned from baby bottles and cups, but it is still widely used everywhere else and can be found in significant amounts in the bodies of 90% of the US population. It is not surprising that BPA could impact migraines because it can produce hormonal estrogen-like effects. Women are three times more likely to have migraines than men, with estrogen being the likely culprit.

The Kansas researchers hypothesized that BPA exposure exacerbates migraine symptoms through estrogen mechanisms. They studied the effect of BPA on female rats, in which a migraine-like state of increased sensitivity was induced. They studied changes in movement of these rats, light and sound sensitivity, grooming, and startle response. They also measured changes in genes related to estrogen and pain perception. After BPA exposure these rats had significantly increased migraine-like behaviors. They moved less, had an increase in light and sound sensitivity, altered grooming habits, and increased startle responses. BPA exposure also increased expression of estrogen and pain-modulating receptors. These results suggest that BPA may be also a contributing factor to migraines in humans.

This study has many limitations, with the main one being that it was done in rats. However, it is possible that BPA is one of many potential triggers which can make migraine headaches worse. However, there is little doubt that BPA is a chemical that should be avoided regardless of its effect on migraines.

White matter lesions (WML) are more common in people who suffer from migraine headaches with or without aura and my recent post mentioned yet another study confirming this finding. Researchers from Johns Hopkins School of Medicine just published a study in the journal Neurology which provides further reassurance about the benign nature of these mysterious lesions. They examined over 1,000 migraine sufferers with two MRI scans separated by 8 to 12 years. While those with migraines had a significantly greater risk of having these WML or as these researchers called them white matter hyperintensities (WMH) the number of these lesions did not increase with the passage of time. This study contradicts a larger, so called CAMERA study which showed progression of the number of WMLs in women. That study was done in younger people and the authors speculate that whatever might be causing these WML may be occurring at a younger age when the disease of migraine is most active. It is a well established fact that migraines are most common in 20s, 30s, and 40s but then tend to subside.

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Vertigo presenting during the peri-menopause can be related to migraine, according to a report by Nashville neurologists led by Dr. Jan Brandes. They collected information on 12 women who presented with a new onset of vertigo during their peri-menopause and who fulfilled the criteria for migrainous vertigo. Only 4 of the 12 were previously diagnosed to have migraine headaches and all of them were treated for at least a year for non-migraine causes of vertigo. Once the diagnosis of migrainous vertigo was made a combination of hormonal and conventional migraine preventive therapy produced a significant improvement in these women. The authors concluded that the appearance of vertigo during the peri-menopause should prompt an evaluation for possible migraine connection and if such connection is found the treatment should include a combination of hormonal and traditional migraine therapies.
Other non-migraine causes of vertigo include inner ear problems, brain disorders, such as strokes and tumors, and neck muscle spasm. The latter usually causes dizziness rather than true vertigo, which is defined as a spinning sensation. Dizziness can also be caused by drop in blood pressure, especially on standing up, peripheral nerve damage (such as in diabetes or vitamin B12 deficiency), eye, and other conditions.

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Fainting spells (syncope) are more common in people who suffer from migraine headaches. Compared with control subjects, migraineurs have a higher lifetime prevalence of syncope (46 vs 31%), frequent syncope (five or more attacks) (13 vs 5%), and being lightheaded on standing up or on prolonged standing (32 vs 12%).

It appears that syncope is also a more common symptom of migraine than previously suspected, according to a study by Case Western Reserve neurologists.

The study involved 248 patients who had at least 3 episodes of syncope. Of these patients, 127 had a headache at the time of syncope and 121 did not. Syncopal headaches were classified as either syncopal migraine or a non-migraine headache. The syncope groups were then compared to 199 patients with migraine headaches.

Nearly one-third of recurrent syncope patients met criteria for syncopal migraine. This group resembled the migraine headache population more than the syncope population in age, gender, autonomic nervous system testing, and associated medical conditions. The syncopal migraine group also reported a longer duration of syncope and a longer recovery time to normal. Finally, anti-migrainous medications reduced syncope in half in the syncopal migraine patients.

The authors concluded that syncope may have a migrainous basis more commonly than previously suspected.

To reduce your propensity to fainting, try to avoid dehydration, hunger, sleep deprivation, alcohol, and other triggers that you can identify. Cardiovascular conditioning is also likely to help.

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Migraine affects people in all socio-economic categories, however it is more likely to occur in poor, according to a report in the latest issue of Neurology. Researchers examined the data from the American Migraine Prevalence and Prevention Study. This study surveyed 132,674 females and 124,665 males 12 years of age and older. The participants were divided into three income groups, income below $22,500, between $22,500 and $60,000 and above $60,000. They found that those with lower income were more likely to develop migraine headaches. This is not a new finding and a possible explanation for this phenomenon is that poor tend to have more physical and psychological stress. However, a new and very interesting finding of this study is that the remission rate was the same in poor and well to do. The authors speculate that this may be because once migraines start only biological and genetic factors influence the timing of remission. We do know that in many women menopause leads to cessation of migraine headaches.

Performing an MRI scan is unnecessary in the vast majority of migraine sufferers. However, many migraineurs end up having this test because they are concerned about having a brain tumor or another serious condition and because many doctors order MRIs to avoid a possible malpractice suit, however remote the possibility. MRI scan does not involve any radiation, so it is not harmful, but it can cause other problems, besides wasting healthcare dollars. The harm often comes from finding an abnormality on the MRI which is benign, but nevertheless can be very anxiety provoking.

Lesions seen on MRI scans which are benign but very upsetting to patients are arachnoid cysts and venous malformations.

The most common finding though is white matter lesions (WMLs), which doctors sometimes jokingly refer to as UBOs – unidentified bright objects. The origin and the meaning of these spots remains unclear, although the most likely explanation is that these spots are due to ischemia or lack of blood flow. A Dutch study of 295 men and women published in 2004 showed that people who have migraine with aura had a higher risk for silent strokes. As far as WMLs, surprisingly, control subjects, that is people without migraines, had the same high chance of having WMLs as those with migraines – about 38%. However, women with migraine were more likely to have these lesions, regardless whether they had auras or not. A follow-up study published in 2012 reported on 203 of the original 295 patients who underwent another MRI scan 9 years later. This study showed that 3 out of 4 women had progression of these lesions, but they did not have any more strokes. They also did not find an increased risk of dementia in these women.

Another important finding from this long-term study is that migraine sufferers who tend to have syncope attacks (fainting) or near-fainting or feeling lightheaded on standing up or when having blood drawn are more likely to have these WMLs. This suggests that lack of blood flow to the brain may be responsible for WMLs. These findings were presented in a separate article in Neurology.

So, while we still don’t know the cause of WMLs they do appear to be benign and do not lead to other serious problems.

If WMLs are related to strokes as suggested by the fact that drop in blood flow to the brain may predispose one to having WMLs and in a severe form drop of blood flow causes strokes, then possibly approaches that prevent strokes may also prevent WMLs. Even if they are benign, having WMLs is concerning because we may not yet know some of their negative consequences. We know that the risk of strokes can be reduced by avoiding smoking, controlling blood pressure in people with hypertension and blood glucose in diabetics, maintaining normal cholesterol levels, maintaining normal weight, and exercising regularly.

A recent study published in Neurology showed that WMLs are strongly correlated with the frequency of exercise – the more people exercised the less likely they were to have WMLs.

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Migraine aura seems to indicate a different underlying brain condition than that of migraine without aura. We know that the risk of strokes is higher in patients who suffer from migraines with aura. The increase in this risk is very slight, although it is three times higher in women than in men and in women it is magnified by oral contraceptives. The risk is also increased in both men and women by the known risk factors, such as high blood pressure, diabetes, high cholesterol, smoking, and other.

A recent study by Stephanie Nahas and other neurologists at Thomas Jefferson University in Philadelphia discovered that aura carries another risk. A study of 139 patients admitted for stroke evaluation showed that those who had a history of migraine aura had a much larger stroke than those without. This is another reason for people who suffer from migraines with aura (or auras without a migraine) to take all possible measures to reduce their risk of strokes. These might include regular exercise, healthy diet, controlling blood pressure, blood glucose, and cholesterol. Some people could also benefit from a daily dose of aspirin (make sure to check with your doctor first), omega-3 fatty acids, and in people with high homocysteine levels, vitamin B12 and other B vitamins.

Bipolar disorder and other psychiatric problems are 2-3 times more common in those who suffer from migraine headaches and migraines are 2-3 times more common in patients with mental illness. Those who suffer from migraines are very familiar with the attitude of doctors, family members and employers who consider migraine to be just another headache, meaning that it is not something that should stop you from doing any activities. Some doctors still blame migraine sufferers for their condition and think that this is a problem of neurotic women. People with mental illness face even more severe discrimination from doctors and everyone else. A very good article on this topic, “When Doctors Discriminate” has appeared in the New York Times this Sunday.

Dr. Robert Shapiro of the University of Vermont recently presented a study which looked at attitudes toward patients with migraine, epilepsy and other conditions. It was an internet-based survey of 705 individuals that examined the levels of stigma by asking following questions:
How comfortable would you be with Jane as a colleague at work?
How likely do you think it is that this would damage Jane’s career?
How comfortable would you be with the idea of inviting Jane to a dinner party?
How likely to you think it would be for Jane’s husband to leave her?
How likely do you think it would be for Jane to get in trouble with the law?

Scoring ranged from 0 to 100. The mean scores were very similar for migraine, panic disorder, and epilepsy and were all significantly greater than for asthma. He concluded that migraine carries as much stigma as epilepsy or panic disorder, although he noted limitations.

Another group of researchers from Philadelphia led by Dr. William Young interviewed 123 patients with episodic migraine, 123 with chronic migraine, and 62 with epilepsy for levels of stigma as perceived by these patients.

Chronic migraine patients had much higher scores on the Stigma Scale for Chronic Illness (SSCI) than the other two groups, but that seemed to be due to chronic migraine patients’ reduced ability to work.

Dr. Young reported that migraine patients reported more “internalized” stigma, that is negative attitudes in themselves or anticipation that others would think negatively of them, and less actual discrimination on the basis of their illness, compared with the epilepsy patients.

These studies and the New York Times article indicate a great need for educating both doctors and the general public about the nature of chronic migraines and mental diseases and for combating the stigma associated with these conditions.

Auditory hallucinations can be associated with chronic headaches, according to a report by our own Dr. Sara Crystal and three other neurologists from the Bronx.

These four doctors reported on 7 of their own patients and also described 8 patients previously reported in the medical literature. Half of the patients had migraine with aura. Regarding hallucination content, the most common sound was distinct human voices in 8 patients, followed by hearing crickets in 2, and ringing bells in another 2, general white noise, also in 2, and repetitive beeping in 1. Regarding timing, 12 experienced hallucinations along with the headache while 3 heard sounds prior to attacks. The duration of the auditory hallucinations was less than one hour but occasionally lasted 4-5 hours or for the duration of the headache. Ten patients had either a current or previous psychiatric disorder, mostly depression. Improvement in both headaches and auditory hallucinations occurred both spontaneously and when prophylactic medications were used, which included propranolol, topiramate, and amitriptyline.

In conclusion, auditory hallucinations are uncommon, but do occur before or during migraine attacks. They usually feature the sound of human voices. Because these are unusual manifestations of migraine, doctors should consider other possible causes, such as a brain tumor, epilepsy, or schizophrenia.

The vascular theory of migraine suggested that changes in the blood vessel size and blood flow were responsible for the development of migraine attacks. This theory went out of fashion and for the past 20 years most headache experts thought that the process of migraine begins in the brain and not blood vessels. A new study by researchers at the University of Pennsylvania seems to again implicate blood vessels as the culprit.

Brain is supplied by four blood vessels that come up from the neck into the brain – two carotid and two vertebral arteries. At the base of the brain they connect with each other making a circle of Willis. Thomas Willis was a 17th century English physician who first described this circle. This circle ensures good blood flow to the brain even if one or even two of the four blood vessels become occluded. Only a third of the population actually has a complete circle connecting all four arteries, while in the rest the circle is incomplete.

This is not a new finding – a group of French physicians reported this discovery in 2009. However, the current study showed that having incomplete circle affected cerebral blood flow and this may be contributing to the process of triggering migraines.

This abnormality appears to be particularly common in those who have migraine with aura. The study looked at 170 people from three groups – a control group with no headaches, a group that had migraine with aura, and a group that had migraine without aura. An incomplete circle of Willis was more common in people with migraine with aura (73 percent) and migraine without aura (67 percent), compared to a headache-free control group (51 percent).

One of the authors commented that “People with migraine actually have differences in the structure of their blood vessels — this is something you are born with” and, “These differences seem to be associated with changes in blood flow in the brain, and it’s possible that these changes may trigger migraine, which may explain why some people, for instance, notice that dehydration triggers their headaches.” A very interesting observation was that “Abnormalities in both the circle of Willis and blood flow were most prominent in the back of the brain, where the visual cortex is located. This may help explain why the most common migraine auras consist of visual symptoms such as seeing distortions, spots, or wavy lines”. It is also possible that the increased risk of strokes in patients with migraine with aura is due to this anatomical defect.

It is most likely that having an incomplete circle of Willis is only one of many predisposing factors. Unfortunately, we cannot do much about this congenital abnormality, but we do have many ways to prevent migraine headaches even without fixing this problem directly.

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It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The reverse is also true: if you suffer from anxiety and depression, you are 2-3 times more likely to develop migraine headaches. These associations are called comorbidities. Anxiety and depression are also comorbid with other pain syndromes. A group of Dutch researchers examined records of almost 3,000 patients with anxiety and depression to look for the presence of comorbid migraines and pain in the back, neck, face, abdomen, joints, and chest. All patients were interviewed twice, with a two year interval, and were asked if they had any of those pains in the preceding 6 months. Their results, published in The Journal of Pain, clearly show that having anxiety and depression increases the risk of developing migraines and other pain syndromes equally. So, this association is not specific to migraines, but applies to all pain syndromes. This means that anxiety and depression do not cause headaches and pain and the other way around. Most likely, one condition predisposes the sufferer to develop the other. It is also likely that shared genetic predisposition or the involvement of certain brain chemicals that are involved in both pain and depression, such as serotonin, adrenalin, and other, may be responsible for these associations.

Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world after dental caries (cavities), according to a new study conducted by the World Health Organization (The Global Burden of Disease Survey 2010) and reported in the journal Headache. Tension-type headaches affects 20.1% of the world’s population and migraine, 14.7%. Migraine is the 7th most disabling of all medical conditions. Migraine sufferers spend more than 5% of all of their time having pain and other symptoms of this condition. Migraine is by far the most disabling of all neurological condition. Hundreds of millions of people in the world suffer unnecessarily from headaches. This is in part due to lack of awareness of the extent, the severity, and the impact of headaches, but also due to limited resources. The National Institutes of Health in the US allocates very little money to researching headache disorders and a disproportionally large amounts on neurological conditions such as epilepsy, MS, Parkinsons, and other. I am not suggesting that these other condition do not deserve to be studied, but suffering by many more people would be relieved by investing more money in headache research.

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Sudden hearing loss is a rare condition, but it is more common in people who suffer from migraine headaches, according to just published study by Taiwanese researchers. Taiwan, just like many Scandinavian countries has national health insurance and the large computerized data base allows doctors to perform reliable studies of many medical conditions. This study, which was published in Cephalalgia, an international headache journal, involved 10,280 migraine sufferers who were compared to 41,120 healthy control subjects. Doctors examined ten years worth of records of these people and discovered that having migraines almost doubled the risk of sudden hearing loss (the medical term is sudden sensorineural hearing loss). The incidence was about 82 per 100,000 person-years in migraine sufferers and 46 in those without migraines. They also discovered that having hypertension (high blood pressure) increased the risk of sudden hearing loss. This suggests that the hearing loss may be due to sudden drop in blood supply to the hearing nerves. Surprisingly the increased risk was not more pronounced in patients with migraine with aura since vascular problems are more common in those with auras. Treatment of sudden hearing loss requires immediate visit to a doctor, who takes a detailed history, examines the patient, does hearing tests, and obtains an MRI scan of the brain. Sudden loss of hearing can be caused by impacted wax in the ear, brain tumor and other brain disorders, but usually no such causes are found. If no obvious cause is found, treatment typically involves taking a steroid medication. Acupuncture may also help.

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Many migraine sufferers report that flickering lights and vigorous exercise trigger their migraine attacks. Danish researchers published a study in the journal Neurology , in which they recruited 27 patients who suffered from migraines with aura. Of these 27, 12 reported that flickering lights triggered their attacks, 10 reported that vigorous exercise did and 4 felt that both of these were triggers, while only one felt that these were not triggers for her migraine headaches. These patients were then subjected to bright flickering lights for 30-40 minutes, exhausting exercise for 1 hour, or both. None of the 11 patients who were exposed to bright flickering lights developed a migraine, exercise alone triggered a migraine in 4 out of 12 patients (one migraine with aura and three had migraine without aura), while both types of stimulation together triggered a migraine with aura in 2 out of 7. This is a surprising finding, but it does not mean that patients are wrong about flickering light and strenuous exercise triggering migraines. A more likely explanation is that any particular trigger may require certain additional conditions, such as location which is associated with the expected headache, prior conditioning, such as stress that accompanies exposure to bright light in a certain room, added triggers, such as lack of sleep, alcohol, blood caffeine level, and many other. It is also possible that migraine with aura, unlike migraine without aura, is less likely to be triggered by exercise and flickering lights.
If you are exposed to one of your known triggers, if possible, you should try avoiding exposure to other triggers at the same time since it is often a combination of triggers that brings on a migraine. Regular aerobic exercise is one of the most effective preventive treatments for migraine headaches, so patients who are convinced that exercise triggers their headaches can be advised to start slow and gradually increase the duration and the intensity of their exercise. Ideally, everyone should exercise at least three times a week. Stationary bike or an elliptical machine may not be as much of a trigger as running because jarring of the head could also contribute to headaches. If even mild exercise causes a headache, taking an anti-inflammatory medication, such as ibuprofen or Migralex prior to exercise may prevent the headache. After a few weeks the medication may no longer be needed. Whatever is the trigger, general preventive measures will often reduce their impact. Besides exercise, these include getting enough sleep, learning biofeedback or meditation, taking supplements such as magnesium, CoQ10, and other, Botox injections, and as a last resort, prophylactic medications.

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Newer oral contraceptives increase the risk of strokes and other types of blood clots in patients with migraines with aura, according to a study to be presented at the next meeting of the American Academy of Neurology in San Diego in March. We have known for many years that estrogen-based oral contraceptives increase the risk of strokes in women who suffer from migraines with aura. However, most of the studies were done looking at the old contraceptives which contain a relatively high amount of estrogen (such as Ortho-Novum 1/50, Ovral, Ogestrel, and other). It was logical to assume that the newer contraceptives (such as Yaz, Yasmin, Loestrin, and other) with lower amounts of estrogen would be safer. Most headache specialists, myself included, were not as adamant about avoiding the newer low-dose estrogen contraceptives in our patients who had migraine auras. I would always discuss the risk of strokes and other blood clots with my patients and would always suggest using other modes of contraception, but if other methods were not acceptable to the woman or if the contraceptive had other benefits (helped PMS, acne, regulated periods, reduced bleeding, etc) I would not make a big fuss. This new study will make me more insistent on stopping the pill because the risk appears to be even higher with the newer contraceptives than with the old ones. Even the vaginal ring (NuvaRing), which I mentioned in a recent post as a good option to reduce menstrual migraines, carries a higher risk than the old oral contraceptives. The ring has a low dose of estrogen, but it is speculated that the risk is further increased because estrogen is released continuously (with the pill estrogen goes in and out of the body daily). The same may apply to estrogen patches, such as Ortho Evra. The study looked at over 145 thousand women, which makes its conclusions fairly reliable. Another surprising finding of this study is that the risk of blood clots in legs (deep vein thrombosis) was very high – 7.6% in women with migraine with aura and 6.3% in those without aura taking contraceptives.
The bottom line, if you suffer from migraines with aura do not take estrogen-based contraceptives, whether in a pill, patch, or ring, unless you and your doctor decide that the benefits outweigh the risks.

Some features of migraine with aura clearly set it apart from migraines without aura. Aura is present in 15% to 20% of migraine sufferers. Most often it is a visual disturbance, which consists of either gradual loss of vision, starting from the periphery of visual field and moving to the midline. Many people see shimmering and sparkling lights with or without loss of vision and some see things smaller than they are. Sensory aura consists of pins-and-needles, tingling and numbness on one side of the body, often starting with the hand, moving up the arm and then involving the face. Typical aura lasts 20-60 minutes, but it can be shorter or longer. Auras are usually followed by a headache, but sometimes it occurs without any pain. People who have auras are at a slightly higher risk of having a stroke. This risk is magnified by other factors, such as smoking, high-dose estrogen contraceptives, hypertension, diabetes, and high cholesterol.
A recent study by Austrian neurologists published in Headache examined 54 patients who kept a detailed diary and recorded a total of 354 migraine auras. Using a statistical tool called multivariate analysis they discovered that smoking, menstruation, and hunger were likely to increase the risk of having an aura. Holidays and days off reduced the possibility of experiencing an aura. They also found that non-migraine headaches and migraine without aura were more likely to occur during menstruation, psychological stress, tiredness, odors, and were decreased by smoking.
The surprising finding in this study is that the risk of having a migraine with aura was doubled in the first three days of menstruation. The consensus of headache specialists has been that menstrual migraine is typically a migraine without aura, although at least one other study by Danish doctors also reported menstruation as a trigger of migraine with aura.

The use of acute anti-migraine medications in patients with episodic migraine (migraine occurring on less than 14 days a month) prevents progression of episodic migraine into its chronic form, according to Dr. Zaza Katsarava and his colleagues in Essen, Germany. They followed 1,601 patients with episodic migraine headaches for two years. None of these patients were taking prophylactic medications and 151 patients took no acute anti-migraine medications. Overall, during the two years of observation, 6.2% of 1,601 patients developed chronic migraines (defined as headaches occurring on 15 or more days each month). However, those who took triptans (sumatriptan and other) had a 66% reduction of risk of headaches becoming chronic, those who took a single pain medicine had a 61% lower risk of chronification, and those who took a combination pain killer, like Excedrin, had a 40% reduction of this risk. This analysis took into account patients’ age, sex, body mass, education level and baseline migraine frequency. A possible explanation for why combination drugs were less protective is that most of them contain caffeine, which is known to make headaches worse. Another very important lesson that can be drawn from this study is that it is important to treat migraine attacks with effective medications because if left untreated these intermittent attacks may become more frequent and even daily. At least two million Americans suffer from chronic migraines and it is likely that in many this debilitating condition could have been prevented by more aggressive and effective treatment of acute attacks.

Many women are denied therapy with combined (estrogen with progesterone) hormonal contraceptives because published guidelines by doctor organizations recommend against their use in migraine with aura. The concern is that these products might further increase the risk of a stroke that accompanies aura. Stroke risk has been reported to vary directly with aura frequency, and aura frequency in turn has been shown to have a direct relationship to estrogen concentration. With the introduction of increasingly lower dosed hormonal contraceptives it is not clear if these risks are as high as with high-dose contraceptives. These formulations are expected to result in a lower frequency of migraine aura. In addition, continuous therapy eliminates monthly estrogen drops which can be expected to prevent menstrual migraines.
Dr. Anne Calhoun and her colleagues in North Carolina examined a database of 830 women seen in a menstrual migraine clinic and identified 23 women who had current history of migraine with aura, had a confirmed diagnosis of menstrually-related migraines, and were receiving extended-cycle (continuous) dosing of a vaginal ring contraceptive. At baseline, subjects averaged 3.23 migraine auras per month. With extended dosing of the vaginal ring contraceptive, median frequency was reduced to 0.23 auras per month after a mean observation of 7.8 months. No at a single woman reported an increase in aura frequency. On this regimen, menstrual migraine was eliminated in 91.3% of women.
The authors concluded that continuous use of vaginal ring contraceptive was associated with a reduced frequency of migraine aura and with resolution of menstrual migraines.
The risk of stroke in an otherwise healthy woman who does not smoke and has migraine auras is higher than in women without aura, but it still extremely small. It is possible that continuous use of very low dose contraceptives, particularly vaginal ring, may not increase the risk of strokes and may even prevent it.

Vertigo is a common symptom in patients suffering from migraine headaches. Vestibular migraine is a new category of migraine proposed by German researchers led by Dr. Andrea Radtke.  In the current issue of Neurology Dr. Radtke and her colleagues report on the long-term outcomes of 61 patients with this condition. The average follow-up period was 9 years. Unfortunately, 87% of sufferers still had vertigo and in 56% it improved, 29% it worsened and in 16% it remained unchanged. In 21% the impact of vertigo on their lives was severe, in 43% moderate and in 36% mild. Mild hearing loss occurred in 11 or 18% of patients.This report does not mention what kind of treatments were attempted in these patients. It is possible that aggressive therapy with vestibular rehabilitation, possibly acupuncture, magnesium, other supplements and medication can make a difference.

Prodrome refers to symptoms that precede an actual attack of migraine. Migraine aura also precedes an attack, but it occurs 20 to 60 minutes before the headache and typically consists of visual disturbances or partial visual loss. Prodrome typically is a period of 24 to 48 hours before a migraine attack and it can consist of a wide variety of symptoms. Many people are aware that these symptoms indicate an impending migraine attack, but some are not. Some people tell me that when they feel unusually full of energy, very happy, and creative they realize that they will get a headache the next day. And some realize that what was happening to them was a prodrome only in retrospect, even after having all of the same symptoms repeat themselves many times. Not many people experience prodrome and its features are varied. Here are some of the symptoms reported in the prodrome period:
Depression
Euphoria
Irritability
Restlessness
Hyperactivity
Fatigue
Drowsiness
Difficulty concentrating
Neck or other muscle stiffness
Feeling hot or cold
Increased thirst
Increased urination
Food cravings
Loss of appetite
Yawning
Tearing
Constipation
Diarrhea
Fluid retention
Sensitivity to light and/or sound
If you do experience a prodrome and are aware of it while it is happening, taking an anti-inflammatory medication (Advil, Aleve, Migralex) or, if that does not work, a triptan may prevent an attack or at least make it milder.

Migraine aura is a visual disturbance that usually precedes the headache in about 20% of migraine sufferers. The aura can sometimes occur without a headache and some people, myself included, always have migraines and auras independently of each other. A typical aura usually lasts 20-30 minutes and consists of partial loss of vision on one side of both eyes, or flashing lights, colored zigzags, or tunnel vision. Most headache specialists and neurologists have always believed that most people have an aura first and when it resolves, the headache begins. A study by Dr. Jakob Hansen suggests that this may not be the case. He examined diaries of 201 adults who experienced 861 migraine attacks and discovered that in 61% of attacks the headache was present within 15 minutes of the onset of aura. Nausea was present in 40%, sensitivity to light (photophobia) in 84% and to noise (phonophobia) in 67% within 15 minutes of the onset of visual aura. I have heard from some of my patients similar reports of a headache and aura starting at the same time, but it seemed that those were a small minority. I will have to be more thorough in questioning my patients. One practical application of this finding is that we usually tell patients who use injectable sumatriptan (Imitrex) to treat their migraine attacks to wait for the aura to resolve and then take the injection. The reason for this delay is a perception that the injection will not help if taken during the aura phase. It is speculated that if the medicine gets into the brain circulation before pain starts it may not be able to attach itself to certain receptors. We do recommend taking a tablet as soon as the aura starts because it takes at least 30 minutes for a tablet to be absorbed. If Dr. Hansen’s results are confirmed, then most people should not wait to give themselves an injection of sumatriptan.
Since we are on the subject of injections, I should point out that they are extremely underutilized. Doctors usually prescribe them if the patient has severe nausea or vomiting and cannot hold down the pill. However, an injection may also be very useful for someone who wakes up with a headache without severe nausea, but they know that the tablet may take 2 hours or longer to provide relief. Taking an injection, which can stop the headache within 10 – 15 minutes, can make a difference between being able to go to work or not. I sometimes take an injection even when I have a mild migraine if it happens at night. The tablet will usually work, but I may have to wait for two hours before I can fall asleep, so I take a shot. From left to right 3 types of sumatriptan injectors: Alsuma, Sumavel, Imitrex injections.

Children with epilepsy are more likely to suffer from migraine headaches than children without epilepsy, according to a study just published in Neurology by researchers from Johns Hopkins University. Dr. Sarah Kelley and her colleagues studied 400 children who were seen at an epilepsy clinic. They discovered that 25% of children with epilepsy also suffered from migraine headaches. Children aged 10 and older, as well as those with JME (juvenile myoclonic epilepsy) and BECTS (benign epilepsy with centrotemporal spikes) were more likely to have migraines than younger children or those with other types of epilepsy.
Unfortunately, pediatric neurologists who were seeing children who had both epilepsy and migraines (with migraines occurring once a week or more) did not discuss their migraines in half of such cases. Primary care doctors treating adults have also been shown to ignore complaints of migraine headaches in many patients, but in this study doctors were pediatric neurologists and they should know better. The education of all doctors, including adult and pediatric neurologists in the treatment of headaches leaves a lot to be desired. Many prominent neurology programs, including those at Cornell, Yale, NYU, and other medical schools lack a dedicated headache specialist. This is probably due to a combination of factors, including low prominence of headaches as compared to conditions such as epilepsy, Alzheimer’s, strokes, and MS, as well as lack of funding for research and lack of faculty trained in headache medicine.
Parents of children with migraines also sometimes minimize the seriousness of migraine as compared to epilepsy, however migraine is often more disabling than epilepsy, even if it is less dramatic in its manifestations. Migraine is highly treatable condition and children often do very well with biofeedback, magnesium, CoQ10 and other supplements and in case of very frequent attacks, Botox injections. If these, safer treatments fail, medications can be very effective. We use both abortive medications, such as sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig), eletriptan (Relpax), almotriptan (Axert) and other triptan drugs, as well as prophylactic medications, such as beta blockers (blood pressure medications), some epilepsy drugs, and antidepressants (although some antidepressants can make seizures worse). If the pediatric neurologist is aware that the child also has migraine headaches she may decide to use an epilepsy drug that can help both conditions. Migraines improved in about 28% of children in this study when they were prescribed an epilepsy drug, but this number potentially might have been higher if doctors were aware of the migraine diagnosis. None of the children with weekly or more frequent migraines were prescribed a triptan drug.

Until now, migraine headaches have not been associated with erectile dysfunction (ED). A study by Taiwanese doctors published in journal Cephalalgia makes a strong case that such a connection exists. The researchers analyzed electronic records of one million patients randomly selected out of almost 24 million who are covered by the Taiwan National Health Insurance. They eliminated from this analysis patients with mental illness and they also controlled for hypertension, diabetes, obesity and other condition known to cause ED. Men who suffer from migraines were 1.6 times more likely to have ED. Surprisingly, younger men with migraines, aged 30 to 39 had the highest risk of having erectile dysfunction – they were twice more likely to have ED than men of that age without migraines. The causes for this association are not clear. We do know that patients with chronic pain are more likely to have sexual dysfunction. We also know that migraine patients have impaired regulation of their brain blood vessels, so it is possible that penile blood vessels are also affected. Men are less likely to see doctors for all medical conditions compared to women and this includes migraines – I see about ten times as many women as men, while we know that women outnumber men only by 3 to 1 ratio. This may apply even more to such an embarrassing condition as sexual dysfunction, making these young men suffer unnecessarily from both migraines and ED. Encourage men with migraines to see a doctor, while in the office they may also get help for their sexual dysfunction, if they have it.

Many migraine sufferers complain of headaches on weekends, vacations, or after a period of stress. Researchers at the Montefiore Medical Center in the Bronx confirmed this observation by observing 17 migraine patients. The patients completed over 2,000 twice daily diary entries about their headaches and the amount of stress they had. The doctors found that patients had 20% higher chance of developing a migraine 12 to 24 hours after their mood changed from “sad” or “nervous” to “happy” or “relaxed”. There are several possible explanations for this phenomenon. One, is that some people have a certain amount of control over their headaches and do not allow themselves to have a headache when they know that they have to perform important functions, but as soon as this demand ends, they pay for the stress by getting a headache. Another possibility is that sleeping longer on weekends, vacations, or after the stress is over, triggers a migraine. Migraine sufferers can be very sensitive to changes in their sleep schedule with both too much and not enough sleep being a trigger. Weekend headaches can be also triggered by caffeine withdrawal – drinking your first cup of coffee at 10 instead of 8 in the morning.

Sinus inflammation can seriously worsen migraine attacks according to a recent presentation by Dr. V. Martin and his colleagues made at the 54th Annual Scientific Meeting of the American Headache Society in Los Angeles. Migraines are often mistaken for sinus headaches because pain of migraine is often felt in the area of sinuses and many migraine attacks are accompanied by a clear nasal discharge. These patients will naturally first see an ENT specialist and often undergo treatment with antibiotics and even surgery before the diagnosis of migraine is considered. However, sinus inflammation, both allergic and non-allergic in nature, can coexist and worsen migraines and increase disability caused by migraine according to these new findings. Many neurologists will often dismiss the diagnosis of sinus headaches and proceed with treating only migraine symptoms. On the other hand, many patients and ENT doctors will focus solely on treating sinus disease and ignore the possibility of migraines. As a neurologist, I also tend to be biased in the direction of migraine headaches, however, but now will try to always consider the possible contribution of sinus disease as an aggravating factor. This study may explain why some of my patients with definite migraines will often report at least some improvement from sinus or allergy medications.

Air pollution has been shown to worsen migraine headaches. Connection between pollution and risk of heart attacks has also been established. A recent study showed that even low levels of particulate matter can increase the risk of a stroke. Doctors looked at 1,705 patients who were admitted to the hospital with an acute stroke and checked pollution records on the days these strokes occurred. They found that strokes were more common within 12 hours of the rise in the level of pollution. The correlation was linear – the higher the pollution, the higher the risk of stroke. The risk of stroke was elevated even at pollution levels considered “satisfactory”.

Weather is a common trigger of migraine headaches. Review of studies linking weather to migraines suggests that there are three weather-related triggers. It is high humidity, high temperature, and drop in barometric pressure. Some migraine sufferers, just like many people with arthritis, can predict rainy weather. We can speculate that the drop in barometric pressure causes blood vessels inside the skull to dilate and trigger a migraine. This happens because of faulty regulation of blood vessels in those with migraine. This is also probably the reason why migraines are sometimes caused by exercise or sexual activity – blood vessels dilate excessively and trigger a migraine. High altitude headache or mountain sickness is another example of headaches caused by low barometric pressure. In fact, one study showed that people living at high altitudes, specifically in Denver, are more likely to have mgraines than those living at sea level. Treatment of barometric pressure headaches involves the usual approaches to migraines – regular exercise, biofeedback, magnesium, CoQ10, Botox, and drugs. Diamox (acetazolamide) is a diuretic drug that is particularly effective for mountain sickness and in some patients can also prevent weather-related headaches.
It is not clear why high humidity causes headaches, but high temperature may lead to a) dehydration, which is a trigger of migraines for many and b) again, dilatation of blood vessels which the body uses to cool itself by bringing more warm blood to the surface (this is why we look red in the heat).
There is an easy way to figure out if your headaches are triggered by weather – download our free app into your iPhone or iPad. Headache Relief Diary (also known as Migralex Diary) automatically downloads barometric pressure, humidity and temperature at the time of your headache. Just enter your zip code once and enter your headache information every time you get one and after a month or two you may be able to find your migraine triggers, including those related to the weather.

Headache is one of the most common complaints reported by patients suffering from AIDS, according to a new study by researchers from the University of Alabama. They evaluated 200 patients with HIV/AIDS and discovered that 107 or 54% of them had headaches. Only 4 of these patients had a serious underlying cause, while 88, or 44% had migraines and the rest had tension-type headaches. This is a much higher incidence of migraines than in the general population, where only 12% have migraines. The severity of HIV (CD4 cell count) correlated with the headache severity, frequency, and disability. The findings of this study suggest the importance of diagnosing and treating migraines in this population which already has reduced quality of life and which migraines make even worse.

Smoking by the mother during pregnancy increases the risk that the child will suffer from headaches. Brazilian researchers published results of their study in the journal Cephalalgia. They collected information on over 1,600 children aged 10 – 11 years and discovered that children of mothers who smoked 10 or more cigarettes a day were more likely to suffer from tension or migraine headaches. Surprisingly, exposure to second-hand smoke was not associated with an increased risk of headaches in children.

Depression is more likely to occur in people with migraines, but migraines are also more likely to develop in those who suffer from depression first. A new Canadian study reexamined this link in 15,254 people. They confirmed this association, but unlike in previous studies the researchers from Calgary discovered that this bi-directional relationship is symmetrical. That is, if you have migraines you are 80% more likely to develop a major depressive episode, but if suffer from depression first, you are only 40% more likely to develop migraines. They found that childhood trauma and stress may be a contributing factor to both conditions. The authors of the study discuss the fact that common genetic abnormalities may also predispose people to both conditions.

Genetic analysis of 594 members of 134 families by Spanish researchers confirmed the results of a previous study that discovered a genetic abnormality on the sixth chromosome that seems to be associated with migraines. This genetic marker is present only in a small proportion of migraine sufferers, but it is very likely that there are several or many other genetic abnormalities that predispose to migraine. In patients with familial hemiplegic migraine very specific genes have been identified, but even in this rare form of migraine different families had different genes that were abnormal. This wide variety of genetic factors will make it difficult to develop genetic therapies for migraine, when such therapies become available (probably 10 or more years from now). However, people who have genetic abnormalities are only predisposed to having migraines, but not necessarily will have them. This predisposition makes it more likely that the person will develop migraines, however, avoiding triggers and improving general health may prevent or at least reduce the frequency and the severity of attacks.

Women who suffer from both episodic and chronic migraines are more likely to have widespread chronic pain, which is often diagnosed as fibromyalgia. Brazilian researchers evaluated 179 women with episodic and chronic migraine. They discovered that the more frequent were their migraine attacks, the more likely they were to have widespread chronic pain. A likely explanation of this association is the phenomenon of allodynia. Allodynia is an increased sensitivity of the skin during and after a migraine attack, which affects many migraine sufferers. Patients often report not being able to brush their hair or wear glasses because the skin becomes very sensitive. This skin sensitivity can spread from the face and scalp to involve the upper body. It is logical to assume that with frequent migraine attacks this sensitivity spreads and can involve the entire body. This sensitivity is is a reflection of increased excitability of brain cells, which has been documented to be present in migraine sufferers. If migraines are frequent and are left untreated, this increased excitability can become persistent and may predispose to other chronic pain conditions. The obvious important lesson of this study is that migraine headaches need to be treated aggressively in order to avoid the development of additional pain syndromes and impaired quality of life. This treatment should utilize all available approaches – abortive drugs such as triptans (as well as Migralex and NSAIDs), and prophylactic therapies, including aerobic exercise, biofeedback, magnesium, CoQ10, Botox injections and prophylactic drugs.

Cyclic vomiting in childhood is often a precursor of migraines in adulthood. Usually a child has attacks of vomiting with or without a headache that can occur 10 – 20 times in a 24-hour period. Most children have family history of migraines and as they get older they develop migraines themselves. A study from the Cleveland Clinic led by Dr. David Rothner (a regular speaker at our annual headache symposium) shows that one third of these children may actually have a metabolic disorder and not just migraine. Most children feel perfectly fine between these episodes of vomiting. If these attacks are frequent Dr. Rothner recommends amitriptyline (Elavil), cyproheptadine (Periactin), and ondansetron (Zofran) to treat this condition. Some of the metabolic disorders could be possibly treated with supplements such as CoQ10, riboflavin (vitamin B2), as well as magnesium.

High blood pressure is not a common cause of chronic headaches. The pressure has to suddenly increase (from say 100/70 to 150/90) or to be very high (like 170/110, or higher) to cause a headache. Mild hypertension is called a silent killer because it does not cause headaches or any other symptoms for many years. Doctors have been debating for a long time what to consider normal blood pressure. A study by University of California researchers just published in Neurology looked at 12 previous studies that involved over half a million people. They determined that what was considered normal blood pressure in the past (130-139 systolic and 85 to 89 diastolic, sometimes called “prehypertension”) in fact is associated with a significant increase in the risk of strokes. This has a practical application in people suffering from migraine headaches. One of the three categories of drugs used for preventive treatment of migraines is drugs used to treat high blood pressure. So, someone with blood pressure is 130/85 may want to request that the doctor prescribes a blood pressure medication rather than a drug from two other categories – epilepsy drugs (Topamax, Depakote, Neurontin) or antidepressants (Elavil, Pamelor, Effexor, Cymbalta, etc). Fortunately, in most cases blood pressure medications tend to have fewer side effects than drugs in the other two categories. Some of the blood pressure medications that have been shown to be effective for the prevention of migraines are beta blockers, such as propanolol (Inderal), timolol (Blocadren), atenolol (Tenormin), nebivolol (Bystolic), and ACE receptor blockers (ARBs), such as candesartan (Atacand) although other ARBs, such as olmesartan (Benicar) may be also effective. Not all blood pressure drugs are equally effective for the prevention of migraine headaches. Calcium channel blockers, such as verapamil (Calan) and amlodipine (Norvasc) and diuretics are probably less effective.

Having migraines with aura increases the risk of having increased total cholesterol and triglycerides. This was found to be the case in a population-based study of 1,155 older people (average age 69) presented by Dr. Tobias Kurth at the International Headache Congress in Berlin. Although only 23 had migraines with aura the statistical data seems strong enough to warrant this conclusion. Having migraine with aura carried a six-fold increase in the risk of having abnormal levels of lipids. It is an established fact that people suffering from migraine with aura are at slightly higher risk of strokes and heart disease but the reason for this association is not known. It is possible that elevated cholesterol and triglycerides in those with migraine with aura lead to cholesterol deposits and clogging of the arteries. It is important to screen all older patients with migraine with aura for abnormal lipid levels. They also need to exercise and try to control other risk factors for strokes and coronary artery disease, such as high blood pressure, high blood glucose, obesity, and smoking.

Difficulty thinking and speaking is not unusual at the onset of a migraine attack. It is not always severe as with the reporter Serene Branson who jumbled words and appeared confused on camera. Many patients report that they have difficulty finding words, remembering well known facts, or unable to say what they want to say. This often happens at the beginning of a migraine attack, according to a study presented at the last scientific meeting of the American Headache Society. The doctors tested attention, processing speed, visual-motor reaction, and other brain functions and found that many patients had significantly lower scores at the onset of a migraine than between attacks. They also found that there was no correlation with the severity of pain – you can have severe cognitive dysfunction with a mild headache. Similarly, many patients get a very severe headache after a visual aura but others get a mild headache or no headache at all. There are no acute treatments that would stop an aura or the cognitive brain dysfunction once it starts. However, preventive treatments can be very effective. We always start with elimination of triggers, aerobic exercise, biofeedback, magnesium (sometimes intravenously) and CoQ10 supplements, and then Botox and preventive drugs. Some patients find that after the first Botox treatment they no longer develop a headache, but may still get an aura or have some other warning symptoms, including cognitive dysfunction. However, with repeated injections of Botox both headaches and other symptoms subside. This probably happens because with fewer headaches the brain becomes less irritable and stops generating auras and other neurological symptoms.

Abdominal migraine was the subject of a study by a group of doctors from a children’s hospital in Norfolk, VA was just published in the journal Headache. The physicians examined the records of 600 children with recurrent abdominal pain. They found that 4% of these children had definite and 11% had probable abdominal migraine. Shockingly, they also discovered that none of these children received correct diagnosis. Making a correct diagnosis is the first step to the correct treatment of this condition. Abdominal migraine is defined as a recurring condition which consists of abdominal pain, typically lasting one to 72 hours. The pain is usually in the middle of the abdomen or the child cannot localize it precisely. The pain is dull and aching and is of moderate or severe intensity. During the bout of pain the child usually has two other of the following features: loss of appetite, nausea, vomiting, or paleness. It is also very important for the doctors to make sure that there is no other possible cause for these attacks. Treatment usually involves avoiding foods which may trigger these attacks, including chocolate, caffeine, hot dogs, cheese and other known migraine-inducing foods. Irregular sleep schedule, skipping meals and stress are also frequent triggers. Regular sleep schedule, frequent exercise, biofeedback or relaxation training can all help. Magnesium and CoQ10 supplements have also been shown to help prevent migraines in kids. Migraine medications, such as sumatriptan (Imitrex) can be tried for severe attacks. When abdominal migraine occurs frequently preventive drugs, such as amitriptyline (Elavil), gabapentine (Neurontin), or cyproheptadine (Periactin). Considering its safety and efficacy in regular migraine, acupuncture may also be worth a try.

Dissection of the cervical artery is a dangerous condition which can lead to a stroke and even death, although in some it can be a benign condition with no lasting effects. A recently published study by Germain researchers in the journal Cephalalgia indicates that this condition is two times more common in people with migraine headaches. Dissection means that the wall of the artery is split and this can close off blood flow in the artery. In most people closing off of an artery is not a problem because there are 4 arteries in the neck that carry blood to the brain. However, in some one artery carries a large portion of the blood and the remaining 3 arteries cannot compensate, leading to a stroke. The dissection usually causes severe neck pain and if blood flow is compromised it also leads to neurological symptoms, such as a droopy eyelid, weakness or numbness on one side, difficulty speaking and other symptoms of a stroke. Neck pain is often the earliest and in benign cases the only symptom. Because migraine sufferers frequently have neck pains, this complaint can be dismissed by doctors as a symptom of their migraine. So, if someone’s neck pain is very severe and different from their usual neck pains it is very important to seek medical attention and insist on an evaluation. The diagnosis is made my an MRA (magnetic resonance angiography) scan. This increased risk of dissection is another reason why migraine sufferers particularly should avoid chiropractic adjustments, which can result in dissection even in non-migraineurs.

Migraine headaches are very common in chronic fatigue syndrome (CFS) sufferers, according to a new study just published by researchers from Georgetown University. Migraine headaches were present in 84% of patients with CFS (60% had migraine without aura and 24% had migraine with aura) and tension-type headaches were present in 81% of CFS sufferers. Only 4% of CFS patients had no headaches at all. This compares to 12% of the general population, or 18% of women (two thirds of CFS patients were women) who suffer from migraines. Fibromyalgia (diffuse muscle pains in four quadrants of the body) was much more common in CFS patients with migraines (about 50%) compared to healthy controls. The authors speculate that the same brain disturbances which cause migraine headaches may be also responsible for the fatigue in patients with CFS and that successful treatment of migraines may improve symptoms of CFS. It is well known that migraine sufferers have increased excitability of their brains, even between attacks, compared to healthy individuals. This may be why migraine sufferers are more likely to have other pain syndromes, such as fibromyalgia, back pain, irritable bowel syndrome, TMJ syndrome, and other. More importantly, several treatments have been shown to be effective (to various degrees) for all of these conditions. These include biofeedback and cognitive-behavioral therapy, tricyclic antidepressants, acupuncture, and aerobic exercise.

Temporo-mandibular joint disorders (TMD) have long been known to be associated with headaches.  A very interesting study conducted in Brazil and published in the Clinical Journal of Pain examined this association in 300 patients with TMD. The researchers carefully evaluated the type of TMD and its severity as well as the type of headache that might have been also present. Compared to those without TMD, patients with myofascial type of TMD were more likely to have chronic daily headaches, migraines and tension-type headaches. The more severe was TMD pain, the more likely it was that these headache conditions were present. An important question which is not answered by this study is, what comes first – TMD or headaches? It is likely that having one condition can cause and make the other worse, forming a vicious cycle. I see patients who can clearly identify that they first developed pain in the jaw and then headaches came along, but treating only their TMD does not seem to help. There are many more patients who present with headaches as the main complaint but who also have TMD. The treatment should always be directed at both conditions and many treatments we use have been shown to be effective for people with only TMD or only headaches. These treatments include regular aerobic exercise, biofeedback, acupuncture, Botox injections, massage, and medications. The list of medications include NSAIDs, such as aspirin (or Migralex), Advil, and Aleve, antidepressants, such as Elavil, Pamelor, and Cymbalta, epilepsy drugs, such as Neurontin and muscle relaxants, such as Zanaflex.

Vertigo and dizziness are common in migraine sufferers.  It is much less common for vertigo to be the only symptom of migraines.  This seems to be the case with vertigo that begin at menopause, according to a recent report presented at the last meeting of American Academy of Neurology.  The report describes symptoms in 12 women, so its conclusions cannot be accepted as definitive.  All of the women had history of menstrual migraines and all had a normal ear-nose-throat examination and a normal MRI scans.  They all suffered from vertigo for at least a year.  Treatment with standard migraine medications and hormonal therapy reduced attacks of vertigo by 50% and was more effective than non-hormonal treatment alone.  It is not surprising that the hormonal therapy helped because some women with menstrual attacks also improve with hormonal therapy, such as continuous contraception.  This report should raise awareness of the fact that menopausal women with vertigo may be suffering from migraines and may respond to hormonal and migraine therapies.

Migraine sufferers are 2 – 3 times more likely to become depressed or anxious than those without migraines.  The reverse is also true – depressed and anxious people are 2 -3 times more likely to develop migraines.  According to a new study published in the journal Cephalalgia, being depressed or anxious does not prevent migraine drugs from working.  The Greek researchers gave participants in the study sumatriptan (Imitrex), 50 mg for 3 attacks, and placebo, for another 3 attacks, without the doctors or the patients knowing what they were getting for any particular migraine attack.  Presence of anxiety or depression did not have an impact on weather after taking sumatriptan the headache returned within 24 hours or not.  Unfortunately, many physicians dismiss patients with migraine headaches as neurotics and hypochondriacs and the presence of anxiety or depression makes this bias even stronger.  These doctors tend not to prescribe effective migraine drugs, which leads to unnecessary suffering.  It is true that for some patients 1,000 mg of aspirin can be as effective as 50 or even 100 mg of sumatriptan with fewer side effects, but when aspirin is ineffective, sumatriptan or another drug in the triptan family should be used.  One surprising detail of this study is that the researchers used 50 mg of sumatriptan, and not 100 mg, which should be the usual starting dose for most patients.

Unfair teachers can cause headaches in adolescents, according to an Italian study published in the journal Headache.  About 40% of 4,386 adolescents suffered from headaches at least once a week.  Girls were more likely to have headaches and kids who had better classmate social support had fewer headaches.  The researchers used an established  “Teacher and Classmate Support Scale” to measure these effects and also took into account other factors that could have skewed the data.  They looked at family and friend empowerment, bullying, school achievement, and trust in people, and none of those factors seemed to play a role in causing headaches.  Psychological stress worsens headaches in adults too, but it seems to have a more pronounced effect in adolescents.

Children with thyroid disease are more likely to have headaches, according to a study done by Dr. David Rothner and his colleagues at the Cleveland Clinic.  36% of children with hypothyroidism and 19% with hyperthyroidism had headaches.  The types of headaches observed included chronic migraine and new daily persistent headache.  The authors conclude that thyroid testing should be part of a standard evaluation of headaches in children, just like it is in adults.

How long will I suffer from migraines?  Will it ever go away?  These are very common questions patients ask their doctors.  Drs. Bigal and Lipton reviewed a recent large study that looked at what happens to migraine patients within one year of observation.  The study found that migraine completely went away in 10%, improved in 3% and worsened and became chronic (occurring on more than 15 days each month) in 3%.  This confirms what we’ve know all along – migraine headaches tend to go away with age.  In women this often happens after menopause and in men at around similar age; however this study and our experience indicates that for many people migraines may go away earlier, at any point in their lives.  The problem is that we can never predict when this will happen and in a small percentage of patients (about 3%) migraines never go away.  

Migraine is most likely to occur at noon, according to an article just published in Headache by Norwegian researchers.  Although only 58 patients participated in this year-long study, there was a very clear peak of occurrence at noon.  This finding is different from what was reported in previous studies, which suggested that the most likely time for a migraine attack is in early morning hours.  The authors speculate that the restorative effects of sleep and work stress may be responsible for their finding.

Migraine is known to subside in most people, often when they reach their 40s or 50s.   A recent report from Sweden suggests that even patients with more severe migraines who end up going to a headache clinic have favorable long-term prognosis.  One third of both men and women reported complete cessation of their migraines.  Of the other two thirds the majority reported reduction in frequency and duration of attacks 12 years after their initial visit to the headache clinic.  The bad news is that many of the patients who continued to have headaches still had some impairment of quality of life.

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

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

Researchers at several companies are using brain images obtained by an MRI machine to train people with chronic pain how to control their pain. These MRI images are not of the type that are routinely taken to look at the brain structure. Instead, these are images obtained by “functional MRI” which show how different parts of the brain react to pain. By seeing these images of pain displayed as a flame patients are able to reduce the size of the flame and also reduce their pain. It is similar to what is done during old-fashioned biofeedback sessions where patients monitor their temperature or muscle tension and by learning to control these functions of the body are also able to reduce their pain and prevent migraine headaches. It is possible that functional MRI feedback training will prove to be more effective, but it is also likely to be much more expensive.

In a study presented at the recent meeting of the American Psychiatric Association Dr. Stephen Woolley found that adults suffering from severe headaches have a 30% to 50% increased chance of having suicidal thoughts or behaviors, independent of the presence of anxiety or depression. The recommendation for the doctors is to routinely screen patients suffering from severe headaches for suicidality even if they do not suffer from anxiety or depression. Family members and friends should also be aware of this fact and discuss it openly with headache sufferers.

A study published in a recent issue of journal Neurology found that adolescents who suffer from chronic daily headache, particularly if they also had migraine with aura had a six times higher risk of suicide than their headache-free peers. This was a community-based study conducted by Dr. Shuu-Jiun Wang in Taiwan. Almost half of adolescents with headaches had at least one psychiatric disorder. The most common disorders were major depression which was found in 21% and panic disorder in 19%.

Brain damage from migraines? Maybe, if you are a mouse. A recent study published in the journal Nature Neuroscience discovered that a process that simulates migraine in mice leads to brain damage similar to that seen with repeated ministrokes. It is true that patients with migraines with aura (visual disturbance that precedes headaches, which occurs in about 15% of migraine sufferers) have an increased risk of strokes, but this risk is still very low. The vast majority of migraine sufferers stop having migraines in their 40s and 50s and we have no evidence that having migraines for many years causes any permanent brain damage. What happens to mice can never be directly extrapolated to humans. (See my comments on Fox News under NYHC in the News)

Cluster headaches are much more common in men. Cluster headaches are much more common in men. However, they do occur in women and in the latest issue of journal Headache Dr. T. Rozen presents the first report of a woman who was having cluster attacks only with her menstrual cycle.

Women with migraine have a higher chance of also having endometriosis. A study by Dr. Gretchen Tietjen and her colleagues published in the latest issue of journal Headache looked at 171 women with migraine and 104 controls. Endometriosis was reported more commonly in migraineurs than in controls (22% vs 9.6%). Frequency of chronic headache was higher in migraineurs with endometriosis ompared to without it and headache-related disability scores were also higher in the endometriosis group. Depression, anxiety, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis were more common in migraine with endometriosis group than in controls. Anxiety, interstitial cystitis and chronic fatigue syndrome were more common in migraine with endometriosis group, than in the patients with migraine without endometriosis.

However, presence of any brain lesion is worrisome to most patients and according to some researchers may be indicative of small strokes or another type of brain damage. Some researchers have been concerned, although without any evidence, about possible accumulation of these lesions with progressive brain damage. A report in the June issue of Cephalalgia by Dr. Todd Rozen presents a case where a brain lesion seen on the first MRI scan was no longer seen on the second one 16 days later. We have always reassured our patients about the benign nature of these lesions, but it is good to have this additional evidence.

Migraines at the end of pregnancy and soon after the delivery increase the risk of strokes and other vascular complications (cerebro-vascular disease, or CVD). Dr. Bushnell and her colleagues presented these findings at the last annual meeting of the American Academy of Neurology. They looked at almost 17 million pregnancies and identified almost 34,000 women who had migraines. There was an increase in migraines with increased maternal age. Women who had migraines around the time of delivery were 19 times more likely to have a stroke, five times more likely to have a heart attack, three times more likely to have a pulmonary embolus, more than twice the risk of deep venous thrombosis, nearly four times he risk of thrombophilia, twice the risk of heart disease and more than twice the risk of preeclampsia/gestational hypertension.

About two thirds of women stop having migraines during their pregnancies, but if headaches are present at the end of pregnancy close observation is warranted. It is possible that magnesium supplementation as well as regular exercise, proper diet and other life style changes may help prevent these serious complications. Long-term risk for strokes and heart attacks is higher in women who keep additional weight gains after pregnancy.